Systemic errors led to a 2012 train derailment in New Jersey that released a dangerous gas into the air, sickening residents and emergency responders, the National Transportation Safety Board said Tuesday in a scathing report.
The NTSB faulted Conrail for continuing to open and close the swinging bridge where the accident occurred despite a consultant's recommendation not to.
The board also criticized Conrail and state and local officials for the way they handled their emergency response.
NTSB member Robert Sumwalt said in the meeting in Washington that he often describes emergency responses as "organized chaos."
"On this day, there was chaos, but it certainly was not organized," he said.
The NTSB issued a list of 20 recommendations to prevent similar accidents and improve the emergency response.
Seven train cars derailed on Nov. 30, 2012, as the train began crossing a swinging bridge Paulsboro, an industrial town across the Delaware River from Philadelphia International Airport. Four of them plunged into Mantua Creek below, and one tanker was punctured, releasing 20,000 gallons of vinyl chloride — a gas used in industrial processes that has been linked to respiratory problems, dizziness or even death.
Twenty emergency responders sought medical treatment as did scores of people who lived near the site. Several lawsuits have been filed in the aftermath.
Officials in Paulsboro said their emergency management officers were in Washington for Tuesday's hearings. Those officials did not immediately return messages.
Conrail issued a statement saying it takes the findings and recommendations seriously and "will implement all appropriate measures." The company also says it is doing more to work with first responders.
Tuesday's report found that the accident could have been prevented.
The NTSB concluded there had been troubles reported on the bridge 23 times in the year before, including 11 times in the month before. The complaints began soon after Superstorm Sandy brought high winds to the area.
In the weeks before the accident, a consultant called in by Conrail had recommended keeping the bridge in its locked position — leaving it open to trains but closing the creek below to boat traffic.
Conrail did not heed the advice, according to the report.
When the train that derailed approached and the bridge swung into its closed position, signal lights remained red, telling the train crew not to proceed.
The conductor got out and inspected the tracks and reported that they were locked into position. A dispatcher told the train operator to cross the bridge despite the red signal light.
The NTSB found that the conductor had inadequate training and did not recognize that the rails were not properly locked. The board recommended changes in training and operations to prevent similar problems.
Sumwalt praised the NTSB staff and board for not simply faulting the conductor. "We've hit the systemic level of this," he said.
The board found deep problems in the emergency response, too:
—Paulsboro's state-required emergency management plan was two years overdue, and the state did not have a strong way to make sure local plans were up to date.
—The fire chief set the initial command station near the leak despite the advice of hazardous materials experts.
— Emergency workers went to the leak without proper protective equipment.
— Emergency management officers on the scene failed to use software to model where the chemical might spread even though it's widely available, including for free from the federal government.
—The New Jersey Department of Environmental Protection reported that the danger had dissipated though there was no evidence that was the case. DEP Spokesman Larry Hajna said Tuesday that he recalled the agency saying the cloud had moved but not that the danger had dissipated.
—Conrail did not give emergency responders details about the chemicals on the train and how they should be handled for more than three hours after the derailment.
The report found that the equipment damage cost $450,000 and the response tally was $30 million.
"If anyone believes that it's too expensive to do things safely," Sumwalt said. "I think this accident is a good example that safety does pay."