National 

Transportation

Safety Board

Washington, D.C.

National Transportation

Safety Board

Washington, D.C. 20594

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NTSB

Permit No. G-200
RAILROAD ACCIDENT REPORT 

NTSB/RAR-05/04 (PB2005-916304) 

COLLISION OF NORFOLK SOUTHERN FREIGHT TRAIN 192 WITH 

STANDING NORFOLK SOUTHERN LOCAL TRAIN P22 WITH 

SUBSEQUENT HAZARDOUS MATERIALS RELEASE AT 

GRANITEVILLE, SOUTH CAROLINA 

JANUARY 6, 2005

• Page 50, fourth paragraph has been updated with the correct company name (Canadian 

Pacific Railway) instead of Canadian National as originally printed. (15 JUNE 2006) 

 

THE CORRECTIONS BELOW ARE INCLUDED

IN THIS VERSION OF THE PUBLISHED REPORT
Railroad Accident Report

Collision of Norfolk Southern Freight Train 192 With 

Standing Norfolk Southern Local Train P22 With

Subsequent Hazardous Materials Release at

Graniteville, South Carolina

January 6, 2005

NTSB/RAR-05/04

PB2005-916304 National Transportation Safety Board

Notation 7710A 490 LíEnfant Plaza, S.W.

Adopted November 29, 2005 Washington, D.C. 20594
National Transportation Safety Board. 2005. Collision of Norfolk Southern Freight Train 192 With 

Standing Norfolk Southern Local Train P22 With Subsequent Hazardous Materials Release at 

Graniteville, South Carolina, January 6, 2005. Railroad Accident Report NTSB/RAR-05/04. 

Washington, DC.

Abstract: About 2:39 a.m. eastern standard time on January 6, 2005, northbound Norfolk Southern 

Railway Company (NS) freight train 192, while traveling about 47 mph through Graniteville, South 

Carolina, encountered an improperly lined switch that diverted the train from the main line onto an 

industry track, where it struck an unoccupied, parked train (NS train P22). The collision derailed both 

locomotives and 16 of the 42 freight cars of train 192, as well as the locomotive and 1 of the 2 cars of train 

P22. Among the derailed cars from train 192 were three tank cars containing chlorine, one of which was 

breached, releasing chlorine gas. The train engineer and eight other people died as a result of chlorine gas 

inhalation. About 554 people complaining of respiratory difficulties were taken to local hospitals. Of these, 

75 were admitted for treatment. Because of the chlorine release, about 5,400 people within a 1-mile radius 

of the derailment site were evacuated for several days. Total damages exceeded $6.9 million.

The safety issues addressed in the report are railroad accidents attributable to improperly lined switches 

and the vulnerability, under current operating practices, of railroad tank cars carrying hazardous materials.

As a result of its investigation of this accident, the Safety Board makes recommendations to the Federal 

Railroad Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, 

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board 

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study 

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board 

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and 

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also 

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Records Management Division

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To 

purchase this publication, order report number PB2005-916304 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports 

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Railroad Accident Report

Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

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

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

Site Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Events Preceding the Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Fire Department Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Sheriffís Office Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Hazardous Materials Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Hazardous Materials Cars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Other Railroad Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Emergency Response Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Train P22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Train 192 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Toxicological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Operations and Track Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Postaccident Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Switch and Track . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Railcars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Tank Car and Hazardous Materials Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Tank Cars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Hazardous Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Sight Distance Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Event Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Laboratory Examination and Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Accidents Involving Improperly Lined Switches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Postaccident FRA Safety Advisory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

FRA Human Factors Working Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

FRA Emergency Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Switch Position Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Postaccident Action by NS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Hours of Service Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Contents iv Railroad Accident Report

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Performance of Train P22 Crew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Train Speeds in Non-Signaled Territory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Hazardous Materials Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Tank Car Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Tank Car Crashworthiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Reduction of Tank Car Vulnerability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Train Crew Protection From Inhalation Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
v Railroad Accident Report

Executive Summary

About 2:39 a.m. eastern standard time on January 6, 2005, northbound Norfolk 

Southern Railway Company (NS) freight train 192, while traveling about 47 mph through 

