National

Transportation

Safety Board

Derailment of Norfolk Southern Railway Company Train 

68QB119 with Release of Hazardous Materials and Fire

New Brighton, Pennsylvania

October 20, 2006

railroad 

ACCIDENT REPORT

NTSB/RAR-08/02

PB2008-916302

National

Transportation

Safety Board

Railroad Accident Report

Derailment of Norfolk Southern Railway Company Train 68QB119 

with Release of Hazardous Materials and Fire

New Brighton, Pennsylvania

October 20, 2006

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

NTSB/RAR-08/02

PB2008-916302

Notation 7853A

Adopted May 13, 2008
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National Transportation Safety Board. 2008. Derailment of Norfolk Southern Railway Company Train 

68QB119 with Release of Hazardous Materials and Fire, New Brighton, Pennsylvania, October 20, 2006.

Railroad Accident Report NTSB/RAR-08/02. Washington, DC.

Abstract: About 10:41 p.m. eastern daylight time on Friday, October 20, 2006, Norfolk Southern Railway 

Company train 68QB119, en route from the Chicago, Illinois, area to Sewaren, New Jersey, derailed while 

crossing the Beaver River railroad bridge in New Brighton, Pennsylvania. The train consisted of a threeunit locomotive pulling 3 empty freight cars followed by 83 tank cars loaded with denatured ethanol, 

a flammable liquid. Twenty-three of the tank cars derailed near the east end of the bridge, with several 

of the cars falling into the Beaver River. Of the 23 derailed tank cars, about 20 released ethanol, which 

subsequently ignited and burned for about 48 hours. Some of the unburned ethanol liquid was released 

into the river and the surrounding soil. Homes and businesses within a seven-block area of New Brighton 

and in an area adjacent to the accident were evacuated for 2 days. No injuries or fatalities resulted from 

the accident. The Norfolk Southern Railway Company estimated total damages to be $5.8 million.

The safety issues identified in this accident are ultrasonic rail inspection and rail defect management, 

oversight of the internal rail inspection process and requirements for internal rail inspection, and the 

placement of hazardous materials cars in trains for crew protection.

As a result of its investigation of this accident, the National Transportation Safety Board makes 

recommendations to the Federal Railroad Administration, the Pipeline and Hazardous Materials Safety 

Administration, and the Norfolk Southern Railway Company
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Contents

Acronyms and Abbreviations....................................................................................... v

Executive Summary ....................................................................................................... vi

Factual Information .........................................................................................................1

Accident Synopsis ...................................................................................................................1

The Accident ............................................................................................................................1

Emergency Response ..............................................................................................................3

Postaccident Site Inspection...................................................................................................5

Injuries.......................................................................................................................................6

Damages ...................................................................................................................................6

Tank Car Damages .............................................................................................................6

Track and Structure Damages ..........................................................................................7

Monetary Damages ............................................................................................................7

Personnel Information............................................................................................................7

Accident Train Engineer....................................................................................................7

Accident Train Conductor.................................................................................................7

NS Track Supervisor ..........................................................................................................7

NS Assistant Track Supervisor.........................................................................................8

Sperry Ultrasonic Rail Inspection Chief Operator.........................................................8

Work/Rest History .................................................................................................................8

Toxicological Information .....................................................................................................9

Meteorological Information...................................................................................................9

Site Description........................................................................................................................9

Track.....................................................................................................................................9

Signals ................................................................................................................................10

Bridge .................................................................................................................................10

Postaccident Inspections ......................................................................................................11

Signal Inspection...............................................................................................................11

Mechanical Inspection .....................................................................................................11

Track and Rail Inspection.....................................................................................................12

NS Track Inspection and Maintenance History...........................................................14

NS Internal Rail Inspection History...............................................................................15

Rail Inspection Requirements ........................................................................................16

Federal Oversight of Track and Rail Inspections.........................................................18

Placement of Hazardous Materials Cars in Trains ...........................................................18

Hazardous Materials Information ......................................................................................21

Ethanol Shipments by Rail ..............................................................................................21

Tests and Research ................................................................................................................22

Examination of Recovered Rail ......................................................................................22

Ultrasonic Inspection of Recovered Rail .......................................................................23

Rail Profile Measurements ..............................................................................................24
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Transverse Defect Growth Rate......................................................................................25

Derailments Caused by Broken Rail..............................................................................26

Other Information .................................................................................................................27

NS Postaccident Actions .................................................................................................27

FRA Postaccident Actions ...............................................................................................27

Beaver County Postaccident Actions.............................................................................28

NS Disaster Preparedness ...............................................................................................28

Previous Safety Board Action Regarding Internal Rail Inspections .........................28

Analysis............................................................................................................................31

Exclusions ...............................................................................................................................31

The Accident ..........................................................................................................................31

Rail Defects and Ultrasonic Inspection ..............................................................................32

Rail Defect Management ......................................................................................................35

Placement of Hazardous Materials Cars in Trains for Crew Protection.......................38

Conclusions.....................................................................................................................40

Findings ..................................................................................................................................40

Probable Cause ......................................................................................................................41

Recommendations..........................................................................................................42

Appendixes

A: Investigation................................................................................................................45

B: Emergency Response Timeline..................................................................................46
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Acronyms and Abbreviations

AAR Association of American Railroads

CFR Code of Federal Regulations

CSX CSX Corporation

DOT U.S. Department of Transportation 

F Fahrenheit 

FRA Federal Railroad Administration 

mgt million gross tons 

MW&S Maintenance of Way and Structures

NS Norfolk Southern Railway Company 

PHMSA Pipeline and Hazardous Materials Safety Administration 

psi pounds per square inch

RSAC Rail Safety Advisory Committee 

Sperry Sperry Rail Service 

Transcaer Transportation Community Awareness and Emergency 

Response

TTCI Transportation Technology Center, Inc.

UP Union Pacific Railroad 
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Executive Summary

About 10:41 p.m. eastern daylight time on Friday, October 20, 2006, Norfolk 

Southern Railway Company train 68QB119, en route from the Chicago, Illinois, area 

to Sewaren, New Jersey, derailed while crossing the Beaver River railroad bridge 

in New Brighton, Pennsylvania. The train consisted of a three-unit locomotive 

pulling 3 empty freight cars followed by 83 tank cars loaded with denatured 

ethanol, a flammable liquid. Twenty-three of the tank cars derailed near the east 

end of the bridge, with several of the cars falling into the Beaver River. Of the 

23 derailed tank cars, about 20 released ethanol, which subsequently ignited and 

burned for about 48 hours. Some of the unburned ethanol liquid was released into 

the river and the surrounding soil. Homes and businesses within a seven-block 

area of New Brighton and in an area adjacent to the accident were evacuated for 

2 days. No injuries or fatalities resulted from the accident. The Norfolk Southern 

Railway Company estimated total damages to be $5.8 million.

The National Transportation Safety Board determines that the probable 

cause of the derailment of Norfolk Southern Railway Company train 68QB119 

was the Norfolk Southern Railway Company’s inadequate rail inspection and 

maintenance program that resulted in a rail fracture from an undetected internal 

defect. Contributing to the accident were the Federal Railroad Administration’s 

inadequate oversight of the internal rail inspection process and its insufficient 

requirements for internal rail inspection.

As a result of its investigation of this accident, the Safety Board identified 

the following safety issues:

• Ultrasonic rail inspection and rail defect management, 

• Oversight of the internal rail inspection process and requirements for 

internal rail inspection, and

• The placement of hazardous materials cars in trains for crew 

protection.

As a result of its investigation of this accident, the National Transportation 

Safety Board makes recommendations to the Federal Railroad Administration, 

the Pipeline and Hazardous Materials Safety Administration, and the Norfolk 

Southern Railway Company.
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Factual Information

Accident Synopsis

About 10:41 p.m. eastern daylight time on Friday, October 20, 2006, 

eastbound1 Norfolk Southern Railway Company (NS) train 68QB119, en route 

from the Chicago, Illinois, area to Sewaren, New Jersey, derailed while crossing the 

Beaver River railroad bridge on main track 1 near a milepost designated PC 29.262

in New Brighton, Pennsylvania. The train consisted of a three-unit locomotive 

pulling 3 empty freight cars followed by 83 tank cars loaded with denatured 

ethanol, a flammable liquid. Twenty-three of the tank cars, the 23rd through 45th, 

derailed near the east end of the bridge, with several of the cars falling into the 

Beaver River. (See figure 1.) Of the 23 derailed tank cars, about 20 released ethanol, 

which subsequently ignited and burned for about 48 hours. Some of the unburned 

ethanol liquid was released into the river and the surrounding soil. Homes and 

businesses within a seven-block area of New Brighton and in an area adjacent to 

the accident were evacuated for 2 days. No injuries or fatalities resulted from the 

accident. The NS estimated total damages to be $5.8 million.

The Accident

The train originated on October 18, 2006, on the Union Pacific Railroad (UP) 

in Eagle Grove, Iowa, as UP train UEEBNF-16. The UP train was interchanged 

to the NS at the UP’s Proviso Yard near Chicago, Illinois, and became NS train 

68QB119 destined for Sewaren, New Jersey. The train was considered a “relay” (runthrough) train because it would remain intact with the equipment as interchanged 

from the UP in Chicago.

After an initial terminal air brake test and equipment inspection, the accident 

train departed Chicago at 11:30 p.m. on October 19, 2006. At Elkhart, Indiana, the 

first NS crew change point, an NS locomotive unit equipped with cab signals was 

added to the head of the train.3 At that point, the train had 3 locomotive units, 3 

empty freight cars, and 83 DOT-111A general service tank cars containing ethanol. 

It had a trailing tonnage of 10,745 tons and a length of 5,327 feet. The train consist 

remained unchanged.

1 In this report all train movements and track references will refer to timetable direction. 

2 The track milepost numbering increases in the westward direction. 

3 Cab signal units display the governing signal indication in the cab of the locomotive. The territory where 

the accident occurred utilized cab signals; it was not equipped with wayside signals except at control points. 
Factual Information

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The two-person (engineer and conductor) train crew went on duty in 

Toledo, Ohio, at 2:30 p.m. on October 20. They boarded the train at 4:20 p.m. and 

departed Toledo at 4:30 p.m. 

The crew described their trip as normal up to and including the time the 

head end of the train, which was being operated under a clear4 signal indication, 

traversed the NS bridge spanning the Beaver River in New Brighton, Pennsylvania. 

The engineer stated that about 200 yards after his locomotive came off the east end 

of the bridge, his cab signal indication went from clear to approach.5 The engineer had 

been using braking to control the train’s speed. He said that his train had traveled 

another 200 to 300 yards when the train’s brakes activated with an emergency 

application. According to the locomotive event recorder, this occurred about 

10:41:23 p.m. while the train was traveling 37 mph. At 10:41:57 p.m., based on the 

event recorder speed data, the train came to a complete stop. The locomotive came 

to rest about a half mile past the east end of the Beaver River bridge. The crew said 

they did not see or feel any irregularities before the emergency brake application.

The crewmembers said that they were not immediately aware that a 

derailment had occurred, but that they saw a bright flash toward the rear of their 

train. Using the locomotive radio, the engineer contacted the NS Cleveland Line

4 A clear indication signals the engineer to proceed not exceeding normal speed (maximum authorized 

speed). 

5 An approach indication signals the engineer to proceed prepared to stop at the next signal. 

Figure 1. View of derailment. NS train 68QB119 was traveling from left to right.
Factual Information

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dispatcher and said, “We got a fire here ... I think we had an explosion.” The 

dispatcher told the crew to evacuate the area, after which the two crewmembers 

walked eastward until they were about 1/2 mile away from the head of the train. 

At 10:45 p.m., the engineer called 911 from his cell phone and reported that he had 

a train with 80 cars of ethanol and that there had been an explosion. He reported 

that the train was on the bridge just west of New Brighton. The conductor used his 

cell phone to call the NS supervisor of train operations.

After providing hand-written statements to NS officials, the crewmembers 

were transported to Heritage Valley Health Systems Medical Center in Beaver, 

Pennsylvania, where they were tested for drugs and alcohol in accordance with 

Federal Railroad Administration (FRA) postaccident requirements. The train crew 

was relieved at 2:29 a.m. on October 21, 2006, and went off duty at 3:52 a.m.

Emergency Response

The Beaver County Emergency Services Center received the first 911 

notification of the accident at 10:42 p.m. from an unidentified cell phone caller. 

