Cherry Valley, Illinois
June 19, 2009
NTSB Number: RAR-12-01
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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.
About 8:36 p.m., central daylight time, on Friday, June 19, 2009, eastbound Canadian National Railway Company (CN) freight train U70691-18 traveling at 36 mph derailed at a highway/rail grade crossing in Cherry Valley, Illinois. The train consisted of 2 locomotives and 114 cars, 19 of which derailed. All of the derailed cars were tank cars carrying denatured fuel ethanol, a flammable liquid. Thirteen of the derailed tank cars were breached or lost product and caught fire. At the time of the derailment, several motor vehicles were stopped on either side of the grade crossing waiting for the train to pass. As a result of the fire that erupted after the derailment, a passenger in one of the stopped cars was fatally injured, two passengers in the same car received serious injuries, and five occupants of other cars waiting at the highway-rail crossing were injured. Two responding firefighters also sustained minor injuries. The release of ethanol and the resulting fire prompted a mandatory evacuation of about 600 residences within a 1/2-mile radius of the accident site. Monetary damages were estimated to total $7.9 million.
1. The use of alcohol or illegal drugs by the rail traffic controller as a factor in the accident could not be determined because there was no toxicological testing conducted.
2. The following were not factors in the accident: mechanical condition of the locomotives and cars on the train; material properties of steels used in the tank car construction; integrity of the track structure, culvert, and rails leading up to the point of derailment; functioning of the signal system and the grade crossing warning system; use of alcohol or illegal drugs by the train crew; training and qualifications of the train crew and the rail traffic controller; and fatigue of the rail traffic controller.
3. Both the emergency response to the accident and the environmental recovery efforts after the fire were timely and appropriate.
4. The derailment occurred when wheel loads on rails that were unsupported because of a washout of the track structure caused the north rail to fracture at a field weld about 8 feet west of the Mulford Road grade crossing.
5. Had the required CN grade crossing identification and emergency contact information been posted at the Mulford Road crossing, the railroad would likely have been notified of the track washout earlier, and the additional time may have been sufficient for the rail traffic controller to issue instructions to stop the train and prevent the accident.
6. The CN police emergency communication system in place at the time of this accident was inadequate, with the result that CN police were unable to prevent the derailment even though adequate time was available for them to have done so.
7. The failure of the CN to conduct post accident toxicological testing on the rail traffic controller demonstrates that the CN post accident toxicological program was ineffective.
8. If the rail traffic controller had followed CN weather procedures and alerted the crew of the accident train to the potential for heavy rains and flash flooding along their route, the crew would have been required to operate the train at a lower speed, which would have reduced the severity of the accident.
9. The CN's weather policies and rules in effect at the time of the accident were inadequate because they provided insufficient and vague guidance in not requiring rail traffic controllers to read weather alerts verbatim to train crews; did not clearly specify whether train crews should operate trains at a restricted speed after receiving an alert; provided no notification requirement that track inspectors conduct severe weather related inspections prior to train operations; and did not consolidate weather alert notices and the appropriate operation of trains into a single rule.
10. A thorough work-risk assessment of dispatching operations may have identified several deficiencies that, if corrected, would have ensured safety-critical tasks were addressed appropriately.
11. The breach in Harrison Park storm water management detention pond 1 that was documented in 2008 posed a downstream risk in the event of a heavy storm, and more timely measures should have been taken to repair the defect and restore the integrity of the pond.
12. Regular inspections by municipalities or other government authorities of storm water detention ponds, both public and private, would help ensure that the ponds function as designed to reduce the likelihood of damage to property or injuries to people.
13. The storm water drainage system in place in the area of the accident was inadequate as evidenced by the washout of the CN tracks on the day of the accident and by previous water damage to the track structure that occurred in 2006 and 2007.
14. This accident demonstrates that storm water issues can affect more than one entity-in this case, the CN and Winnebago County-and can require that multiple entities work jointly in a collaborative effort to solve any underlying defects or inadequacies.
15. If enhanced tank head and shell puncture-resistance systems such as head shields, tank jackets, and increased shell thicknesses had been features of the DOT-111 tank cars involved in this accident, the release of hazardous materials likely would have been significantly reduced, mitigating the severity of the accident.
16. The safety benefits of new specification tank cars will not be realized while the current fleet of DOT-111 tank cars remains in hazardous materials unit train service, unless the existing cars are retrofitted with appropriate tank head and shell puncture resistance systems.
17. Requirements for protection of the top fittings of the DOT-111 tank cars involved in this accident are inadequate because the protective housings were not able to withstand the forces of the derailment.
18. The existing standards and regulations for the protection of bottom outlet valves on tank cars do not address the valves' operating mechanisms and therefore are insufficient to ensure that the valves remain closed during accidents.
19. Tank car design standards for the attachments of draft sills to sill pads and of sill pads to the tanks are insufficient to protect the integrity of the tanks in accidents in which the draft sills are subjected to significant downward deformation.
20. The inaccurate train consist carried by the crew did not affect the emergency response to this accident; however, had a mixture of hazardous commodities been involved, the inaccurate consist information could have hampered the response effort or put the safety of emergency responders and others at risk.
21. Had an effective Safety Management System been implemented at CN, the inadequacies and risks that led to the accident would have been identified and corrected and, as a result, the accident may have been prevented.
