NTSB: NS Train Crew Failed to Reline Switch

WASHINGTON — The crew of a Norfolk Southern train failed to return a main line switch to the normal position after the crew completed work at an industry track in Graniteville, S.C., the National Transportation Safety Board has found.

On Jan. 6, 2005, a northbound Norfolk Southern Railway freight train (No. 192) encountered an improperly lined switch that diverted the train from the main line onto an industry track where it struck an unoccupied, parked train (P22).

The collision derailed both locomotives and 16 of the 42 freight cars of train 192 as well as the locomotive and one of two 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 5,400 people within a 1-mile radius of the derailment site were evacuated for several days, many of them complaining of respiratory difficulties.

“This was a tragic chain of events that did not have to happen and unfortunately resulted in the loss of life,” Acting NTSB Chairman Mark Rosenker. “The Board can not stress enough the importance of following proper procedures and protocols, at all times, when operating these massive machines.”

The Board determined that the crew of train P22 failed to reline a switch back to the mainline after using it, leading to the subsequent and unexpected diversion of train 192 into an industry track where it struck train P22 and derailed. The Board also concluded that had the conductor of train P22 held a comprehensive job briefing at the industry track, as required by NS operating rules, the crew may have attended to the main line switch, and the accident may not have occurred.

Contributing to the accident was the absence of any feature that would have reminded crewmembers of the switch position. Post-accident inspections revealed that the switch was lined and locked for the industry track, as it had been when train P22 used the switch on the evening prior to the wreck.

Investigators noted there was no evidence of tampering and no other trains used the track in the area from the time the P22 crew left until the wreck. The Board stated that contributing to the severity of the accident was the puncture of the ninth car, a tank car containing chlorine.

The chlorine gas release that occurred when the shell of the ninth car on the train was punctured by the coupler of the 11th car. Metallurgical examination of the damage on the shell round the puncture documented several impression marks on the shell that matched damage found on projecting surfaces of the coupler.

The Safety Board concluded that the chlorine gas release occurred when the coupler of the 11th car punctured the shell of the ninth car.