The caller reported that a train had derailed off the bridge into the river and that 

there was a massive fire. The New Brighton Borough fire chief was at a nearby 

residence; he stated that he heard two large “swooshes” and responded to the area 

immediately.

At 10:45, the 911 operator received the call from the train engineer reporting the 

explosion. At 10:47 p.m., the NS Cleveland Line dispatcher called the New Brighton 

area 911 to report a train on fire just east of Beaver Falls; the 911 operator advised 

that emergency response personnel were already responding to the accident (a total 

of 158 calls were received within a short time of the accident). At 10:52 p.m., the NS 

police communications center confirmed the notification with the 911 operator and, 

at 11:05 p.m., faxed a copy of the train consist to the Emergency Services Center. The 

NS assistant division superintendent was notified, and he responded to the incident 

command post with the train consist. He arrived on scene about 11:30 p.m.

Emergency responders established a command post, staging area, rehab 

area,6 and accountability group7 in the accident vicinity. New Brighton fire and 

police department personnel went door-to-door and evacuated persons in New 

Brighton. In Beaver Falls, emergency responders evacuated residents of Bridge 

Street. The initial evacuation zone in New Brighton was from the river to 5th Street 

and 5th Avenue. This zone was subsequently expanded from the river to 8th Street 

and 7th Avenue. The evacuation was estimated to have affected about 150 people. 

Evacuees were directed to the First Methodist Church, the New Brighton Middle 

School cafeteria, or the Patterson Township Fire Department. (See figure 2.)

6 The rehab area is a location where responders can get rest, food, and drink.

7 The accountability group was responsible for tracking personnel coming into and out of the accident 

area.
Factual Information

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The incident commander suspended railroad traffic on the CSX Corporation 

(CSX) tracks north and across the river from the derailment site. The tracks were 

returned to operation at 10:00 a.m. on Saturday, October 21.

Firefighters staged in a parking lot near the north (railroad west) end of the 

bridge. From this position, they did not have a good view of the cars that fell off the 

bridge. Firefighters began defensive operations by setting up water supply lines 

and applying an unmanned fog spray to the house nearest to the bridge because of 

the heat generated by the fire. Water streams were not immediately sprayed onto 

the railcars because of concerns about the cars’ structural integrity.

Overnight, fire command decided to continue defensive operations, 

monitor conditions, and allow the fires to burn overnight. On Saturday morning, 

October 21, two teams consisting of firefighters and railroad hazardous materials 

responders (including NS contractors and NS environmental protection and 

hazardous materials personnel) entered the accident area to assess the condition 

of the site and the tank cars.

Wreck clearing and off-loading of ethanol from some tank cars began 

Saturday evening. By Sunday morning, October 22, wrecking crews had removed 

eight cars from the riverbank and eight cars from the track area. All fires were 

extinguished by 11:15 p.m. on Sunday. On Monday morning shortly after 9:00 a.m., 

Figure 2. Limits of New Brighton evacuation area.
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emergency response activities were concluded, and residents were allowed to 

return to their homes. The last derailed car had been removed by 12:50 p.m. 

Of the 660,952 gallons of ethanol that had been loaded into the 23 derailed 

tank cars, about 175,674 gallons were recovered. About 485,278 gallons of 

product were estimated to have been released. A January 2007 report prepared 

by the environmental consulting firm ENSR Corporation and submitted to the 

Pennsylvania Department of Environmental Protection on behalf of the NS stated 

that the fire consumed most of the ethanol released, and that the exact volume of 

ethanol released to the soil or into the Beaver River could not be determined. The 

report also stated that any release into the Beaver River did not result in observable 

negative effects such as fish kills or sheen on the river, and no downstream water 

treatment facilities were affected. The Department of Environmental Protection 

approved the report on January 31, 2007.

Postaccident Site Inspection

Safety Board investigators found no track anomalies or evidence of dragging 

equipment west of the location between a destroyed track section near milepost 

PC 29.26 and milepost PC 30.5 on main track 1. Based on the footprint8 of the 

derailment, investigators determined the point of derailment to be the north rail at 

milepost PC 29.26. At this location, investigators found pieces of broken rail under 

the last derailed car, some of which exhibited markings consistent with rail-end 

batter.9 A total of seven segments of broken rail were recovered east of milepost PC 

29.26 and sent to the Safety Board’s Materials Laboratory for further examination. 

(The results of these examinations are detailed in the “Tests and Research” section 

of this report.) Five rail defects described as “detail fracture from shelling”10 (also 

called a shell crack) were visibly evident on the fracture faces of the rail head 

segments. (See figure 3.)

8 The footprint included visible evidence such as marks on the ties, marks on the track components and 

rails, and car and truck component positions and conditions.

9 Batter is the deformation of the surface of the rail head, usually close to the end of the rail. Receiving 

rail-end batter is a deformation of the rail head caused when an oncoming wheel strikes the rail end. Trailing 

rail-end batter deformation occurs when the wheel rolls over and off the rail head end.

10 The Sperry Rail Service Rail Defect Manual defines a detail fracture from shelling as a progressive 

fracture (fatigue crack) starting from a longitudinal separation close to the running surface of the rail head, 

then turning downward to form a transverse separation substantially at right angles to the running surface. 

Shelling is surface cracking by metal fatigue near the gage corner caused by repetitive shearing stresses. It is 

a progressive separation that may crack out at any level on the gage side of the rail but generally at the gage 

corner. 
Factual Information

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Injuries

No injuries occurred as a result of the accident.

Damages

Tank Car Damages

Safety Board investigators inspected the derailed ethanol tank cars after 

they had been moved to a work site adjacent to the tracks in New Brighton’s Big 

Rock Park. Of the 23 tank cars that derailed, 12 lost their full loads of about 28,700 

gallons of ethanol. Eight other tank cars lost partial loads ranging from 20 gallons 

to 27,613 gallons. 

Twelve tank cars received extensive shell damage, including eight tank cars 

that fell from the bridge following the derailment and lost their entire contents. 

Heat from the fire caused one additional tank car to overpressurize and rupture. 

Eight additional cars lost product from their fittings, valves, and connectors during 

the fire following the derailment.

Figure 3. Recovered rail showing detail fracture from shelling in head area.
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Track and Structure Damages

The east bridge spans of both tracks sustained minor damage to the steel 

supporting structures and substantial damage to the concrete supporting decks. 

About 990 feet of tracks 1 and 2 were destroyed.

Monetary Damages

The NS estimated monetary damages from the accident as $1,985,000 for 

the damaged tank cars; $882,919 for track, structures, and signals; and $354,432 for 

nonhazardous materials derailment cleanup. The estimated cost of lost product/

lading, emergency response/remediation, environmental site remediation, and 

incidental costs was $2,546,304. These estimated damages totaled $5,768,655.

Personnel Information

Accident Train Engineer

The accident train engineer began service as a brakeman with Conrail on 

May 17, 1999, and transferred to the NS on June 1, 1999. He became an engineer 

on October 20, 2002, and had 4 years’ experience as an engineer at the time of the 

accident. On his last rules examination, in May 2003, he was commended for a 

perfect score. He passed his last engineer’s certification on March 7, 2006. He was 

assigned to the extra list11 working from Conway yard.

Accident Train Conductor

The accident train conductor had 4 years of service. He started with the 

NS on October 3, 2002, and was promoted to conductor on April 10, 2003. He was 

assigned to work between Conway yard and Toledo, Ohio. He estimated that he 

had made between 200 and 300 round trips between Conway yard and Toledo 

without incident.

NS Track Supervisor

The NS track supervisor at Conway, Pennsylvania,12 was the NS front line 

manager responsible for track maintenance and inspection on the portion of the 

territory where the accident occurred. The NS track supervisor at Conway began 

working with the Penn Central Railroad in 1972 as a track laborer and stayed in 

11 The extra list, or extra board, is a pool of employees assigned to jobs as needed either to substitute for a 

regular employee who is unavailable for duty or to serve as a crewmember on an unscheduled assignment.

12 Conway yard is about 6 miles south of New Brighton and is a major NS train yard terminal and 

maintenance facility.
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that job for about 2 years. He then worked as a track foreman and an assistant 

supervisor. He was promoted to track supervisor at Wellsville, Ohio, in 1976 

and at Conway in 1984. Beginning in 1992, he worked in assets management and 

projects for about 5 years. When the NS purchased Penn Central Railroad assets 

from Conrail in the late 1990s, he was reassigned as an assistant track supervisor 

and in November 2004 was promoted to track supervisor at Conway.

NS Assistant Track Supervisor

The NS assistant track supervisor at Conway had inspected the track in the 

accident area on the day of the accident. The assistant track supervisor had 14 years 

of railroad experience, having started working for Conrail on April 26, 1992. He 

worked various positions in the track department, beginning with track laborer, 

then assistant foreman and foreman. After he completed an NS supervisory 

training program in 2004, he was promoted to assistant track supervisor in 

Danville, Virginia. In April 2006, he was promoted to assistant track supervisor 

at Conway. The position required him to perform FRA-required track and switch 

inspections.

Sperry Ultrasonic Rail Inspection Chief Operator

The Sperry Rail Service (Sperry) chief operator, who had conducted the last 

ultrasonic rail inspection before the accident,13 started work with the company on 

June 22, 2002. After 28 weeks of on-the-job training, he completed a corporate track 

safety certification course during which he continued his training on actual railroad 

tracks. He then worked for 2 years with a qualified operator to gain additional 

experience. He passed the operator’s examination in 2003 and passed the chief 

operator’s examination in 2004. In September 2004, after completing 40 hours of 

training at Sperry’s offices in Danbury, Connecticut, he obtained his ultrasonic 

level one certification.14 He became a chief operator in June 2005.

Work/Rest History

Safety Board investigators developed a 96-hour work/rest history for both 

the engineer and the conductor. The investigation determined that at the time of 

the accident, the engineer had been on duty for 8 hours 11 minutes and had been 

continuously awake for a little more than 14 hours. The conductor was determined 

to have been on duty for about 8 hours 11 minutes when the accident occurred and 

had been continuously awake for about 11 hours 41 minutes.

13 Sperry had contracted with the NS to conduct an internal inspection of the accident track in 2006.

14 The American Railway Engineering and Maintenance of Way Association Committee 4, Rail, 

recommends that operators achieve this certification to learn basic knowledge of ultrasonic/nondestructive 

testing.
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Toxicological Information 

In accordance with 49 Code of Federal Regulations (CFR) Part 219, 

Subpart C, “FRA Post-Accident Toxicological Testing,” toxicological specimens 

were obtained from the engineer and the conductor of train 68QB119. The tests 

screened for substances including cannabinoids, cocaine, opiates, amphetamines, 

methamphetamines, phencyclidine, barbiturates, benzodiazepines, and ethyl 

alcohol. For both the engineer and the conductor, the results were negative for the 

presence of any of the tested drugs or for alcohol.

Meteorological Information

The closest weather stations to the accident site were Pittsburgh International 

Airport—about 23 miles south of New Brighton with weather data from 10:51p.m.—

and the Beaver County Airport—about 5 miles northwest of New Brighton with 

weather data from 8:49 p.m. The stations recorded 7 miles visibility, winds calm to 

6 knots from the west-southwest, mostly cloudy skies, and a temperature of about 

42° Fahrenheit (F).

Site Description

The accident occurred in New Brighton, Pennsylvania, on the NS bridge 

over the Beaver River about 26 miles northwest of Pittsburgh, Pennsylvania. The 

2004 United States Census showed a population of 17,231 for New Brighton and 

the area surrounding the derailment.

Track

The derailment occurred on the NS Pittsburgh Division’s Fort Wayne 

Line on track 1 about milepost PC 29.26. This portion of the Fort Wayne Line had 

double main-line tracks. The NS designated this segment as a “key route.”15 It 

was maintained to Class 4 track standards with a maximum authorized timetable 

speed of 50 mph for freight trains and 79 mph for passenger trains. 

The NS tracks are located on a fill between the New Brighton business 

district and a community park adjacent to the Beaver River. The CSX Pittsburgh 

Subdivision tracks are located on the west side of the Beaver River and cross under 

the NS tracks north of New Brighton. The NS Youngstown Line is located north of 

15 The Association of American Railroads defines a key route as “any track with a combination of 10,000 

car loads or intermodal portable tank loads of hazardous materials, or a combination of 4,000 car loadings of 

[poisonous inhalation hazard] or [toxic inhalation hazard] (Hazard zone A, B, C, or D), anhydrous ammonia, 

flammable gas, Class 1.1 or 1.2 explosives, environmentally sensitive chemicals, [spent nuclear fuel], and 

[high-level radioactive waste] over a period of 1 year.” 
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New Brighton on the east side of the Beaver River, and it connects to the NS main 

tracks east of New Brighton. East of the bridge was a tunnel, PC-29.2, over the NS 

Youngstown Line, which was not damaged or involved in the accident, but the 

derailed cars also spanned the tunnel.

