NTSB reveals cause of 2023 toxic train crash in East Palestine, Ohio

Federal investigators confirmed Tuesday that a hot railcar wheel bearing sparked a fire and caused the massive derailment of a Norfolk Southern train carrying tank cars with hazardous materials in East Palestine, Ohio, in 2023. Investigators said a series of missteps, faulty track sensors and delayed communications about the train's toxic cargo from the railroad company 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 endangered the lives of first responders could have been avoided.

"Today we present our findings mindful of the challenges faced by those affected. We are here to ensure that the lessons learned from this derailment will lead to meaningful change so no other community has to relive the challenges faced by the people of East Palestine," Mike Graham, an NTSB board member, said Tuesday during a public hearing in East Palestine.

Jennifer Homendy, chair of the NTSB, opened the hearing by apologizing on behalf of her agency to the residents of East Palestine, saying some outside the NTSB sought to minimize the toxic threat caused by the crash because no one was killed or injured.

"The absence of a fatality or injury does not mean the presence of safety," Homendy said.

Researchers estimate that 110 million residents in 16 states, or one-third of the nation's population, were impacted by pollution, according to a study published in the Environmental Research Letters.

The findings released Tuesday confirmed and expanded on findings in the preliminary investigative report the NTSB released about three weeks after the crash.

Officials said the train comprised three locomotives and 149 freight rail cars, including 17 tank cars loaded with hazardous materials. The crash caused 38 rail cars to derail, officials said.

Eleven of the derailed cars were tank cars carrying flammable and combustible material, including vinyl chloride chloroethene.

"Post-accident inspections revealed that about 25% of the cars had federal defective conditions," NTSB investigator Ruben Payan said while giving a summary of the agency's investigative findings.

The investigation focused on the wheel bearing of rail car 23 that caught fire and caused the axle to fall off and derail the train in East Palestine around 8:54 p.m. local time, resulting in an explosion and fire, Payan said.

The crash occurred as the train was en route from Madison, Illinois, to the Conway Yard in Pennsylvania.

Before the crash, the train's rail cars were inspected in Toledo, Ohio, and again in Decatur, Illinois, and no obvious defects were detected, Payan said.

He said investigators reviewed video taken from security cameras of private homes and businesses along the route from Decatur to East Palestine and saw the wheel bearing of car 23 initially glowing from being overheated to being in flames as the train approached East Palestine.

NTSB investigators said the train tracks are equipped with sensors to detect dangerously overheated bearings and trigger critical alarms to the crew.

As the train passed through Salem, Ohio, about 17 miles from East Palestine, an alarm was triggered and alerted a Norfolk back office analyst, who deemed it non-critical because the trackside sensor only showed car 23's wheel bearing at 103 degrees, the NTSB investigation found. Investigators said the sensor did not properly detect the true temperature of the overheated bearing and that Norfolk Southern's policies don't call for a train to be stopped and inspected until the hot bearing reaches at least 115 degrees.

As the train approached East Palestine, critical alarms sounded on the train indicating that the overheated bearing had reached 253 degrees, prompting the train operator to apply the brakes in an attempt to stop the train, which was traveling at 42 mph, NTSB investigators said. By then, investigators said it was too late to avoid the derailment.

The NTSB also found that when East Palestine police and firefighters arrived on the scene at around 9 p.m. the incident commander called the Norfolk Southern center in Atlanta to ask what hazardous materials were in the derailed tank cars. The person who picked up the phone said they would check but did not get back to the incident commander, NTSB officials said.

Fire crews attempting to extinguish the fire with water didn't learn of the specific hazardous materials on the train until 10 p.m.

About 2,000 residents in the vicinity of the crash were initially ordered to shelter in place, NTSB officials said. But around 11 p.m., fire officials, who learned some of the derailed tankers contained vinyl chloride chloroethene, ordered the residents to evacuate. Around midnight, volunteer firefighters stopped batting the blaze, retreated to a safe distance and moved the command center back, according to the NTSB.

NTSB also found it was unnecessary for Norfolk Southern to recommend firefighters perform what was described as a "vent and burn" procedure on the tank cars containing vinyl chloride, sending a toxic plume of smoke into the air and causing further potential health hazards.

The NTSB made several recommendations to prevent similar incidents, including ways to advance the speed of communication between Norfolk Southern and first responders and establishing standards for how railroads should respond to bearing failure alarms. The agency, whose recommendations are not binding, also suggested that the Federal Railroad Administration establish rules governing railroad responses to the alarms.

In addition, the agency recommended establishing a database to report hot wheel-bearing incidents.

The agency also recommended that volunteer firefighters receive training on how to handle emergencies involving hazardous materials.

"We will continue to pursue and advocate for these safety recommendations until each one is implemented," Graham said.

In April, Norfolk Southern 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 designed to provide finality and flexibility for settlement class members," the company said in a statement at the time. "Individuals and businesses will be able to use compensation from the settlement in any manner they see fit to address potential adverse impacts from the derailment. This could include healthcare needs and medical monitoring, property restoration and diminution, and compensation for any net business loss."

On Tuesday, the company issued a new statement saying it has implemented measures to address the Federal Railroad Administration's recommendation from its 2023 Safety Culture Assessment.

Some of the recommendations Norfolk Southern addressed are similar to those of the NTSB, including approving communications, training, trust and "going above and beyond" regulatory minimums.

"We appreciate the strong partnership with FRA on advancing safety and are grateful for its thorough assessment of our culture and their thoughtful recommendations, all of which serve as building blocks to our goal of becoming the gold standard for safety in the industry," said Alan H. Shaw, president and CEO of Norfolk Southern.