In the Graniteville Tragedy Aftermath: Working for Rail Safety so the Death of a Young Engineer will not have been in Vain

On January 6, 2005, at 2:39 a.m., a 42-car Norfolk Southern train approaching northbound into Graniteville, South Carolina was improperly diverted into an industrial track. The train, which was traveling about 45 miles per hour, collided with a parked train. Another train crew had not realigned the switch after parking their train in the industrial track, thus diverting the NS train operated by a 28-year-old engineer into the industrial track. There was no advance warning of the misaligned switch and there was nothing the young engineer could do to avoid the collision.

As a result of the collision, a tank car carrying chlorine gas was gashed open. The liquefied chlorine turned into vapor and formed a chlorine cloud that enveloped the Graniteville area. Ultimately, the engineer and eight residents died from inhaling chlorine vapors. Two hundred and fifty people were injured and 5,400 residents were displaced. Millions of dollars of property damage was sustained. It is estimated by authorities in the field that had this tragedy occurred in Washington, D.C., the risk of death or injury would have exceeded 100,000 people.

Nothing could bring the young engineer back to life, but his parents, his union, and Gene Napier, who had been selected by his parents to represent the family, were committed to seeing that his death would not be in vain by working for measures that would prevent tragedies such as this in the future.

In late May 2005, Mr. Napier, a partner in the Hubbell Law Firm, traveled with the parents of the engineer to Washington, D.C. and attended a meeting with BLET President Don Hahs, Vice President and National Legislative Representative Raymond Holmes, Chief of Staff John Tolman, Fred McLuckie, Legislative Director for the Teamsters, and Congressman Jim Oberstar, the ranking Democrat on the House Transportation and Infrastructure Committee.

Returning to Washington, D.C. in July 2005, the family and Gene Napier, in the company of Chief of Staff John Tolman and Legislative Director Fred McLuckie, met with Congressman Steve LaTourette, Chairman of the House Railroad Subcommittee of the Committee on Transportation and Infrastructure. They also met with officials of the National Transportation Safety Board regarding their investigation of the Graniteville disaster, and finally, with the Rail Division of the Transportation Trades Department.

In each meeting, the family of the young engineer conveyed a strong message regarding improving rail safety, not only on the Norfolk Southern, but the railroad industry nationally. These discussions included reducing the number of dark territories where the rail carriers are transporting hazardous materials, reducing the speed that trains travel while hauling hazardous materials, addressing train crew fatigue, the railroad’s failure to equip its locomotives with escape hoods or other breathing gear, the fact that the railroads have not properly trained railroad crew members on how to react and what to do with respect to being exposed to different toxic chemicals. The family pointed out and discussed in these meetings that they had learned that tank cars used to haul these hazardous materials number approximately 60,000. Thirty thousand of these cars do not even meet minimum standards. Of the 30,000 that do meet standards those tank cars are crash-proof only to 18 miles per hour.

On November 29, 2005, the engineer’s parents and Mr. Napier were invited by the National Transportation Safety Board to attend a public meeting wherein the National Transportation Safety Board staff presented their findings to the Safety Board. That report is presented at the end of this article. The Safety Board reached eleven conclusions, determined the probable cause of the incident and made four safety recommendations to the Federal Railroad Administration. The safety recommendations that the NTSB reached were very similar to the recommendations that the engineer’s family conveyed to the officials of the NTSB at the July 2005 meeting. If these recommendations are adopted and implemented, the railroad workplace will be much safer, as will be communities, large and small, along thousands and thousands of miles of railroad track, and more especially, the people living in those communities.

It is anticipated that Congress will hold public hearings on rail safety in 2006, wherein it is likely that the parents of the engineer will be called to testify. With the continuing efforts of rail labor and courageous, caring families such as this one which the Hubbell Law Firm was privileged to represent, it is hoped that rail safety will improve to prevent the unfortunate results of the Graniteville tragedy and a number of subsequent tragedies resulting from similar causes.

The Hubbell Law Firm will continue to assist the family in all possible ways to make sure that rail safety remains an issue in our nation’s Capitol.

 

NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of November 29, 2005
(Information subject to editing)

Report of Railroad Accident
Collision of Norfolk Southern Freight Train 192 with Standing
Norfolk Southern Local Train P22 With Subsequent Hazardous Materials Release
Graniteville, South Carolina
January 6, 2005
NTSB/RAR-05/04

This is a synopsis from the Safety Board’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