NS records for the full length of track 1 showed that the line carried 63.5 

million gross tons (mgt) per year. About 70 NS freight trains and 2 scheduled 

Amtrak passenger trains operated daily over the accident portion of the Fort 

Wayne Line. The NS estimated that about 29 mgt had moved across the accident 

area in the 6 1/2 months preceding the accident.

The track structure conformed to NS standards for continuous welded rail 

on timber ties. It was anchored every other tie, fastened to steel tie plates with two 

rail-holding spikes and one tie-holding spike per tie plate, and it had about 23 

inches of ballast from the bottom of the tie to the top of the concrete bridge deck. 

The rail was 140-pound continuous welded rail rolled in 1976 and installed in 

1977.

Investigators took track geometry measurements of track 1 at 14 stations. 

Measurements were taken every 15.5 feet starting at the identified point of 

derailment, milepost PC 29.26, and continued west, and no exceptions were 

noted.

Signals

Train movements through the area of the derailment were governed by 

signal indications of a traffic control system controlled by a computer-aided train 

dispatching facility under the direction of the NS Cleveland Line train dispatcher at 

Greentree, Pennsylvania. The system primarily used cab signals (signal indications 

displayed in the cab of a train’s lead locomotive unit); no wayside signals were 

present except at control points.

Bridge

The NS Beaver River bridge is a 10-span steel and concrete-ballasted 

deck bridge that spans both the river and the CSX railroad tracks. The top of 

the rail is about 35 feet above the river. The 1,314-foot-long bridge was built for 

the Pennsylvania Railroad in 1926 by the Mount Vernon Bridge Company. Two 

parallel bridge structures support a double main track with the track on the south 

side of the bridge designated track 1 and the track on the north side designated 

track 2. The train derailed at the eastern end of the bridge where the two main 

tracks that cross the bridge begin curving away from each other on separate bridge 

spans. (See figure 4.)
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Postaccident Inspections

Signal Inspection

Investigators examined signal system data, cab signal equipment from 

the lead locomotives, and dispatching logs. No exceptions were noted, and 

postaccident testing of the signal system indicated that the system was working as 

designed and that the clear and approach signals received by the locomotive before 

the derailment were the correct signals for the conditions.

Signal systems utilize the rails as conduits for electrical circuits. Therefore, 

a signal system may detect a broken rail if the rail ends are separated and the 

discontinuity does not occur where a track component such as a tie plate could 

bridge the discontinuity. In this case, the signal system did not detect a discontinuity 

in the rail before the accident.

Mechanical Inspection

The accident train passed a wheel impact load detector near Vine Creek, 

Indiana, about 347 miles west of New Brighton. The detector measures the impact 

of each wheel on the rail and compares impacts between wheels for shifted loads. 

No exceptions were noted, and all wheel impact forces were determined to be 

within NS tolerances.

Figure 4. View of derailment showing track layout and curved track.
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The train passed a hotbox16 and dragging equipment detector at 10:04 p.m., 

about 37 minutes and 21 miles before the accident. No exceptions were noted. At 

10:39 p.m., about 2 minutes and 1.3 miles before the derailment, the train passed 

another hotbox and dragging equipment detector, again with no exceptions 

noted. 

The derailment separated the train into three sections. The first section 

comprised the 3 locomotive units and the first 22 nonderailed cars; the second was 

made up of the 23 derailed cars; the third section was the rear 41 nonderailed cars. 

After the accident, the NS moved the first section about 6 miles to Conway yard 

and moved the rear section westward to Beaver Falls.

Safety Board investigators inspected the 3 locomotives and the first 22 

nonderailed cars at the NS Conway yard. The units were used to supply air for 

a service air brake application measurement. A 27-psi (pounds per square inch) 

reduction was made on the 90-pound train line brake pipe, and each car’s piston 

travel was measured. All measurements met FRA requirements. The Safety Board 

investigators then inspected the 41 nonderailed cars at Beaver Falls in the same 

manner and did not find any significant defects.

Track and Rail Inspection

Two types of inspections will be discussed in this section: track inspections 

and internal rail inspections. The track inspections are visual inspections that look 

at the track structure (including ballast, crossties, track assembly fittings, and the 

physical conditions of rails), the roadbed and areas immediately adjacent to the 

roadbed, and the track geometry to determine whether these meet Federal and 

company requirements. Track inspections are to be made on foot or by riding 

over the track in a vehicle at a speed that allows the person making the inspection 

to visually inspect the track structure. Mechanical, electrical, and other track 

inspection devices may be used to supplement visual inspections.

Railroads inspect rail for internal defects using ultrasonic and induction 

inspection devices either on a specialized inspection vehicle or manually using 

handheld equipment. In ultrasonic inspection, a transducer emits ultrasonic sound 

waves that penetrate the rail from various angles. Rail defects, such as cracks in 

the steel, and rail features17 will normally reflect the sound waves back to the 

transducers, and the reflected signals are displayed on a monitor. The equipment 

operator assesses these reflected signals to identify the cause of the reflection, which 

could be a crack or other rail defect or a rail feature. In induction inspection, coils 

moving along the rail at a fixed distance above the rail head detect and measure 

any distortion within the magnetic field, and this distortion is then assessed by the 

equipment operator.

16 A hotbox is an overheated wheel axle bearing on a railcar.

17 Rail features include bolt holes, welds, and joint bars.
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Railroads and rail inspection contractors typically use similar ultrasonic 

inspection equipment, although differences exist in data processing speed, the 

presentation of information, and vehicle configuration and setup. During these 

inspections, data from transducers and induction coils are assessed by the 

equipment operator. If the operator considers an indication suspect, the inspection 

vehicle is stopped and backed up to the location of the indication. The operator 

may then exit the vehicle and inspect the rail by hand using an inspection set 

mounted on the rear of the car. If a defect is confirmed, it is marked, and a rail 

work crew following the inspection car can repair or remove the defective rail 

or ensure that the area is protected.18 Detail fractures from shelling are difficult 

to detect using these inspection methods because shelling can impede both the 

transfer of ultrasonic signals into the specimen and the reflection of the signals 

back to the detector. Other rail conditions, such as head checks19 and spalling,20

and the presence of excess rail lubricants also impede the detection of rail defects.

Sperry representatives said that hand inspection may be more likely to 

detect a detail fracture from shelling. When performing a hand inspection with 

a 70° transducer, the operator may be able to orient the transducer sufficiently 

to get signal penetration underneath some of the surface condition. The vehicle 

performing the inspection does not have the capability to orient the transducer in 

this way.

In 1999, the Transportation Technology Center, Inc., (TTCI) conducted 

a controlled study of rail flaw detection technology.21 Six inspection vehicles 

representing a variety of manufacturers were tested on rail with various types and 

sizes of known defects. The study found that the overall probability of detecting a 

flaw increased with increasing flaw size. (See table 1.) 

Table 1. Probability of defect detection.a

Defect Size (as % of Rail Head) Probability of Detecting Defect

5 58%

10 68%

25 85%

> 60 > 95%

a

 Values from Jeffrey and Peterson, 1999, graph 8.

18 Depending on the type of rail defect identified, protection can include rail replacement, application of 

joint bars, operating speed restriction, or re-inspection of the rail at regular intervals.

19 Head checks are small hairline cracks in the gage (inside) corner of the rail head. 

20 Spalling is the breaking out of metal pieces from the gage corner of the rail head. 

21 B.D. Jeffrey and M.L. Peterson, Assessment of Rail Flaw Inspection Data, Colorado State University, 

disseminated under sponsorship of the U.S. Department of Transportation, University Transportation Centers 

Program, August 1999.
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NS Track Inspection and Maintenance History

Safety Board investigators reviewed the NS track inspection records for 

the track segment between mileposts PC 20.4 and PC 34.5 for the period from 

June 1, 2006, to October 20, 2006. Records showed that the inspection frequency 

complied with the FRA Track Safety Standards.22

The accident track had been visually inspected by an NS track inspector in 

a hy-rail inspection vehicle23 earlier on the day of the accident. No track defects 

were noted on the inspection record. The track had been inspected with a track 

geometry vehicle24 on October 2, 2006, with no track geometry defects noted for 

track 1 on the bridge.

The most recent track work in the accident area included rail head grinding 

(using rotating grinding wheels to remove metal from the rail head) on April 9, 2006, 

and track surfacing, adjusting alignment, and leveling on October 10, 2006. 

Rail grinding is a technique used to control rail profile and manage wheel/

rail contact stresses. A rail car wheel rolls on a small contact area of the rail head, 

and this type of contact loading can lead to rail surface conditions such as head 

checks, spalling, flaking,25 and shelling. While these surface conditions are not 

considered defects, they can serve as features that initiate internal defects, such 

as transverse defects,26 and can impede the detection of internal defects during 

internal rail inspections. Detail fractures from shelling are particularly susceptible 

to detection problems during ultrasonic inspections, because the shelling from 

which this type of detail fracture initiates can impede the penetration and return 

of sound waves through the rail head. Rail grinding is intended to control these 

rail surface conditions so they will not lead to internal rail defects and rail 

failures.

The NS monitored the rail profiles at several sites of a test route27 (the 

derailment area was not part of the test route). The NS found that rails that were 

subjected to corrective rail grinding experienced a dramatic increase in wear 

immediately after each rail-grinding event but returned to a steady wear rate after 

a short time. The NS determined that too much metal was being removed from the 

22 The FRA “Track Safety Standards” (49 CFR 213.233) require that Class 4 track be inspected at least 

twice weekly with a specified interval between inspections.

23 A hy-rail vehicle, or hy-rail, is a truck that has flanged wheels attached to the front and rear so it can 

travel over railroad tracks and easily get on or off the track at a road crossing.

24 Track geometry vehicles are capable of a continuous loaded measurement of gage, track cross level, 

track alignment, track warp, and ride quality.

25 Flaking is a progressive separation of small, thin pieces of the running surface, often near the gage 

corner. 

26 Transverse defects are progressive cracks oriented perpendicular to the length of the rail. 

27 Stephen S. Woody, “Applying Quality Concepts to the Wheel/Rail Interface,” Interface: The Journal of 

Wheel/Rail Interaction, October 2007, http://www.interfacejournal.com/features/10-07/quality/1.html, accessed 

on October 2, 2007.
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rail head during the grinding operations. The excessive grinding was removing 

the work-hardened layer of the rail, resulting in as-ground rail profiles that were 

not stable.

In 2006, the NS began work to stabilize the rail profiles on its system by 

prioritizing routes and determining a grinding frequency. It also began using 

a rail profile measuring system to perform pregrind inspections and to select a 

grinding pattern that would produce the best finished profile without removing 

the work-hardened layer. The track supervisor responsible for track maintenance 

in the derailment area said he did not notice an increase in rail defects after the rail 

in that area was ground.

NS Internal Rail Inspection History

The NS contracted with Sperry to inspect track 1 for internal rail defects four 

times per year, or an interval of about 16 mgt between inspections. This inspection 

frequency was determined based on a point system model developed for the NS 

that takes into account track speed, annual tonnage, whether or not hazardous 

materials are transported over the route, whether the territory is signaled or 

nonsignaled, rail weight and age, curvature, and rail defect/failure history.

An April 27, 2005, letter from the NS had informed Sperry of the 

implementation of new inspection procedures for the detection of vertically 

oriented rail head defects. The NS letter stated that “vertically oriented longitudinal 

rail head defects can be classified into two types: vertical split heads[28] and shear 

breaks[29],” which, the letter stated, are similar in appearance.

The new NS procedure for detecting vertical defects included the following 

point:

Any rail tested that does not encompass an area where a switch component 

or track structure is present (point, frog, etc.), and produces a zero degree 

ultrasonic loss of bottom equipment response [indicating less than full 

vertical signal penetration] exceeding five feet in length or greater [Emphasis 

added], alone or in conjunction with another test channel, is to be repeated 

(rerun) by the detector car operator. All efforts are to be made to clear any 

equipment responses of this nature that are caused by alignment or foreign 

matter (grease, snow debris, etc.). 

28 A vertical split head is a progressive longitudinal fracture in the head of the rail where separation along 

an internal seam, segregation, or inclusion propagates vertically through the rail head.

