Federal investigators confirmed Tuesday that a hot railcar wheel bearing caused a fire in the 2023 derailment of a Norfolk Southern Railroad train carrying tank cars loaded with hazardous materials in East Palestine, Ohio. Investigators said a series of mistakes, faulty track sensors and delayed communication from the railroad company about the train’s toxic cargo contributed to the disaster.
In its final report on the Feb. 3, 2023, crash, the National Transportation Safety Board concluded that the crash, which caused the evacuation of more than 2,000 residents and put the lives of emergency responders at risk, could have been avoided.
“Today, we are releasing the findings of our investigation, mindful of the hardships faced by those affected. We are here to ensure that lessons learned from this derailment lead to meaningful change and ensure that other communities do not again experience the hardships faced by the people of East Palestine,” NTSB Director Mike Graham said at a hearing in East Palestine on Tuesday.
NTSB Chair Jennifer Homendy opened the hearing by apologizing on behalf of the NTSB to the residents of East Palestine, and said some outside the NTSB had tried to downplay the toxic threat from the crash because there were no deaths or injuries.
“Just because there are no deaths or injuries doesn’t mean it’s safe,” Homendy said.
In a study published in the journal Environmental Research Letters, researchers estimated that 110 million residents in 16 states — one-third of the U.S. population — were affected by the contamination.
The findings released Tuesday confirm and expand on those of a preliminary investigation report the NTSB released about three weeks after the crash.
The train consisted of three locomotives and 149 freight cars, including 17 tank cars carrying hazardous materials, and 38 of the cars were derailed, authorities said.
Eleven of the derailed cars were tank cars carrying flammable materials, including polyvinyl chloride (chloroethylene).
“Post-accident inspections found that approximately 25 percent of the vehicles had federally regulated deficiencies,” NTSB investigator Ruben Payan said while outlining the agency’s findings.
Payan said the investigation was focusing on the wheel bearing of carriage 23, which caught fire in eastern Palestine at about 8:54 pm local time, causing an axle to come loose and derail the train, sparking an explosion and fire.
The accident occurred while the train was traveling from Madison, Illinois to Conway Yard, Pennsylvania.
Payan said the train’s cars were inspected in Toledo, Ohio, and Decatur, Illinois, before the accident, and no obvious defects were found.
He said investigators reviewed security camera footage from homes and businesses along the line from Decatur to East Palestine, which showed wheel bearings in car 23 glowing red as the train approached East Palestine, initially overheating and then bursting into flames.
NTSB investigators said the tracks are equipped with sensors that can detect dangerously hot bearings and send critical alerts to train crews.
An alarm sounded as the train passed through Salem, Ohio, about 17 miles from East Palestine, and was notified to a back-office analyst at Norfolk, but the analyst determined it was not serious because trackside sensors showed a wheel bearing temperature of just 103 degrees on car 23, the NTSB investigation found. Investigators said the sensors did not properly detect the actual temperature of the overheated bearings, and Norfolk Southern Railway policies did not require the train to be stopped and inspected until the hot bearings reached at least 115 degrees.
As the train approached East Palestine, a critical alarm sounded on the train, indicating an overheated bearing had reached 253 degrees Fahrenheit, and the driver applied the brakes to try to stop the train, which was traveling at 42 mph, according to NTSB investigators. By that point, it was too late to avoid a derailment, investigators said.
The NTSB also found that as East Palestine police and firefighters arrived on the scene about 9 p.m., the incident commander had called the Norfolk Southern Railroad Center in Atlanta to inquire about what hazardous materials were in the derailed tank car. The person who answered the phone said they would check but did not call the incident commander back, NTSB officials said.
Firefighters, who were trying to put out the fire with water, were unaware that the train was carrying hazardous materials until 10pm.
Initially, about 2,000 residents near the accident site were ordered to evacuate, NTSB officials said. But around 11 p.m., fire officials learned that parts of the derailed tanker contained polyvinyl chloride (chloroethylene), and ordered residents to evacuate. Around midnight, volunteer firefighters stopped fighting the fire, retreated to a safe distance and moved their command center to the rear, the NTSB said.
The NTSB also found that Norfolk Southern was not required to advise firefighters to perform what are known as “vent and burn” procedures on tank cars loaded with polyvinyl chloride, which could have released toxic fumes into the air and caused further health problems.
The NTSB made several recommendations to prevent similar accidents, including ways to improve communication speeds between Norfolk Southern and emergency responders and establishing standards for how railroads should respond to bearing failure alerts. The agency’s recommendations are not binding, but it also suggested that the Federal Railroad Administration issue rules governing railroads’ responses to alerts.
Additionally, the agency recommended establishing a database for reporting high temperature wheel bearing incidents.
The agency also recommended that volunteer firefighters receive training on how to respond to emergencies involving hazardous materials.
“We will continue to pursue and advocate until every single one of these safety recommendations is implemented,” Graham said.
Norfolk Southern Railway in April agreed to a $600 million settlement to resolve a class-action lawsuit stemming from the train derailment. The settlement was approved by a judge in May.
“The agreement is intended to provide finality and flexibility to members of the settlement class,” the company said in a statement. “Individuals and businesses can use the settlement proceeds in any way they see fit to address the potential adverse effects of the derailment, which may include compensation for medical needs and medical monitoring, restoration and diminution of assets, and net business losses.”
The company issued a new statement Tuesday saying it has implemented measures to address recommendations from the Federal Railroad Administration’s 2023 Safety Culture Assessment.
Some of the recommendations Norfolk Southern addressed are similar to those of the NTSB, including communications, training, trust endorsements and “going beyond” minimum regulatory standards.
“We value our strong partnership with FRA on safety improvements and appreciate their thorough assessment of our culture and thoughtful recommendations, all of which are foundational to our goal of becoming the gold standard in safety for the industry,” said Alan H. Shaw, Norfolk Southern’s president and CEO.
