EAST PALESTINE, Ohio - The National Transportation Safety Board (NTSB) returned to the Village of East Palestine Tuesday morning to discuss the final investigative report on the fiery train derailment in the village back in February of 2023.

During the hearing held at East Palestine High School, the Board discussed the results of the final investigative report on the derailment identifying some of the issues that led to the derailment and how to address them to prevent something similar happening in the future.

The NTSB found that the probable cause of the February 3 derailment was the failure of a wheel bearing on the 23rd rail car causing it to separate from its axle. 

On the subject of wayside detectors, the NTSB found that there are no standards pertaining to operational responses to wheel bearing alerts and alarms.

Investigators say a bearing database that captures bearing failure and replacement information could help identify failure risk factors.

Additionally, investigators suggested that wayside detectors should be subject to regulatory requirements for installation, inspection and maintenance.

On the subject of wheel bearings, the NTSB found that the hot bearing detector in Salem did not reflect the true temperature of the failed wheel bearing, which was captured on surveillance camera video from an area business.

The Board also found that internal bearing temperatures are likely to exceed external measured bearing temperatures and that hot bearing detectors have a limited ability to measure a failed bearing's actual temperature.

Investigators say further research is necessary to determine these alarm and alert thresholds, distance between detectors and review newer technologies.

On the subject of locomotive image recorders, the NTSB found that inward-facing and outward-facing image and audio recorders improve safety and support accident investigations and help railroads verify that crews are following safety procedures.

Investigators also found that the Federal Railroad Administration's (FRA's) final rule in response to the Fixing America's Surface Transportation (FAST) Act did not cover freight rail locomotives or require audio in passenger locomotives.

On the subject of availability of consist information, investigators found that the delayed transmittal of information resulted in unnecessary exposure to emergency responders and the public to post-derailment hazards.

On the subject of critical bearing alarms, investigators found that the FRA has no regulations regarding wayside detection and that the Association of American Railroads (AAR) defines an overheated bearing as 170 degrees Fahrenheit.

Before the derailment, class I railroads had a threshold of 136 and 190 degrees Fahrenheit for acceptable temperatures for wheel bearings. Following the derailment, that threshold decreased to 136 and 190 degrees Fahrenheit.

As for the topic of non-critical alerts, investigators found that the AAR does not have a recommendation for trending and when a bearing is deemed overheated and that Class I railroads each have different protocols in regard to trending.

Defining bearing temperature thresholds for normal operating temperatures and at-risk temperatures will require further investigation.

The NTSB went on to recap the emergency response to the situation. The first 911 call came in around 8:56 p.m. First responders were dispatched two minutes later and arrived on the scene at 9:00 p.m.

East Palestine's dispatch center called for Norfolk Southern to come to the scene at 9:04 p.m. Norfolk Southern arrived at the scene around 11:00 p.m

Around 10:00 p.m. the Columbiana County Emergency Management Agency (EMA) received an email on the contents of the train, which was then passed along to East Liverpool's fire chief.

It was learned through phone communications that one of the contents on that train was vinyl chloride.

At first, residents were told to shelter in place, but were then ordered to evacuate around 11:00 p.m. The command post was moved to one mile from the derailment around midnight.

The draft report states that while the East Palestine deputy fire chief and firefighters acted in good faith, their response did not conform to the emergency response guidebook guidance for fires involving tank cars and unknown materials.

This put firefighters at an unnecessary risk.

On top of that, the East Palestine Fire Department is strictly a volunteer fire department with the exception of the chief. Investigators with the NTSB found that Ohio's statutory requirements for volunteer firefighter training were insufficient to support a safe response to the derailment.

In addition, because there were not common radio channels between all responding agencies, the emergency response lacked coordination. 

Additionally, the delay in communication regarding the contents of the train, resulted in unnecessary and increased exposure to those hazardous materials.

The NTSB described this delay in communication "unacceptable" and said the information on the contents of the car should have been communicated to EMA and first responders in real time. 

On the topic of communications between Norfolk Southern and Oxy Vinyls, the vinyl chloride monomer manufacturer and shipper, investigators say Oxy Vinyls assessed a low probability of dangerous polymerization and recommended monitoring tank car temperatures for evidence of exothermic reactions.

Investigators say a lading temperature of 185 degrees Fahrenheit was required to activate a pressure relief device and no oxygen had been introduced into tanks to destabilize the vinyl chloride monomer.

Investigators went on to say Oxy Vinyls had no contact with the incident commander and its conclusions were not relayed to the incident commander.

On the topic of the vent and burn process, which was done in the days following the derailment, investigators say the process was approved based on information provided by Norfolk Southern and its contractors.

However, investigators say Norfolk Southern did not convey complete and accurate information to the incident commander and the failure to do so was not justified.

A vent and burn is a process that uses explosives to breach a tank shell in order to reduce internal vapor pressure to reduce potential for sudden tank failure.

Investigators say a vent and burn is not a procedure that is used often and that the FRA recognizes it as a valid process, but considers it a high-risk last-resor option. Investigators say alternative options had been overlooked.

Additionally, investigators found that the vent and burn process was not actually necessary to prevent polymerization-induced tank ruptures since vinyl chloride monomers did not undergo polymerization.

Investigators say more comprehensive FRA guidelines are needed for vent and burns and that the incident commander did not have access to the FRA's current guidance on vent and burns during the process.

The NTSB noted calls by the community for widely-available guidelines on what circumstances and hazardous materials would justify a vent and burn and also said the incident commander having that information in advance of the vent and burn could have made a difference in decision making.

The decision to vent and burn came from concerns of a "drastic temperature change" in a rail car with one car's temperature rising by three degrees from 135 to 138 degrees Fahrenheit.  

However, investigators say just prior to the vent and burn, that same car's temperature dropped by 12 degrees to 126 and was on a "downward temperature trend."

This means there was no imminent danger to justify a vent and burn at that point.

NTSB Jennifer Homendy said neither the incident commander nor Ohio Governor Mike DeWine were made aware of these dropping temperatures.

The NTSB says the alternative to the vent and burn was continue to let the car cool and inspect them afterwards.

"Norfolk Southern Railway and its contractors compromised the integrity of the vent and burn decision by creating unwarranted urgency and not communicating expert opinion and information completely and accurately to the incident commander," the draft report reads.