29 A shear break is a longitudinal separation of the rail head typical to a rail with a sufficient amount of rail 

head material loss due to mechanical forces and is not typically associated with inherent conditions resulting 

from the manufacturing process.
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Sperry had conducted three ultrasonic/induction inspections for internal rail 

defects on the accident track in 2006 before the derailment, on January 20, April 18, 

and August 1. A fourth inspection was scheduled for November. The January 20 

inspection revealed no internal rail defects. The April 18 inspection found three rail 

defects on track 1, two of them on the bridge: one at milepost PC 29.279, and one 

at milepost PC 29.2565. The August 1 inspection, the last internal rail inspection 

before the accident, found one rail defect on track 1, at milepost PC 29.271 on the 

bridge. All of these defects were repaired the same day they were found.

According to interviews with participants, during the August 1 inspection, 

the Sperry operator stopped to confirm a rail defect at a point immediately west of 

the identified point of derailment for this accident, milepost PC 29.26. He marked 

the defect in the presence of the NS assistant track supervisor. The NS assistant 

track supervisor told Safety Board investigators that the operator hand 

inspected within about 2 feet on either side of a defect indication to verify the 

defect’s location. He said he did not recall if the rail in the derailment area 

exhibited shelling and wear.

A track repair crew, which included the local NS track supervisor, was 

following the inspection vehicle. The crew repaired the defective rail by cutting 

out a 42-foot-long rail section that included the defect and installing a replacement 

rail plug of the same length. The track supervisor said his intention was to remove 

rail that contained shop welds and some of the rail that had shelling. The east end 

of this plug abutted the rail segment that failed in this accident. The replacement 

rail was held in place with bolted joint bars until the joints could be field welded, 

which occurred on October 10, 2006.

A review of the data from the August 1, 2006, inspection for internal rail 

defects showed an intermittent loss of bottom signal as the inspection vehicle 

moved over about a 9-foot length of track 1 in the area of the derailment. The longest 

continuous loss encompassed about 7 inches of track. Sperry representatives told 

Safety Board investigators that the shelling on the rail head surface of the recovered 

rail from the area of the derailment would have interfered with the ultrasonic signal 

returning from the base of the rail, causing an intermittent loss of bottom signal. 

A review of the data showed that the location of the largest defect was within a 

2-inch area that had a loss of bottom signal in the August 1, 2006, inspection data. 

The Sperry operator stated that he did not stop the inspection vehicle to 

conduct a reinspection or to hand inspect the rails in the area of the intermittent 

loss of signal because the area of continuous loss was less than 5 feet and thus did 

not, according to NS instructions, require reinspection. 

Rail Inspection Requirements 

The FRA regulations regarding rail inspection are found at 49 CFR 213.237. 

At 49 CFR 213.237(a) (effective January 1, 1999) the FRA states that a continuous 
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search for internal defects shall be made of all rail in Classes 4 through 5 track, and Class 3 

track over which passenger trains operate, at least once every 40 million gross tons (mgt) 

or once a year, whichever interval is shorter.

The FRA’s Track Safety Standards Compliance Manual defines “continuous 

search” as an 

uninterrupted search by whatever technology is being used, so that there 

are no segments of rail that are not tested. If the test is interrupted (e.g., as a 

result of rail surface conditions that inhibit the transmission or return of the 

signal) then the test over that segment of rail is not valid because it was not 

continuous. Therefore, a non-test is not defined in absolute technical terms. 

Rather, the provision leaves this determination to the rail test equipment 

operator who is uniquely qualified on that equipment.

Title 49 CFR 213.237(d) states:

If the person assigned to operate the rail defect detection equipment being 

used determines that, due to rail surface conditions, a valid search for 

internal defects could not be made over a particular length of track, the 

test on that particular length of track cannot be considered as a search for 

internal defects under paragraph (a) of this section.

When there is a loss of the internal defect detection signal, paragraph (e) 

should be adhered to. Title 49 CFR 213.237(e) states:

If a valid search for internal defects cannot be conducted for reasons 

described in paragraph (d) of this section, the track owner shall, before the 

expiration of time or tonnage limits:

(1) Conduct a valid search for internal defects;

(2) Reduce operating speed to a maximum of 25 mph until such time as a 

valid search for internal defects can be made; or

(3) Remove the rail from service.

The staff director for the FRA Track and Structures Division told the Safety 

Board that the agency was unaware of the NS procedures allowing for a 5-foot loss 

of bottom signal during internal rail inspections. He stated that a search for defects 

that allowed this amount of complete or intermittent loss of bottom signal would 

not constitute a continuous search for defects as defined by the FRA. He stated that 

he had conducted a telephone query of other railroads and had found instructions 

similar to those of the NS concerning loss of bottom signals, with some railroads 

having a 2-foot exception to the requirement for a continuous inspection.
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The Association of American Railroads (AAR) addresses the inspection 

of rail over which hazardous materials are transported in AAR Circular OT-55-I, 

“Recommended Railroad Operating Practices for Transportation of Hazardous 

Materials.”30 Circular OT-55 was initially published on January 4, 1990, and was 

most recently modified on July 17, 2006 (version “I”). In this version, the AAR 

addresses increased rail inspections for hazardous materials routes. In its guidance 

regarding key routes, Circular OT-55-I states the following:

Main track on ‘Key Routes’ is [to be] inspected by rail defect detection and 

track geometry inspection cars or any equivalent level of inspection no less 

than two times each year; sidings are similarly [to be] inspected no less 

than one time each year, and main track and sidings will have periodic 

track inspections that will identify cracks or breaks in joint bars.

Federal Oversight of Track and Rail Inspections

FRA track inspectors conduct visual “spot checks” of actual track conditions 

in selected areas to determine whether a railroad’s track inspectors are accurately 

assessing track conditions and properly documenting them on the records of visual 

inspections. An FRA spot-check inspection over the NS main track was last conducted 

on April 18, 2006. No track defects were noted in the area of the derailment. 

The FRA reviews the documentation and reports generated from a railroad’s 

internal rail inspections to determine whether the periodic inspections are in 

compliance with FRA regulations. A railroad’s inspection report must document 

all locations where a valid inspection was not conducted. FRA inspectors typically 

verify that the required internal rail inspection frequency is met and any rail 

defects found are repaired or, if repairs are postponed, protections are put in place 

as required. The NS’s most recent preaccident ultrasonic inspection reports for the 

track in the derailment area did not identify any locations where a valid internal 

rail inspection was not conducted, and the FRA took no exceptions to the reports. 

Placement of Hazardous Materials Cars in Trains

The NS’s operating instructions for handling hazardous materials in trains31

were effective May 31, 2006, and were incorporated into the NS train operating 

rules. The NS requires each transportation employee to have a copy of and comply 

with the instructions. 

30 Circular OT-55 has been adopted without reservation by members of the AAR and the American Short 

Line and Regional Railroad Association for their operations within the United States.

31 NS United States Hazardous Materials Instructions for Rail (HM-1), effective May 31, 2006.
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The instructions for handling hazardous materials require the use of “buffer” 

cars to separate placarded32 hazardous materials cars from the locomotive units 

and any other occupied cars for the protection of train crews. NS representatives 

told the Safety Board that the company’s hazardous materials instructions allow a 

single car to be used as a buffer between a placarded hazardous materials car and 

the locomotive(s) on unit trains33 transporting hazardous materials if no additional 

buffer cars are available on the train. The UP, which delivered the accident train 

to the NS in Chicago, states in its hazardous materials rules34 that if five buffer 

cars are not available to separate the placarded hazardous materials cars from the 

locomotive unit on a train, all available buffer cars are to be placed between the 

locomotive unit and the placarded cars, but at least one buffer car is required.

The Pipeline and Hazardous Materials Safety Administration (PHMSA) 

in the U.S. Department of Transportation (DOT) has the authority to develop 

and promulgate regulations for the safe transport of hazardous materials in all 

transportation modes. The regulation governing the use of buffer cars in trains for 

the protection of the crew is in 49 CFR Part 174, and the FRA has the authority to 

enforce these regulations. A table at 49 CFR 174.85(d) states, in part: 

1. When train length permits, [a] placarded car may not be nearer than the 

sixth car from the engine or occupied caboose.

2. When train length does not permit, [a] placarded car must be placed 

near the middle of the train, but not nearer than the second car from an 

engine or occupied caboose.

The requirements in 49 CFR 174.85 do not specifically address unit trains 

transporting hazardous materials or otherwise make a distinction between general 

freight trains, unit trains, and short trains operating between industrial facilities 

and local rail yards. However, both the FRA and PHMSA have recently issued 

interpretations of 49 CFR 174.85 regarding unit trains.

In a January 31, 2006, letter, the FRA responded to a petition filed on behalf of 

the United Transportation Union. The union had challenged another major railroad’s 

practice of using a one-car buffer on its ethanol unit trains as a violation of the DOT 

Hazardous Materials Regulations. In its response, the FRA stated the following:

If a train is made up of all hazardous materials cars, like a unit train of 

ethanol tank cars, this requirement may be met by a single buffer car 

separating the locomotive from the hazardous materials cars.

32 Placards are signs affixed to railroad freight cars, highway trailers and tanks, and intermodal freight 

containers to signify that the car, trailer, or container is carrying hazardous materials. The placards are colorcoded and bear numbers that identify the specific hazardous material being carried and its hazards.

33 A unit train is a freight train in which all cars carry the same commodity and are bound for the same 

destination.

34 UP Instructions for Handling Hazardous Materials, Form 8620, dated April 6, 2003.
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The director of PHMSA’s Office of Hazardous Materials Standards, in a 

March 29, 2007, letter in response to a Safety Board inquiry regarding specific buffer 

car requirements for unit trains containing only placarded hazardous materials 

cars, stated that the requirement to place placarded cars no nearer than the sixth 

car from the engine or occupied caboose 

applies so long as there are sufficient non-hazardous materials rail cars 

within the standing train consist to fulfill the requirement. The regulations 

do not require railroads to change business or operating decisions 

concerning the number and types of cars placed in the train.

The letter added that when the number of nonhazardous cars within a train 

is insufficient to provide a five-car buffer, at least one buffer car should be placed 

between the loaded placarded cars and the locomotives.

In June 2005, the FRA submitted a report to Congress—Safe Placement of Train 

Cars—in response to a mandate under the Hazardous Materials Transportation 

Authorization Act of 1994 (Public Law 103-311). The Secretary of the DOT was 

asked to conduct a study of 

two related, but distinct, issues: first, the make-up of trains in such a 

manner as to prevent derailments caused by in-train forces and, second, 

placement of hazardous materials cars in trains so as to avoid harm to crew 

members or interaction of hazardous materials, should a train accident or 

other unintended release occur.

The report also contained a brief history of the development and evolution of 

the car placement standards for crew protection that are found in 49 CFR 174.85(d). 

According to the report, just after the turn of the 20th century Congress directed 

the Interstate Commerce Commission to 

formulate and publish “Regulations For The Transportation of Explosives” 

to promote the safe transportation in interstate commerce of explosives 

and other dangerous articles. 

The FRA report further noted that the impetus for the early laws and 

regulations was due to the number of accidents involving the transportation of 

explosive black powder. The early regulations required cars with explosives to 

be placed near the center of the train and at least 16 cars from the engine and 10 

cars from the caboose when the length of the train would permit. The standard 

of a 16-car buffer was selected because it was considered to be a safe distance 

to prevent cinders from steam locomotives from reaching wooden box cars 

containing explosives. By 1922, new regulations were in effect that required a fivecar separation between placarded cars transporting flammable materials and either 

a locomotive or an occupied caboose. When the length of the train did not permit, 

the car transporting the hazardous materials was to be placed in the middle of the 

train and separated from the engine or caboose by at least one car. 
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The report also noted that the current in-train placement requirements 

are founded “on no more rigorous a scientific basis than were the original 

[requirements].” The FRA emphasized that the current requirements are based on 

the “empirical evidence of history” and that there is no body of evidence from the 

analysis of accident data to support the need for “sudden or drastic overhaul” of 

these requirements. 

The FRA noted in the report that Canada and the United Kingdom also 

have evaluated the effectiveness of buffer cars and the placement of placarded 

hazardous materials cars in trains for the protection of train crews. Although the 

Canadian regulations are similar to the DOT Hazardous Materials Regulations, 

they do not require buffer cars in unit trains transporting hazardous materials. 

