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NTSB Announces Ruling on Graettinger Train Wreck

November 6, 2018
By Anesa McGregor , Emmetsburg News

by Anesa McGregor

Northwest Iowa now knows it can happen anywhere. It was a cold March morning. Trains pulling tanker cars loaded with ethanol from Superior. The train riding this track had just passed through the community of Graettinger and was approximately one and a half miles southeast of the town and was headed for the community of Emmetsburg. The entire train consisted of 98 cars, three locomotive and two buffer cars full of sand. At about 12:50 a.m., the train derailed--a derailment unlike anything ever seen in Palo Alto County.

Just after the first 20 cars crossed a wooden train bridge running across Jack Creek, cars 21 through 40 derailed for some unknown reason. According to the lead locomotive's recorder, the train was traveling 30 mph and shortly after the first 20 cars went across the bridge, the emergency brake was activated about 12:50 a.m. without crew input.

Article Photos

TANK CARS BURNED at the site of the March 10, 2017 Union Pacific Railroad train derailment near Graettinger. The train consisted of 98 tank cars loaded with ethanol, three locomotives and two buffer cars filled with sand. Twenty of the 98 tank cars derailed, 14 of the 20 released about 322,000 gallons of undenatured ethanol, fueling a post-accident fire that burned for over 36 hours. --Dan Voigt photo

The preliminary investigation revealed the DOT-111 type tank cars had not been retrofitted with safety requirements that the Department of Transportation requires of all DOT-111 type cars by May 1, 2023. The lack of safety requirements allowed 14 tanks cars to release about 322,000 gallons of ethanol causing a fire to erupt. Of the 14 cars, 10 were breached for mechanical damage, which according to the National Transportation Safety Board.

At approximately 2:15 a.m., there was a large explosion, which resulted in the evacuation of three residences which were one-half mile away or less. The resulting blaze burned for over 36 hours.

No one was injured; however, the incident caused an estimated $4 million in damages, including the destruction of 400 feet of railroad track and a 152 foot wooden railroad bridge.

The NTSB gathered pieces of track and other items at the site of the wreck, including the locomotive's event recorder. It has taken seven months for the NTSB to reach a conclusion, but on October 30, the aagency held a hearing to give their results for the cause of the derailment.

According to the NTSB the following are three safety issues in this accident: adequacy of Union Pacific Railroad's track maintenance and inspection program; adequacy of the Federal Railroad Administration oversight; and transportation of fuel ethanol without the use of volatile organic chemical denaturants.

FINDINGS

Here are the findings of the NTSB as they pertain to the Union Pacific train wreck March 10, 2017 near Graettinger.

1. Union Pacific Railroad was not maintaining the track structure on the Union Pacific Railroad Estherville Subdivision in accordance with Federal Railroad Administration minimum track safety standards.

2. Union Pacific Railroad supervisors and managers were not ensuring defective crosstie conditions were being identified, reported, and remediated in accordance with Union Pacific Railroad track maintenance standards and Federal Railroad Administration track safety standards.

3. FRA inspectors did not report all defective crosstie conditions on the Union Pacific Railroad Estherville Subdivision in the two years prior to the derailment.

4. Federal Railroad Administration inspectors were not using all available enforcement options, such as a recommendation for civil penalties, to require Union Pacific Railroad to

comply with FRA minimum track safety standards on the Union Pacific Railroad Estherville Subdivision.

5. Based on the observation of the fresh horizontal impact damage ob- served on the wheel tread of the fourth through the 20th non-derailed cars, examination of the rail recovered from the accident, the condition of the crosstie structure on the Union Pacific Railroad Estherville Subdivision, the train likely derailed from a broken south rail that occurred prior to or at the 20th car of the Union Pacific train as it was traveling over the west approach of the Jack Creek Bridge, resulting from UP's inadequate track maintenance and inspection program and the FRA's inadequate oversight of the application of federal track safety standards.

6. Based on federal research and observed accident performance of tank car head protection systems in this accident, it is likely that had the legacy US Department of Transportation Specification-111 tank cars involved in this accident been replaced with US Department of Transportation Specification-117 tank cars equipped with head shields, breaches and punctures which resulted in the loss of hazardous material from six of the tank car heads could have been mitigated or prevented.

7. Tank car shell puncture resistance improvements required for new or retrofitted US Department of Transportation Specification-117 tank cars transporting flammable liquids that are scheduled to replace the existing fleet of US Department of Transportation Specification-111 eth-anol tank cars by May 1, 2023, could have mitigated and might even have prevented some of the tank shell breaches from six of the tank cars involved in this accident.

8. If the tank cars involved in this accident had been retrofitted or replaced with US Department of Transportation Specification-117 compliant tank cars, the breaching damage to the top fittings of the 21st and 25th tank cars could have been avoided.

9. Ethanol would not have released from the 22nd tank car had it been equipped with a bottom outlet valve operating mechanism that was designed to prevent actuation during an accident scenario.

10. More research should be conducted to determine whether operational changes to shipping ethanol in its undenatured form would improve safety.

11. The erroneous shipping documentation identifying the hazardous material as denatured alcohol, instead of undenatured ethanol, did not have any adverse impact on the emergency response to this accident.

12. None of the following were factors in this accident: (1) the mechanical condition of the train to include the train's braking system, (2) the performance of the train crew, (3) cell phone use by the train crew, (4) alcohol or other drugs by the train crew and (5) the emergency response.

PROBABLE CAUSE

The NTSB determines that the probable cause of the derailment was a broken rail that occurred as the train wa traveling over the west approach of the Jack Creek Bridge resulting from Union Pacific Railroad's inadequate track maintenance and inspection program and the FRA's inadequate oversight of the application of federal track safety standards. Contributing to the consequences of this accident was the continued us of US Department of Transportation Specification-111 tank cars.

RECOMMENDATIONS

As a result of these investigations, the NTBS includes the following new safety recommendations in their findings:

To the FRA:

1. Provide additional training to all your track inspectors on regulatory track safety standards compliance and provide guidance of available enforcement options to obtain compliance.

To the Pipeline and Hazardous Materials Safety Administration:

2. Sponsor research to study and publish the difference in characteristics between denatured and undenatured ethanol and the benefits that could be achieved by transporting fuel ethanol without the use of volatile organic chemical denaturants.

To Union Pacific Railroad:

3. Re-examine your track maintenance and inspection program standards on all routes that carry high hazardous flammable materials and ensure those track inspection standards are complied with by both track inspectors and track supervisors.

During the NTSB's recommendations, the NTSB reiterated the previously issued safety recommendation:

To the Pipeline and Hazardous Materials Safety Administration:

1. Require an aggressive, intermediate progress milestone schedule, including: 20 percent yearly completion over a five-year implementation period for the replacement or retrofitting of legacy DOT-11 and CPC-1232 tank cars to appropriate tank car performance standards and equipping these tank cars with jackets, thermal protection and appropriately sized pressure relief devices.

To read a synopsys of the report, visit:

go.usa.gov/xPm73

 
 
 

 

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