22. Had the gas pipeline been installed at the railroad crossing with the minimum level of ground cover required by the current federal and industry pipeline construction standards, it likely would have failed as a result of being struck by derailed equipment in this accident.
23. The erroneous pipeline hazard communication to emergency responders by Nicor Gas Company likely occurred as a result of the Nicor dispatch center clerk's misreading of a map
The National Transportation Safety Board determines that the probable cause of the accident was the washout of the track structure that was discovered about 1 hour before the train's arrival, and the Canadian National Railway Company's (CN) failure to notify the train crew of the known washout in time to stop the train because of the inadequacy of the CN's emergency communication procedures. Contributing to the accident was the CN's failure to work with Winnebago County to develop a comprehensive storm water management design to address the previous washouts in 2006 and 2007. Contributing to the severity of the accident was the CN's failure to issue the flash flood warning to the train crew and the inadequate design of the DOT-111 tank cars, which made the cars subject to damage and catastrophic loss of hazardous materials during the derailment.
To the U.S. Department of Transportation:
1. Develop a comprehensive storm water drainage assessment program to be conducted jointly by railroads and public entities that ensures the adequate flow of water under both railroad and highway facilities, and require railroads and public entities to coordinate any changes to storm water drainage systems before their implementation.
2. Notify railroads and public entities about the circumstances of this accident and the importance of exchanging information related to storm water drainage system design issues that may adversely affect the adequate flow of water under both railroad and highway facilities.
To the Federal Railroad Administration:
3. Inform railroads about the circumstances of the accident and advise them of the need to immediately notify pipeline operators of accidents occurring in railroad rights-of-way and to ensure that pipeline inspections have been accomplished prior to resumption of service.
4. Require that safety management systems and the associated key principles, including top-down ownership and policies; analysis of operational incidents and accidents; hazard identification and risk management; prevention/mitigation programs; and continuous evaluation and improvement programs, be incorporated in railroads' risk reduction programs as required by Public Law 110-432, Rail Safety Improvement Act of 2008, enacted October 16, 2008.
To the Pipeline and Hazardous Materials Safety Administration:
5. Require that all newly manufactured and existing general service tank cars authorized for transportation of denatured fuel ethanol and crude oil in Packing Groups I and II have tank head and shell puncture resistance systems and top fittings protection that exceed existing design requirements for DOT-111 tank cars.
6. Require that all bottom outlet valves used on newly manufactured and existing non-pressure tank cars are designed to remain closed during accidents in which the valve and operating handle are subjected to impact forces.
7. Require that all newly manufactured and existing tank cars authorized for transportation of hazardous materials have center sill or draft sill attachment designs that conform to the revised Association of American Railroads' design requirements adopted as a result of Safety Recommendation 9.
8. Inform pipeline operators about the circumstances of the accident and advise them of the need to inspect pipeline facilities after notification of accidents occurring in railroad rights-of-way.
To the Association of American Railroads:
9. Review the design requirements in the Association of American Railroads Manual of Standards and Recommended Practices C-III, "Specifications for Tank Cars for Attaching Center Sills or Draft Sills," and revise those requirements as needed to ensure that appropriate distances between the welds attaching the draft sill to the reinforcement pads and the welds attaching the reinforcement pads to the tank are maintained in all directions in accidents, including the longitudinal direction.
To the American Association of State Highway and Transportation Officials, the National Association of County Engineers, the American Public Works Association, and the Institute of Transportation Engineers:
10. Inform your members about the circumstances of this accident and the importance of exchanging information related to storm water drainage system design issues that may adversely affect the adequate flow of water under both railroad and highway facilities.
To the National League of Cities, the National Association of Counties, the Association of State Dam Safety Officials, the National Association of Towns and Townships, and the U.S. Conference of Mayors:
11. Inform your members of the circumstances of this accident and emphasize the importance of periodically inspecting storm water management detention ponds (both private and public) to ensure that no deterioration has occurred that would result in the failure of a pond to function as designed.
To the Canadian National Railway Company:
12. Implement a program consistent with principles of safety management systems to periodically test all aspects of your internal emergency communication system to ensure that personnel are familiar with the system's operation and that emergency notifications can be communicated immediately to any chief dispatcher or rail traffic controller in your system.
13. Implement a process, consistent with the principles of a safety management system, to ensure accuracy and visibility of emergency contact information at all highway-rail grade crossings on your system.
14. Examine and revise your post accident toxicological testing program to ensure that rail traffic controllers are tested unless there is clear and convincing evidence that they were not involved in the accident.
15. Modify your weather warning operating and safety rules and procedures to (1) consolidate weather policies in a single rule, accessible to all operating personnel, (2) require that rail traffic controllers promptly and precisely notify affected train crews of weather alerts and identify for train crews the specific hazards to train operation represented by a weather alert, and (3) require either that a track inspector inspect the affected track before train operations are permitted within an affected weather alert area or that engineers operate their trains at restricted speed and crews watch for water on tracks, possible washouts, and misaligned track in the affected areas until the track is inspected.
To the Federal Railroad Administration:
Assist the Pipeline and Hazardous Materials Safety Administration in developing regulations to require that railroads immediately provide to emergency responders accurate, real-time information regarding the identity and location of all hazardous materials on a train. (R-07-2)
To the Pipeline and Hazardous Materials Safety Administration:
With the assistance of the Federal Railroad Administration, require that railroads immediately provide to emergency responders accurate, real-time information regarding the identity and location of all hazardous materials on a train. (R-07-4)