Canadian regulations do require a five-car separation between cars carrying 

flammable gases and loaded tank cars transporting chlorine, anhydrous ammonia, 

or sulfur dioxide, all of which are either toxic by inhalation or designated inhalation 

hazards. British regulations do not require a buffer car between occupied rail 

cars and cars transporting hazardous materials. However, in its report the FRA 

did note that British regulations tend to be more restrictive regarding chemical 

compatibility requirements.

The FRA concluded in its 2005 report that 

Existing regulations regarding train placement of hazardous materials 

have been fashioned through long experience and have functioned well. 

The requirement that tank cars carrying hazardous materials be placed at 

least six deep provides suitable protection for train crews without creating 

excessive issues regarding train make-up (e.g., location of loaded cars). 

... Existing in-train placement requirements appear to provide for an 

appropriate level of safety.

The 2005 report did not otherwise address the risks specifically associated 

with a one-car buffer on unit trains transporting hazardous materials.

Hazardous Materials Information

Ethanol Shipments by Rail

Natural gasoline35 was used to denature the ethanol carried in the 

accident train. According to the Ethanol Product Materials Safety Data Sheet, the 

components of the blend of denatured ethanol on the accident train were ethyl 

alcohol (95.0 percent), natural gasoline (5.0 percent), and benzene (less than 0.25 

percent). Denatured ethanol is a flammable liquid with a flash point near 49° F. 

It burns without a visible flame in daylight. It is a clean, colorless liquid with a 

35 Natural gasoline is gasoline that is extracted from natural gas rather than produced at an oil refinery.
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characteristic odor; it is lighter than water and soluble in water. Its vapors are 

heavier than air, and it is used as a fuel, solvent, anti-freeze, and to make other 

chemicals. Denatured ethanol is regulated by the DOT as “alcohols N.O.S., Class 

3–flammable liquid.”

According to the AAR, the number of annual rail shipments of denatured 

alcohol/ethanol increased from 33,288 to 76,734 between 2000 and 2005. The 

growing demand for ethanol is largely due to the increasing use of ethanol as an 

additive to automotive gasoline.

Tests and Research

Examination of Recovered Rail

About 19 feet of broken rail (five pieces varying in length from 13.75 to 60.5 

inches and two small pieces) from the accident area were recovered and transported 

to the Safety Board’s Materials Laboratory for examination. The rail pieces came 

from the north rail (left rail in direction of train movement) and included the rail 

from the identified point of derailment. Initial examination and measurement 

revealed that a rail piece about 64 inches long had not been recovered. The total 

length represented by the recovered rail was thus about 24 feet 4 1/2 inches. The 

rail pieces were laid out and matched to determine their original placement, as 

shown in figure 5.

Figure 5. Field side of recovered rail after reassembly. (The rail pieces are lettered west to east; 

fractures are numbered west to east. The missing 64-inch-long rail section is bounded by fractures 

3 and 4.)
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Shell flakes, spalling, and 

open shell cracks were present 

along the length of recovered 

rail. The rail contained seven 

complete fractures (through the 

rail head, web, and base), which 

are numbered 1 through 7 in 

figure 5. Six of the seven fracture 

faces contained transverse 

defects encompassing from 8 to 

78 percent of the worn rail head 

area. All the defects showed 

features consistent with a detail 

fracture from shelling, with 

several fractures emanating 

from an open shell crack at the 

gage corner. The largest defect, 

covering 78 percent of the worn 

rail head, was found at fracture 

4. The second largest defect, 

covering 45 percent of the worn 

rail head, was at fracture 5. 

Both fracture surfaces showed 

features consistent with detail 

fracture from shelling. (See 

figure 6.)

Fractures 4 and 5 were at 

each end of a 14-inch-long piece 

of rail. This piece had receiving 

rail-end batter at fracture 4, and 

the other end of this piece had no trailing batter at fracture 5. The mating piece of 

recovered rail had a relatively small amount of receiving batter at fracture 5.

Ultrasonic Inspection of Recovered Rail

The five larger recovered rail pieces were inspected using handheld 

ultrasonic inspection equipment. Inspection began with a 0° transducer for a signal 

reflection from the bottom of the rail at the center of the running surface. Next, a 

70° transducer was used to check for indications of transverse defects by scanning 

in both directions longitudinally along the rail surface at the center, gage, and field 

sides and along the sides of the head at the field and gage sides.36

36 Several areas of the rail had open spall cracks in the gage side of the head, preventing these areas 

from being inspected using the handheld equipment. Also, the narrow width of the rail head on the gage side 

sometimes made it difficult for the standard-size transducer to maintain proper contact with the rail surface.

Figure 6. View of east surface of fracture 4. (The dashed 

line indicates the boundary of a detail fracture covering 

about 78 percent of the worn rail head and extending into 

the web. The defect emanated from an open shell crack 

at the gage corner.)
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Except for some small sections on one rail piece and at other areas of known 

interference (such as welds and joint bar holes), a bottom signal was received 

throughout the entire length of the rail pieces. Inspection of the rail from the 

running surface using the 70° transducer identified an indication of a potential 

flaw on the gage side near the running surface. Inspection of the rail from the 

gage side of the rail head with the same transducer resulted in six indications of 

potential defects at five locations. 

At each of the six locations where the ultrasound inspection had indicated a 

possible defect, Safety Board investigators cut and then fractured the rail. Four of the 

fractures had uniform rough gray features consistent with overstress fracture with 

no indications of transverse defects intersecting the lab fracture surface. A portion 

of the surface of one lab fracture had features consistent with a defect that had not 

opened to the surface. This defect covered about 5 percent of the worn rail head 

area. Two areas of the surface in another lab fracture had features consistent with 

a pair of transverse defects in proximity to one another. These combined defects 

covered less than 5 percent of 

the remaining head area. A shell 

crack that was oriented almost 

parallel to the gage corner was 

observed at the inner boundary 

of the detail fracture areas, and 

the fracture features radiated 

outward toward the surface from 

the intersection with the shell 

crack. None of the transverse 

defects that were found at 

the lab fracture locations had 

been indicated during the 

lab’s inspection using the 70° 

transducer from the running 

surface of the rail. 

Rail Profile Measurements

Figure 7 superimposes 

the outline of a new 140-pound 

rail onto a photograph of a 

transverse section of rail from 

the derailment area. As shown, 

the vertical head loss at the 

center of the head was 0.70 inch. 

Measuring radially inward, the 

loss from the gage corner was 

0.76 to 0.79 inch. At the lower 

end of the gage side of the head, 

Figure 7. Cross section of one of the recovered 

rail pieces examined in the Safety Board’s Materials 

Laboratory. (Superimposed on the rail is a profile of new 

140-pound rail. The inset image shows the amount of 

head loss since rail was new.)
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the loss in the horizontal direction was 0.24 inch. About 40 percent of the head 

area had been worn away or removed by a combination of wear and rail grinding. 

The lower edge of the rail head on both the gage and the field sides also extended 

below the profile, which is consistent with the overall downward deformation of 

a worn head under wheel loads.

NS standards allow rail head (top-vertical) wear of 11/16 (0.6875) inch 

for 140-pound rail in main line service with accumulated tonnage of more than 

5 mgt before the rail is recommended for replacement, that is, listed for future 

replacement. If vertical wear exceeds 13/16 (0.8125) inch, trains are to be put under 

a slow order until the rail is replaced. An NS chief engineer stated that the NS 

standard for 140-pound rails allows 1/2 (0.5) inch of gage face wear before the rail 

is recommended for replacement. If gage face wear exceeds 10/16 (0.6250) inch, 

trains are put under a slow order until the rail is replaced.

Measurements of vertical head loss of the rail pieces 

examined in the Safety Board’s Materials Laboratory showed 

rail head losses ranging from 0.38 to 0.70 inch. When measured with a rail wear 

template of the type that railroads used to evaluate rail wear, the vertical head loss 

was indicated to be about 1/8 (0.1625) inch less than the actual loss. 

Transverse Defect Growth Rate

Studies by the DOT37 have shown that the primary factor in the rate of 

crack growth from internal defects in rail is the traffic load. Influences on the rate 

of transverse defect growth in rail include bending stresses applied to the rail 

during train operations and sudden or large temperature variations. Temperature 

changes can place rail under tension or compression, making internal flaws more 

susceptible to growth. Bending stresses from heavy-axle-load traffic make these 

defects even more susceptible to fatigue damage and progression. Traffic load is 

the primary factor in producing stress cycles for crack growth in rail. 

Sperry calculated the anticipated normal growth rate of detail fractures in 

rail as 1.6 to 2.0 percent of the cross section of the head of new rail38 with every 

1 mgt of traffic. Based on the estimated traffic load and calculated growth rate, 

Sperry calculated that detail fractures found in the rail at the point of derailment 

likely would have progressed about 20 percent (for a new rail head) between 

the latest inspection and the accident. According to Sperry representatives, the 

internal transverse rail flaws were at or below borderline detection size at the time 

37 (a) D.Y. Jeong, T.H. Tang, O. Orringer, and A.B. Perlman, Propagation Analysis of Transverse Defects 

Originating at the Lower Gage Corner of Rail, U.S. Department of Transportation, DOT/FRA/ORD-98/06 (1998). 

(b) D.Y. Jeong, Analytical Modeling of Rail Defects and Its Applications to Rail Defect Management, U.S. 

Department of Transportation, Research and Special Programs Administration, Volpe National Transportation 

Systems Center (2003).

38 Standard industry practice is to define defect size as a percentage of the cross-sectional area of the 

rail head of a new rail.
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of the August 1 inspection, leading Sperry to assign “growth” as the reason for 

nondetection.

The largest defect found in the accident rail recovered from the accident site 

encompassed about 78 percent of the worn rail head. The area of the defect on the 

worn accident rail head equates to a defect size of 47 percent of a new rail head. 

The likely size of this fracture at the time of the most recent ultrasonic inspection, 

on August 1, was calculated by the DOT’s Volpe National Transportation Systems 

Center using its analytical model for transverse defect growth. The variables 

entered into the calculation included 140-pound rail on a 0.8° curve in Class 4 

track, a critical crack size of 47 percent, vertical head loss of 0.7 inch, gage face loss 

of 0.24 inch, and an accumulated tonnage of 14 mgt. Using this data, the estimated 

size of the defect at the time of the last inspection was between 8 and 14 percent of 

a new rail head. 

In the absence of precise data on temperature differential39 and average 

wheel loads, a range of values was used. In each case, higher values for temperature 

differential or average wheel loads or both resulted in faster transverse defect growth 

rates and correspondingly smaller estimated defect sizes at last inspection. 

The DOT studies previously referenced have shown that detail fractures 

grow faster in worn rail and the critical size for failure is lower. In the 1998 study 

that analyzed transverse defect growth, calculations showed that for 132-pound 

rail on a 5° curve with a Class 3 or 4 level of foundation stiffness and no thermal 

loads, a defect grows from 10 percent of the rail head to a critical size of more than 

80 percent of the head area after about 55 mgt has moved over it. Under the same 

conditions but in rail with a 40-percent vertical head loss, the defect grows from 

10 percent to a critical size of 25 percent after carrying 7.5 mgt. Under baseline 

conditions of a 15° F temperature differential and an average wheel load of 16,500 

pounds (baseline values from Jeong, 2003), a transverse defect in 140-pound rail at 

the NS’s established rail wear standard could grow from 11 to 12 percent to critical 

size within 14 mgt of traffic load.

Derailments Caused by Broken Rail

According to data compiled by the FRA, 158 main track derailments caused 

by broken rail occurred in 2006, resulting in about $65 million in damages. The 

most frequently cited cause (35 incidents) was “transverse/compound fissures 

broken rails.” The second leading cause (25 incidents) was “shelling/head checks 

broken rails.” In 2005, “shelling/head checks broken rails” was also the second 

leading cause of derailments (35 incidents), just ahead of “transverse/compound 

fissures broken rails” (33 incidents).

39 Temperature differential refers to the difference between the rail’s neutral temperature (the temperature 

at which the rail is under neither tension nor compression) and its actual temperature.
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Other Information

NS Postaccident Actions 

On October 19, 2007, the NS issued a memorandum to Sperry with the 

subject “Testing Critical and Open Deck Bridges.” The memorandum provided 

instruction for use by all NS-assigned detector cars when inspecting track on 

“critical and open deck bridges along with bridges over navigable waterways.” 

Attached to and referenced by the memorandum is MW&S [Maintenance of Way 

and Structures] Standard Procedure No. 030: “Instructions for Inspection of Bridges, 

Culverts, and Tunnels.” The memorandum includes the following instructions:

• Test speed shall not exceed 5 mph.