EXECUTIVE SUMMARY

About 2:39 a.m. eastern standard time on January 6, 2005, northbound Norfolk Southern Railway Company (NS) freight train 192, while traveling about 47 mph through Graniteville, South Caroline, encountered an improperly lined switch that diverted the train from the main line onto an industry track where it struck an unoccupied, parked train (NS train P22). The collision derailed both locomotives and 16 of the 42 freight cars of train 192 as well as the locomotive and 1 of the 2 cars of train P22. Among the derailed cars from train 192 were three tank cars containing chlorine, one of which was breached, releasing chlorine gas. The train engineer and eight other people died as a result of chlorine gas inhalation. About 554 people complaining of respiratory difficulties were taken to local hospitals. Of these, 75 were admitted for treatment. Because of the chlorine release, about 5,400 people within a 1-mile radius of the derailment site were evacuated for several days. Total damages exceeded $6.9 million. The National Transportation Safety Board determines that the probable cause of the January 6, 2005, collision and derailment of Norfolk Southern train 192 in Graniteville, South Caroline, was the failure of the crew of Norfolk Southern P22 to return a main line switch to the normal position after the crew completed work at an industry track. Contributing to the failure was the absence of any feature or mechanism that would have reminded crewmembers of the switch position and thus would have prompted them to complete this final critical task before departing the work site. Contributing to the severity of the accident was the puncture of the ninth car in the train, a tank car containing chlorine, which resulted in the release of poisonous chlorine gas.

The safety issues identified in this investigation are as follows:

• Railroad accidents attributable to improperly lined switches;
  
• The vulnerability, under current operating practices, of railroad tank cars carrying hazardous materials.

As a result of its investigation of this accident, the National Transportation Safety Board makes safety recommendations to the Federal Railroad Administration.

CONCLUSIONS

1. Neither train equipment defects nor track condition were causal or contributory to this accident.
   
2. In regard to the crew of train 192, fatigue, crew training and qualifications, and drugs and alcohol were not factors in this accident.
   
3. In regard to the crew of train P 22, neither crew qualifications and training nor fatigue were causal or contributory to this accident, and no evidence was found to suggest drug or alcohol use.
   
4. The execution of the emergency response to this accident was timely, appropriate, and effective.
   
5. The crew of train P22 failed to reline a main line switch after using it, leading to the subsequent and unexpected diversion of Train 192 into an industry track where it struck train P22 and derailed.
   
6. The crew of train P22 failed to reline the main line switch for one or more of the following reasons: (1) the task of relining the switch was functionally isolated from other tasks the crew was performing, (2) the crewmembers were rushing to complete their work and secure their train before reaching their hours-of-service limits, (3) the crew had achieved their main objective of switching cars and were focused on the next task of securing their equipment and going off duty, and (4) the switch was not visible to the crew as they worked, leaving them without a visual reminder to reline the switch.
   
7. Had the conductor of train P22 held a comprehensive job briefing at the Avondale Mills industry track, as required by Norfolk South operating rules, the crew may have attended to the main line switch, and the accident may not have occurred.
   
8. At the speed train 192 was traveling as it entered Graniteville, the distance required for the train crew to perceive the banner of the misaligned switch, react to it, and bring the train to a safe stop was greater than the distance available.
   
9. The chlorine gas release that occurred in this accident resulted when the shell of the 9th car on the train was punctured by the coupler of the 11th car.
   
10. As shown in the Graniteville accident, even the strongest tank cars in service can be punctured in accidents involving trains operating at moderate speeds.
    
11. Had the engineer of train 192 been wearing appropriate, fully functioning emergency escape breathing apparatus when he walked away from the collision site, he may not have succumbed to the effects of chlorine gas inhalation.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of the January 6, 2005, collision and derailment of Norfolk Southern train 192 in Graniteville, South Caroline, was the failure of the crew of Norfolk Southern train P22 to return a main line switch to the normal position after the crew completed work at an industry track. Contributing to the failure was the absence of any feature or mechanism that would have reminded crewmembers of the switch position and thus would have prompted them to complete this final, critical task before departing the work site. Contributing to the severity of the accident was the puncture of the ninth car in the train, a tank car containing chlorine, which resulted in the release of poisonous chlorine gas.

SAFETY RECOMMENDATIONS

As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations:

To the Federal Railroad Administration:

1. Require that, along main lines in non-signaled territory, railroads install an automatically activated device, independent of the switch banner, that will, visually or electronically, compellingly capture the attention of employees involved with switch operations and clearly convey the status of the switch both in daylight and in darkness.
   
2. Require railroads, in non-signaled territory and in the absence of switch position indicator lights or other automated systems that provide train crews with advance notice of switch positions, to operate those trains at speeds that will allow them to be safely stopped in advance of misaligned switches.
   
3. Require railroads to implement operating measures, such as positioning tank cars toward the rear of trains and reducing speeds through populated areas, to minimize impact forces from accidents and reduce the vulnerability of tank cars transporting chlorine, anhydrous ammonia, and other liquefied gases designated as poisonous by inhalation.
   
4. Determine the most effective methods of providing emergency escape breathing apparatus for all crewmembers on freight trains carrying hazardous materials that would pose an inhalation hazard in the event of unintentional release and then require railroads to provide these breathing apparatus to their crewmembers along with appropriate training.

top of page