• Any equipment response generated by the test system within 234 

feet of either side of bridge must be acknowledged with an icon or 

supporting remarks representing the operator’s interpretation.

• Any equipment response typical to a fillet or weld reflector[40] 

must be confirmed visually by the operator.

• All suspect equipment responses must be hand tested and verified 

that a defective condition is not present.

• Extra care should be taken with surface conditions and/or any 

unexplained ‘Loss of Bottom’ [signal] that may prevent the 

detection of an underlying defect. All such indications must be 

ground examined and hand tested. Any surface condition that 

prevents a valid test must be reported as a Rail Test Exception 

governed by FRA Track Safety Standard 213.237(d). 

NS representatives told investigators that because the railroad’s Beaver River 

bridge spans a navigable waterway, it would be covered by the new instructions. 

FRA Postaccident Actions

In an effort to help reduce the number of derailments caused by broken 

rails, the FRA is in the process of establishing a Rail Integrity Section within its 

Track and Structures Division. The responsibilities of this group will include 

reviewing railroads’ rail-inspection procedures, auditing railroads’ rail-inspection 

requirements, developing new information to be used in rail inspection, and 

investigating broken-rail derailments, including reviewing rail inspection reports 

for the derailment area. The FRA has informed the Safety Board that it hired a 

manager for the Track and Structures Division in March 2008 and is currently 

seeking to hire eight regional rail integrity specialists.

40 Fillets and weld deflectors are not rail defects.
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Beaver County Postaccident Actions

In September 2007, Beaver County Emergency Services, along with 

emergency services in 13 other counties, participated in the Southwest Pennsylvania 

Region 13 annual emergency-response group exercise. The NS participated in the 

Beaver County portion of the exercise. The exercise involved a tank car leak/release 

and focused on testing crisis management, communication, incident command, 

and entry into a rail yard.

NS Disaster Preparedness

On February 17, 2006, NS hazardous materials personnel held a security 

awareness event at Conway yard for local firefighters and police officers. About 

33 people attended. On September 5, 2002, the NS participated in a full-scale drill 

with Allegheny County.

One month before the accident, on September 20, 2006, the NS hosted the 

Transcaer41 Whistle-Stop event in Pittsburgh. About 222 individuals attended the 

event, including the Beaver County director of emergency services (the incident 

commander for the accident) and the director of Allegheny County Emergency 

Services. 

The NS also provides funding for local emergency responders to attend 

the Emergency Response Training Center in Pueblo, Colorado. The Center has a 

1-week course that includes hands-on training, mock derailments, and exercises. In 

recent years, participants have included the Beaver County director of emergency 

services, a representative of Allegheny County Emergency Services, a representative 

of the Pittsburgh Fire Department, a representative of the Washington County 

Hazardous Materials Team, and a representative of the Big Beaver Volunteer 

Fire Department. In 2007, the NS invited personnel from the New Brighton Fire 

Department, the Pittsburgh Fire Department, Allegheny County, and the Beaver 

County Emergency Services Center to participate in training at the Emergency 

Response Training Center.

Previous Safety Board Action Regarding Internal Rail Inspections

In its investigation of a June 30, 1992, derailment of a Burlington Northern 

freight train on an approach to a bridge in Superior, Wisconsin,42 which resulted 

in a hazardous materials release and the evacuation of more than 40,000 people, 

41 Transportation Community Awareness and Emergency Response (Transcaer), is a voluntary national 

outreach effort to help communities prepare for and respond to a hazardous materials transportation incident. 

Transcaer is sponsored by the AAR, the American Chemistry Council, Chemical Educational Foundation, 

CHEMTREC®, the Chlorine Institute, Inc., and National Tank Truck Carriers, Inc.

42 National Transportation Safety Board, Derailment of Burlington Northern Freight Train No. 01-142-30 

and Release of Hazardous Materials in the Town of Superior, Wisconsin, June 30, 1992. Railroad/Hazardous 

Materials Accident Report NTSB/HZM-94-01 (Washington, DC: NTSB 1994).
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the Safety Board identified a safety issue involving ultrasonic rail inspections. The 

investigation determined that an undetected internal rail defect (a detail fracture) 

caused the rail to break and derail the train. 

The broken rail had been ultrasonically inspected about 1 month before the 

accident. The ultrasonic rail equipment operator had observed fluctuations in the 

initial inspection readings, but after repeated inspection, both with the rail-carmounted ultrasonic equipment and with handheld equipment, he had recorded 

the inspection results as “marginal to satisfactory” because of the age of the rail 

and the rail surface conditions that interfered with signal penetration. As a result 

of its investigation of the accident, the Safety Board, on April 1, 1994, issued the 

following safety recommendations:

To the FRA:

R-94-1

Research and develop, with the assistance of the Association of American 

Railroads, inspection methods that will identify internal defects in rail that 

has significant shelling and other surface conditions.

R-94-2

Perform the necessary research and develop standards that (1) provide 

defined limits of allowable rail surface conditions (such as shelling) that 

can hinder the identification of internal defects, and (2) require remedial 

action for rail with surface conditions that exceed defined limits.

To the AAR:

R-94-4

Assist the Federal Railroad Administration in researching and developing 

inspection methods that will identify internal defects in rail that has shelling 

and other surface conditions.

R-94-5

Assist the Federal Railroad Administration in correlating rail surface 

conditions with detail fractures and with rail service failures, including the 

provision of samples of rail with detail fractures.

In a February 8, 1996, letter in response to Safety Recommendation R-94-1, the 

FRA stated that the recommended research was unnecessary because the industry 

was already performing similar efforts. The same FRA letter responded to R-94-2 

stating that the chances of producing a useful outcome from such a research effort 

were doubtful and that no research was planned in this area. Because the FRA 

did not express a willingness to sponsor or encourage research and development 

of new inspection methods capable of identifying internal defects in rail with 

significant head surface conditions, the Safety Board, on April 9, 1996, classified 

Safety Recommendations R-94-1 and -2 “Closed—Unacceptable Action.” 
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In a December 9, 1997, letter in response to Safety Recommendation R-94-4, 

the AAR informed the Safety Board that a joint FRA-AAR project was underway to 

conduct research and to develop inspection methods to identify defects in rail that 

has shelling or other surface defects. Based on this response, the Board classified 

Safety Recommendation R-94-4 “Closed—Acceptable Action” on May 14, 1998.

Although the FRA had not responded favorably to its two safety 

recommendations arising from the Superior, Wisconsin, accident investigation, 

the AAR informed the Safety Board in a January 14, 2002, letter that the AAR and 

its member railroads had worked with the FRA through the FRA’s Rail Safety 

Advisory Committee (RSAC) process to implement new provisions in the FRA 

Track Safety Standards. These new provisions became effective in September 

1998. The new provisions that were made as a result of the Safety Board’s safety 

recommendations developed during the Superior, Wisconsin, accident investigation 

were implemented through paragraphs (d) and (e) of 49 CFR 213.237 of the Track 

Safety Standards (provided earlier in this report). Because these changes were 

responsive to the Board’s concerns, the Board, on May 2, 2002, classified Safety 

Recommendation R-94-5 “Closed—Acceptable Alternate Action.”43

43 Although the AAR advised the Safety Board that the FRA had participated through the RSAC process 

to revise the Track Safety Standards to address Safety Recommendations R-94-1 and -2, because of the 

FRA’s lack a of timely positive response to the recommendations and its failure to inform the Board that it 

had addressed the intent of recommendations, the classification of those safety recommendations remains 

“Closed—Unacceptable Action.”
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Analysis

Exclusions

The investigation determined that the engineer and conductor of NS train 

68QB119 were qualified employees who had been trained and tested in the proper 

performance of their duties. The work and rest histories of the two crewmembers 

did not indicate that either of them was suffering from fatigue before or at the time 

of the accident. Postaccident toxicological tests were negative for the presence of 

alcohol as well as FRA-specified drugs. The crew stated that they had not noted 

any irregularities or problems with the train between Toledo and the point of 

the derailment, and investigators found nothing unusual in the crewmembers’ 

handling of the train. The Safety Board therefore concludes that the following were 

not factors in the accident: crewmembers’ qualifications, fatigue, drugs or alcohol, 

and the crewmembers’ operation of the train. 

A review of preaccident equipment mechanical inspections, data from 

wayside defect detectors, and train crew statements did not reveal anything 

unusual. Postaccident equipment inspections found no defective equipment on the 

train. All wheel impact readings for the accident train were within normal limits 

as specified by the NS. The Safety Board concludes that the mechanical condition 

of the train was not a factor in the derailment. 

The NS provided timely and accurate information about the train consist to 

local emergency responders, identifying denatured ethanol as the only hazardous 

materials product involved in the derailment. The investigation found that the 

incident command system worked well, with railroad personnel available to assist 

in coordination. The Safety Board concludes that the emergency response and the 

command system were effective and appropriate. 

The Accident

Postaccident inspection by Safety Board investigators found pieces of 

broken rail under the last derailed car. When, as in this instance, a rail completely 

breaks (through the rail head, web, and base) and separates, the electrical circuit 

continuity in the track signal system may be interrupted, causing the most restrictive 

signal indication to be displayed to the locomotive. The engineer of the accident 

train stated, and signal system data confirmed, that the train was operated on a 

clear signal indication over the bridge. After the locomotive left the east end of 

the NS bridge over the Beaver River and traveled about 200 yards, the cab signal 

indication went from clear to approach, as the train entered another track circuit. 
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Shortly afterward, as the rest of the train was crossing the bridge, the train brakes 

went into an emergency application because of the rail separation and derailment. 

The Safety Board concludes that the derailment occurred when the north rail of 

track 1 separated under the load of the accident train. 

Rail Defects and Ultrasonic Inspection

During the examination of seven pieces of broken rail recovered from 

the accident scene, the Safety Board’s Materials Laboratory found pre-existing 

transverse defects (fatigue cracks) at the site of breaks in the north rail of track 1, 

as well as at other locations within the unbroken rail segments. All the transverse 

defects found in the rail, including the defect at the primary fracture, were identified 

as detail fractures from shelling.

The largest defect size was at fracture 4; it covered about 78 percent of 

the existing worn rail head. The next largest defect size was at fracture 5, which 

covered about 45 percent of the rail head. These two fractures were at the ends 

of a 14-inch-long piece of rail. Rail-end batter patterns observed at the fractured 

ends of the recovered pieces indicated that the rail initially broke at fracture 4. 

Therefore, the primary rail break occurred at the location of the largest defect, with 

the other fractures secondary to the initial separation. The Safety Board concludes 

that the failure of the north rail of track 1 was precipitated by a detail fracture 

(fatigue crack) that originated from shelling on the rail head, reached critical size, 

and caused a piece of rail to break out under the train. 

The rail had been inspected for internal defects about 2 1/2 months before 

the accident using an instrumented vehicle. At that time, the vehicle operator did 

not identify any internal rail defects in these sections of rail. The investigation 

determined that the site of the rail failure was within a 9-foot length of rail where, 

because of rail surface conditions, the ultrasonic inspection equipment had received 

only intermittent signal returns from the bottom of the rail. 

Based on defect (crack) growth calculations, at the time of the August 1, 2006, 

rail inspection, the size of the largest defect, which initiated the rail fracture, 

would likely have been approximately 8 to 14 percent of a new rail head area.44

Based on Safety Board laboratory evaluations and the TTCI data in table 1, the size 

of the initiating defect was likely too small45 at that time to be reliably detected. 

Also, the shelling that was evident on the rail surface as well as the crack patterns 

from flaking that were observed on a cross section of the accident rail could 

have prevented ultrasonic signals sent from the running surface from detecting 

44 Defect size is typically given as a percentage of the rail head area of a new rail. The area of the largest 

defect at the time of the August 1 rail inspection would likely have covered approximately 13 to 23 percent of 

the existing worn rail head.

45 The TTCI data estimates a 64-percent probability of detection for a defect size of 8 percent of the rail 

head using an inspection vehicle.
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the defect. A correlation of the data from the August 1, 2006, inspection with the 

locations of the recovered rail from the area of the derailment showed that the 

location of the initiating defect was within a 2-inch area that had a loss of bottom 

signal. The Safety Board therefore concludes that rail surface conditions prevented 

the effective transmission of the ultrasonic signals, and the defect (fatigue crack) 

that led to the derailment may not have been large enough at that time to be reliably 

detected by the inspection vehicle. 

FRA regulations require that all railroads conduct a “continuous search” 

when inspecting rail for internal defects. In the FRA’s interpretation of the 

regulations, any rail inspection that is interrupted “as a result of rail surface 

conditions that inhibit the transmission or return of the signal” is not considered 

to be continuous under the regulation and therefore is not to be considered a valid 

inspection of the affected rail segment. 

About a year and a half before the accident and without consulting the 

FRA, the NS gave its inspection contractor (Sperry) new procedures for inspecting 

rail for internal defects. In effect, the new procedures permitted the equipment 

operator to ignore any loss of bottom signal as long as the continuous loss-ofsignal distance did not exceed 5 feet of linear rail length. The new procedures 

were intended to address the detection of vertically oriented longitudinal rail 

head defects, not transverse defects. Although the new procedures were designed 

to address a different type of defect, the procedures were applied to the entire 

inspection process and thereby also affected the detection of transverse defects.

The point of derailment was within a rail segment about 9 feet long 

where, during the August 1 ultrasonic inspection, the inspection equipment had 

encountered an intermittent loss of bottom signal. Because the longest loss of 

bottom signal distance was only about 7 inches of linear rail length (which did not 

exceed the 5-foot minimum specified by the NS that would have required a repeat 

inspection), this rail segment was not examined further. 

The flaking and shelling conditions found on the recovered rail head likely 

blocked the ultrasonic signals at several locations and caused the intermittent loss 

of bottom signal at the point of derailment. Because the NS did not require the 

contractor to repeat the inspection of the rail at these locations, the area was not 

examined further by Sperry, and the internal condition of the rail at these locations 

was left undetermined. The NS exception to the continuous search requirement 

eliminated an opportunity to detect the defect that led to the derailment by 

rerunning the inspection vehicle or by using more effective handheld inspection 

equipment.

Reinspection of a rail segment having a loss of bottom signal usually entails 

a handheld scan in which the inspector runs a handheld transducer across the 

running surface of the rail. Handheld scans can be more effective than inspection 

vehicles, but data are not available on the probability of detection for handheld 

inspections at a range of defect sizes. In tests conducted in the Safety Board’s 
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Materials Laboratory, handheld scans of segments of rail showed that two rail 

head internal defects having a size of 3 percent46 or less were not detected by hand 

inspections at the running surface of the rail head. (These defects were found 

using a laboratory technique that scans the side of the rail head.) The estimated 

defect size at the time of the last inspection before the accident was only slightly 

larger than the defects found using the laboratory technique. Even if the Sperry 

equipment operator had used a handheld scanning device to inspect the rail where 

the bottom signal was intermittently lost during his inspection on August 1, he 

still may not have found the defect that led to the rail fracture. Therefore, it could 

not be determined whether the defect that led to the rail fracture would have been 

found had a handheld inspection device been used to reinspect the area that had 

the loss of bottom signal on August 1, 2006.

Exempting any length of rail from a valid inspection could result in missing 

a defect that could grow to critical size before the next inspection and lead to rail 

failure under the load of a train. The Safety Board concludes that NS procedures 

that do not require a re-examination of rail where there is a signal loss during 

ultrasonic inspection means that those segments of rail can remain uninspected 

and in service indefinitely. Therefore, the Safety Board believes that the NS should 

revise its ultrasonic rail inspection procedures to eliminate exceptions to the 

requirement for an uninterrupted, continuous search for rail defects. 

The Safety Board issued recommendations that addressed the effectiveness 

of internal rail inspections as a result of its investigation of the Burlington Northern 

freight train accident that occurred in Superior, Wisconsin, in 1992. New provisions 

were added to the Track Safety Standards through paragraphs (d) and (e) of 

49 CFR 213.237 that were responsive to the Board’s recommendations. These 

provisions appear to ensure that railroads are required to conduct valid continuous 

searches for internal defects and that no segments of rail are to remain in service 

without being inspected. 

The FRA reviews the documentation and reports generated from a railroad’s 

internal rail inspections to determine whether the required inspection frequency 

is met and that any rail defects found are repaired or, if repairs are postponed, 

protections are put in place as required. These reviews are an important part of 

the FRA’s oversight responsibilities to identify potential safety deficiencies on 

the railroad. However, the investigation found that the NS procedures allowed 

as much as 5 continuous feet of signal loss during its ultrasonic inspections, 

which is not consistent with the requirement in the Track Safety Standards for 

a continuous search. The NS’s preaccident ultrasonic inspection reports for the 

rail in the derailment area did not identify locations where a valid inspection was 

not conducted, even though a 9-foot length of track in the area of the derailment 

showed an intermittent loss of signal. Further, the FRA was not aware that the 

NS and other railroads had enacted various exceptions to the requirement for a 

continuous search. The FRA’s reviews of railroad rail inspection programs should 

46 Defect size is stated as a percentage of rail head area of a new rail head.
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have identified these inconsistencies. The Safety Board concludes that the FRA’s 

oversight of the NS’s and other railroads’ internal rail inspection processes was 

inadequate. Although the Board notes that the FRA is in the process of establishing 

a rail integrity group that will examine railroads’ internal rail inspection programs, 

the Board understands that the FRA has not required that railroads eliminate 

potential exceptions to the requirement for a continuous search. The Safety Board 

believes that the FRA should review all railroads’ internal rail defect detection 

procedures and require changes to those procedures as necessary to eliminate 

exceptions to the requirement for an uninterrupted, continuous search for rail 

defects. 

Rail Defect Management

The rail in the accident area had been in service at this location since 1977. 

No records were found to indicate the total gross tonnage over the track since that 

time, but because this track was a main east-west line for the predecessor railroads 

(Pennsylvania, Penn Central, and Conrail) as well as the NS, it could reasonably 

be estimated to have carried in excess of 1 billion gross tons (1,000 mgt) before the 

derailment. Most railroads measure rail wear and consider those wear levels when 

scheduling rail for replacement. Measurements taken after the accident showed 

that the rail in some locations in the accident area was near or exceeded the wear 

level at which the NS would list the rail to be replaced. However, the wear on 

the rail had not yet reached the level at which the NS would implement a speed 

restriction.

Over the years, transverse defects have been among the leading causes 

of train derailments on Class 3, 4, and 5 track.47 To find defects that can lead to 

derailments, the FRA Track Safety Standards require that a continuous search for 

internal rail defects be made for Classes 4 and 5 track (and Class 3 track over which 

passenger trains operate) after every 40 mgt of traffic or once a year, whichever 

interval is shorter. The interval between inspections is intended to provide a safe 

time frame for detection of internal rail flaws before they can grow to critical size 

and cause a rail break. 

To reduce the risk that an ultrasonic inspection will miss a rail defect that 

will later become critical, some railroads have developed databases to capture 

information on track conditions, train activities, and rail defects found by 

inspection or in-service fractures. These railroads use this information to monitor 

rail conditions and predict future performance. The NS based its ultrasonic rail 

inspection schedule on a model that takes into account track speed, annual tonnage, 

hazardous materials transported over the route, whether the territory is signaled 

or nonsignaled, rail weight and age, curvature, and rail defect/failure history. Rail 

head wear is not a parameter in the model. Using this model, the NS determined 

47 FRA database: Rail, Joint Bar, and Rail Anchoring Derailments, for all railroads, on main track. 
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that the track in the accident area should be inspected with ultrasound equipment 

four times per year. 

NS records indicated that track 1 carried about 63.5 mgt per year. Therefore, 

ultrasonic inspections of this track four times per year resulted in an average 

interval of about 16 mgt, which was well within the 40-mgt maximum established 

by the FRA. However, one of a number of factors that can influence growth 

rates of transverse defects in rail is the amount of rail head wear. When a rail 

has less material to support the load it carries, the stress levels are higher, which 

leads to higher crack growth rates and reduced tolerance for a given crack size. 

Studies conducted by the DOT’s Volpe Center have confirmed that detail fractures 

grow faster in worn rail than in new rail, and the critical crack size for failure is 

smaller. 

For worn rail, the time a defect takes to grow from undetectable to critical 

size is shorter, which increases the risk of failure between inspections. The rail 

at the point of derailment showed a loss of 40 percent of the rail head area from 

wear and grinding. Calculations indicate that in the area of the accident, a defect 

size of 8 to 14 percent48 at the time of the August 1 inspection grew to critical size 

after passage of about 13.8 mgt of traffic, which was less than the average 16 mgt 

inspection interval developed by the NS. The Safety Board concludes that the NS 

did not conduct internal rail inspections frequently enough to reliably detect an 

internal defect before it could grow to critical size in the significantly worn rail. 

The New Brighton accident illustrates that as rail wears, it requires more 

frequent inspections to detect internal defects before they can reach critical size 

and cause a failure. A defect that was too small to be reliably detected during an 

internal inspection grew to critical size between inspections even when the interval 

was more frequent than the 40-mgt or at-least-once-per-year interval required by 

the FRA. The Safety Board concludes that the FRA’s required minimum intervals 

for internal rail inspections are inadequate because they do not take into account 

the effect of rail wear, which can allow undetected internal rail defects to grow to 

critical size between required inspections. 

The degree of wear on the accident rail was a factor in the rapid progression 

of the defect from small to critical size. One of the issues highlighted by the 

circumstances of this accident is the inadequacy of the internal rail inspection 

requirement based solely on time and tonnage as set forth in Federal regulations, 

rather than a damage-tolerance approach. 

A damage-tolerance approach would establish an inspection frequency 

that allows internal rail defects to be identified before they reach critical size. 

The term damage tolerance means the ability of a structure to withstand damage 

without failure, including damage such as fatigue cracking or wear, which can 

develop from undetected manufacturing defects or from use in service. For most 

48 Defect size is stated as a percentage of rail head area of a new rail head.
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engineered structural components, including rail, an inspection and maintenance 

program to detect and repair damage in any component before it reaches critical 

size is integral to the damage tolerance of the structure. A damage-tolerance 

approach should (1) identify areas of rail that are prone to failure from high 

stress and fatigue and (2) determine appropriate inspection intervals based on the 

defect size detectable by the inspection method being used, the stress level, and 

the defect (crack) propagation characteristics in the structure. Such an approach 

would consider all the factors that can affect defect growth rates, including rail 

head wear, accumulated tonnage, rail surface conditions, track geometry, track 

support, steel specifications, temperature differentials, and residual stresses in 

the rail. The capabilities and limitations of the inspection methods used to detect 

defects are a major factor in determining appropriate inspection intervals in a 

damage-tolerance approach.

Each railroad should have a rail inspection and maintenance program that 

addresses its unique operating environment and the effectiveness of its inspection 

methods. As noted previously, the NS had established rail wear standards, but the 

amount of wear on the accident rail was sufficient to facilitate rapid progression 

of a relatively small defect. The Safety Board concludes that, in the absence of 

a damage-tolerance-based program, rail can remain in use with excessive 

accumulated wear, which increases the risk of rail failure from rapid growth of 

undetected internal defects. The Safety Board believes that the FRA should require 

railroads to develop rail inspection and maintenance programs based on damagetolerance principles, and approve those programs. Include in the requirement 

that railroads demonstrate how their programs will identify and remove internal 

defects before they reach critical size and result in catastrophic rail failures. Each 

program should take into account, at a minimum, accumulated tonnage, track 

geometry, rail surface conditions, rail head wear, rail steel specifications, track 

support, residual stresses in the rail, rail defect growth rates, and temperature 

differentials. 

As this accident shows, accurately measuring the level of rail wear is 

important in order to determine the appropriate frequency for conducting internal 

rail inspections. When investigators measured the accident rail using a template 

of the type typically used by railroads to measure rail head wear, they found that 

the rail head vertical loss appeared to be about 1/8 inch less than was actually 

measured. Because of downward deformation of the worn rail head under loads, 

the rail head on both sides of the rail web extended below the profile of new or 

less worn rail. The rail wear template fits under the rail head, and the downward 

displacement could have caused the NS to underestimate the amount of wear. The 

Safety Board concludes that downward deformation of a severely worn rail head 

can affect the measurement of rail head wear using a rail wear template and may 

cause a railroad to underestimate the actual amount of wear. The Safety Board 

believes that the FRA should require that railroads use methods that accurately 

measure rail head wear to ensure that deformation of the head does not affect the 

accuracy of the measurements. 
Analysis

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Placement of Hazardous Materials Cars in Trains for Crew 

Protection

Twenty-three placarded ethanol tank cars derailed, starting with the 23rd 

car behind the locomotive units. The 3 locomotives, the first 22 cars (3 empty 

buffer cars and 19 placarded tank cars), and the last 41 cars (all placarded tank 

cars) did not derail. Because the first derailed tank car was the 23rd car behind 

the locomotive units, the train crew was not endangered by the ethanol that was 

released from the derailed tank cars. Therefore, the placement of the ethanol 

tank cars in the accident train was not a factor with respect to crew protection in 

the accident. However, because the accident train was a unit train transporting 

hazardous materials, questions were raised on scene about the number of buffer 

cars needed to separate train crews from the hazardous materials on unit trains. 

Regulations governing the placement of hazardous material cars in trains 

for crew protection are contained in 49 CFR 174.85. The regulations specify that, 

“when the length of the train permits,” a hazardous materials car must be no closer 

than the sixth car from the locomotive. However, when the length of the train 

(meaning the number of available buffer cars in the train) does not allow a five-car 

buffer, trains may move with only a single buffer car. Buffer car regulations were 

initially developed to address the risks of transporting explosives, which needed 

to be isolated from ignition sources and from the train crew. 

When the basic provisions of 49 CFR 174.85 were developed in the early 

1900s, main-line freight trains consisted mostly of a mix of hazardous materials 

and non-hazardous materials freight cars. As is still the case today, main line 

trains traveled from one yard to the next (sometimes picking up or dropping off 

cars along the way), where they were broken down and reassembled into other 

trains, or where cars were interchanged with other carriers. While the intent of 

49 CFR 174.85 was clearly to mandate a minimum five-car buffer on all main-line 

trains, the regulation made allowances for short trains moving small numbers of 

cars during switching operations at or between yards. This was the basis for the 

allowance of a one-car minimum buffer. 

Although unit trains transporting nonhazardous commodities such as coal 

and grain have existed for many years, 49 CFR 174.85 does not address unit trains 

transporting tank cars or other freight cars containing a single hazardous materials 

commodity. The FRA, PHMSA, and the railroads have recognized that buffer cars 

should be required on unit trains transporting hazardous materials to comply 

with the intent of 49 CFR 174.85. Because a unit train does not permit the 

repositioning of cars in the train to provide the five-car buffer (because all the 

loaded cars contain hazardous materials), the FRA, PHMSA, and the railroads have 

interpreted the regulation to mean that a one-car buffer is applicable to unit trains 

transporting hazardous materials. This can result in the contradictory circumstance 

in which a train of mixed freight cars with a single hazardous materials car must 
Analysis

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have a five-car buffer and a unit train consisting of all hazardous materials cars 

may travel across the country with a one-car buffer. 

The Safety Board recognizes that the five-car buffer standard was not based 

upon any rigorous engineering safety analysis, but since the 1920s it has become 

accepted by regulators and railroads as a proven and effective standard. Although 

the five-car buffer standard is considered to have been validated over many years, 

the one-car buffer standard for unit trains does not have as lengthy a historical 

record and may not be sufficiently validated by historical data.

The Safety Board therefore concludes that without sufficient validation of 

the one-car buffer standard, the current regulations for the separation of hazardous 

materials cars from locomotives and their interpretation by the FRA, PHMSA, and 

the railroads create different levels of safety for crew protection from hazardous 

materials on unit trains and general freight trains.

The FRA has indicated that the one-car minimum buffer is justified and 

has concerns regarding regulations that will increase the switching movement for 

cars of hazardous materials. But unit trains typically involve switching only at the 

origin and at the final destination. Consequently, adding a specified number of 

buffer cars to a train at the originating yard generally should not entail additional 

switching of the hazardous materials cars and therefore would not cause increased 

risks. Rather, the additional separation could provide greater protection to train 

crews in the event of an accident. 

Unit trains that carry hazardous materials present a special risk because 

of the high concentration of hazardous materials. The Safety Board believes that 

PHMSA, with the assistance of the FRA, should evaluate the risks posed to train 

crews by unit trains transporting hazardous materials, determine the optimum 

separation requirements between occupied locomotives and hazardous materials 

cars, and revise 49 CFR 174.85 accordingly. The Safety Board believes that the FRA 

should assist PHMSA in its evaluation of the risks posed to train crews by unit 

trains transporting hazardous materials, determination of the optimum separation 

requirements between occupied locomotives and hazardous materials cars, and 

any resulting revision of 49 CFR 174.85. 
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Conclusions

Findings

1. The following were not factors in the accident: crewmembers’ qualifications, 

fatigue, drugs or alcohol, and the crewmembers’ operation of the train. 

2. The mechanical condition of the train was not a factor in the derailment.

3. The emergency response and the command system were effective and 

appropriate.

4. The derailment occurred when the north rail of track 1 separated under the 

load of the accident train.

5. The failure of the north rail of track 1 was precipitated by a detail fracture 

(fatigue crack) that originated from shelling on the rail head, reached critical 

size, and caused a piece of rail to break out under the train.

6. Rail surface conditions prevented the effective transmission of the ultrasonic 

signals, and the defect (fatigue crack) that led to the derailment may not 

have been large enough at that time to be reliably detected by the inspection 

vehicle.

7. NS procedures that do not require a re-examination of rail where there is a 

signal loss during ultrasonic inspection means that those segments of rail can 

remain uninspected and in service indefinitely.

8. The Federal Railroad Administration’s oversight of the Norfolk Southern 

Railway Company’s and other railroads’ internal rail inspection processes was 

inadequate. 

9. The Norfolk Southern Railway Company did not conduct internal rail 

inspections frequently enough to reliably detect an internal defect before it 

could grow to critical size in the significantly worn rail. 

10. The Federal Railroad Administration’s required minimum intervals for internal 

rail inspections are inadequate because they do not take into account the effect 

of rail wear, which can allow undetected internal rail defects to grow to critical 

size between required inspections.
Conclusions

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11. In the absence of a damage-tolerance-based program, rail can remain in use 

with excessive accumulated wear, which increases the risk of rail failure from 

rapid growth of undetected internal defects.

12. Downward deformation of a severely worn rail head can affect the measurement 

of rail head wear using a rail wear template and may cause a railroad to 

underestimate the actual amount of wear.

13. Without sufficient validation of the one-car buffer standard, the current 

regulations for the separation of hazardous materials cars from locomotives 

and their interpretation by the Federal Railroad Administration, the Pipeline 

and Hazardous Materials Safety Administration, and the railroads create 

different levels of safety for crew protection from hazardous materials on unit 

trains and general freight trains.

Probable Cause

The National Transportation Safety Board determines that the probable 

cause of the derailment of Norfolk Southern Railway Company train 68QB119 

was the Norfolk Southern Railway Company’s inadequate rail inspection and 

maintenance program that resulted in a rail fracture from an undetected internal 

defect. Contributing to the accident were the Federal Railroad Administration’s 

inadequate oversight of the internal rail inspection process and its insufficient 

requirements for internal rail inspection.
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Recommendations

As a result of its investigation of the October 20, 2006, derailment of 

Norfolk Southern train 68QB119 in New Brighton, Pennsylvania, the National 

Transportation Safety Board makes the following safety recommendations:

To the Federal Railroad Administration:

Review all railroads’ internal rail defect detection procedures and 

require changes to those procedures as necessary to eliminate 

exceptions to the requirement for an uninterrupted, continuous 

search for rail defects. (R-08-9)

Require railroads to develop rail inspection and maintenance 

programs based on damage-tolerance principles, and approve 

those programs. Include in the requirement that railroads 

demonstrate how their programs will identify and remove internal 

defects before they reach critical size and result in catastrophic rail 

failures. Each program should take into account, at a minimum, 

accumulated tonnage, track geometry, rail surface conditions, 

rail head wear, rail steel specifications, track support, residual 

stresses in the rail, rail defect growth rates, and temperature 

differentials. (R-08-10)

Require that railroads use methods that accurately measure rail 

head wear to ensure that deformation of the head does not affect 

the accuracy of the measurements. (R-08-11)

Assist the Pipeline and Hazardous Materials Safety Administration 

in its evaluation of the risks posed to train crews by unit trains 

transporting hazardous materials, determination of the optimum 

separation requirements between occupied locomotives and 

hazardous materials cars, and any resulting revision of 49 Code of 

Federal Regulations 174.85. (R-08-12)

To the Pipeline and Hazardous Materials Safety Administration:

With the assistance of the Federal Railroad Administration, 

evaluate the risks posed to train crews by unit trains transporting 

hazardous materials, determine the optimum separation 

requirements between occupied locomotives and hazardous 

materials cars, and revise 49 Code of Federal Regulations 174.85 

accordingly. (R-08-13)
Recommendations

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To the Norfolk Southern Railway Company:

Revise your ultrasonic rail inspection procedures 

to eliminate exceptions to the requirement for an 

uninterrupted, continuous search for rail defects. (R-08-14)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

Mark V. Rosenker Deborah A. P. Hersman

Chairman Member

Robert L. Sumwalt Kathryn O’Leary Higgins

Vice Chairman Member

 Steven R. Chealander

Member

Adopted: May 13, 2008

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Appendix A

Investigation

The National Response Center notified the National Transportation 

Safety Board of the New Brighton accident on October 21, 2006, at 12:24 a.m. 

The investigator-in-charge and other members of the Safety Board investigative 

team were launched from the headquarters office in Washington, D.C., and from 

a field office in Chicago, Illinois. Investigative groups were established to study 

track, structures and signals, operations, mechanical, survival factors, human 

performance, and hazardous materials issues. The Vice Chairman, Robert L. 

Sumwalt, accompanied the team to the accident site.

Parties to the investigation included the Norfolk Southern Railway 

Company, the Federal Railroad Administration, the Brotherhood of Locomotive 

Engineers and Trainmen, the United Transportation Union, the Beaver County 

Emergency Services Center, the Brotherhood of Maintenance of Way Employes 

Division, and POET Ethanol Products. 
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Appendix B

Emergency Response Timeline

DAY TIME EVENT

Friday

October 20

10:49 p.m. to 

10:53 p.m.

Fire departments dispatched—New Brighton, City of Beaver 

Falls, Fallston and Baden Boroughs, Pulaski, Daugherty, and 

Rochester Townships.

11:00 p.m. Evacuation began with local fire and police going door to door.

11:05 p.m. Beaver County hazardous materials team bus dispatched.

11:17 p.m. Beaver County ECS notified CSX of accident and requested 

stopping trains.

11:27 p.m. Water authorities downstream notified of accident (Beaver Falls 

and Midland Borough).

Saturday

October 21

12:07 a.m. Foam fire fighting fire equipment arrived from Pittsburgh 

International Airport.

12:12 a.m. Pennsylvania Department of Environmental Protection on scene.

1:20 a.m. Water spraying directed for cooling the second derailed (24th car 

in consist) that was near a house (25th car on fire).

2:40 a.m. NS moved head-end nonderailed cars and locomotive to 

Conway yard.

4:20 a.m. NS moved rear-end nonderailed cars to Beaver Falls.

8:15 a.m. NTSB Go team arrived on site.

9:00 a.m. Two teams of firefighters and NS hazmat responders entered 

derailment area to assess condition of tank cars.

10:00 a.m. Responders considered stimulating the burning by pumping air 

into the cars to increase the burn rate of the product.

10:00 a.m. CSX train traffic returned to service.

11:45 a.m. Two teams went into derailment area again to assess tank cars.

1:00 p.m. to 

3:00 p.m.

Emergency responders planned response tactics and off-loading 

of product. Decided not to stimulate the burning of product.

5:35 p.m. NS contactor began moving the first four derailed cars and 

transferring product.

8:38 p.m. Evacuation zone size reduced.

10:20 p.m. Responders decided to cool the still burning 29th car (SHPX 

206699) and use an aqueous film forming foam.

Sunday

October 22

2:02 a.m. Fire burning from the 29th car (SHPX 206699) extinguished.

2:00 a.m. to 

10:49 a.m.

NS contractor removed 16 cars from track area to a site located 

in an adjacent city park between the track and river.

10:49 a.m. Beaver Falls residents on Bridge Street allowed to return to their 

residences.

12:30 p.m. NS number 2 main track repaired.

4:10 p.m. Two cars still on number 1 main track and two in river.

6:39 p.m. Northbound lanes of highway bridge for PA 18 and PA 65 opened 

to traffic.
Appendix B

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DAY TIME EVENT

Sunday

October 22

10:55 p.m. Responders began to cool the still-burning 44th car (NATX 

301037) and use an aqueous film forming foam.

11:15 p.m. Fire from 44th car (NATX 301037) extinguished.

Monday

October 23

9:21 a.m. Evacuation restriction lifted by incident commander.

12:50 p.m. Last derailed car removed.