Graniteville, South Carolina, encountered an improperly lined switch that diverted the 

train from the main line onto an industry track, where it struck an unoccupied, parked train 

(NS train P22). The collision derailed both locomotives and 16 of the 42 freight cars of 

train 192, as well as the locomotive and 1 of the 2 cars of train P22. Among the derailed 

cars from train 192 were three tank cars containing chlorine, one of which was breached, 

releasing chlorine gas. The train engineer and eight other people died as a result of 

chlorine gas inhalation. About 554 people complaining of respiratory difficulties were 

taken to local hospitals. Of these, 75 were admitted for treatment. Because of the chlorine 

release, about 5,400 people within a 1-mile radius of the derailment site were evacuated 

for several days. Total damages exceeded $6.9 million.

The National Transportation Safety Board determines that the probable cause of 

the January 6, 2005, collision and derailment of Norfolk Southern train 192 in 

Graniteville, South Carolina, was the failure of the crew of Norfolk Southern train P22 to 

return a main line switch to the normal position after the crew completed work at an 

industry track. Contributing to the failure was the absence of any feature or mechanism 

that would have reminded crewmembers of the switch position and thus would have 

prompted them to complete this final critical task before departing the work site. 

Contributing to the severity of the accident was the puncture of the ninth car in the train, a 

tank car containing chlorine, which resulted in the release of poisonous chlorine gas.

The safety issues identified in this investigation are as follows:

ï Railroad accidents attributable to improperly lined switches;

ï The vulnerability, under current operating practices, of railroad tank cars 

carrying hazardous materials.

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

Board makes safety recommendations to the Federal Railroad Administration.

1 Railroad Accident Report

Factual Information

Accident Synopsis

About 2:39 a.m. eastern standard time on January 6, 2005, northbound Norfolk 

Southern Railway Company (NS) freight train 192, while traveling about 47 mph through 

Graniteville, South Carolina, encountered an improperly lined switch that diverted the 

train from the main line onto an industry track, where it struck an unoccupied, parked train 

(NS train P22). The collision derailed both locomotives and 16 of the 42 freight cars of 

train 192, as well as the locomotive and 1 of the 2 cars of train P22. Among the derailed 

cars from train 192 were three tank cars containing chlorine, one of which was breached, 

releasing chlorine gas. The train engineer and eight other persons died as a result of 

chlorine gas inhalation. About 554 people complaining of respiratory difficulties were 

taken to local hospitals. Of these, 75 were admitted for treatment. Because of the chlorine 

release, about 5,400 people within a 1-mile radius of the derailment site were evacuated 

for several days. Total damages exceeded $6.9 million.

Site Description

Graniteville, South Carolina,1 is an unincorporated community of about 1,200 

(1990 data) in a mixed rural and suburban area of Aiken County. Graniteville is about 4.5 

miles west of the commercial/retail district of the city of Aiken, South Carolina, and about 

9.8 miles northeast of the commercial/retail district of Augusta, Georgia. (See figure 1.) 

Principals of local emergency response agencies estimated that 5,400 people live 

within a 1-mile radius of the accident site; this includes peripheral areas of adjacent 

communities. The fire district of the local responding fire and rescue agency (the 

Graniteville, Vaucluse, and Warrenville Volunteer Fire Department) has an approximate 

population of 22,000, which includes communities adjacent to Graniteville that were not 

directly affected by the incident.

NS main line track runs in a north-south direction through the center of 

Graniteville. To the east of the main line and extending in a southerly direction is an area 

of primarily residential properties. To the west and extending in a northerly direction is an 

area comprising several moderate- to large-sized industrial plant facilities, some of which 

operate continuously. A small commercial/retail district is adjacent to and north of the 

main line right-of-way (about 1,000 feet from the accident site). Two principal north-south

thoroughfares run parallel to and on either side of the NS main line. These thoroughfares 

are Canal Street2

 to the west and Trolley Line Road to the east.

1 Local maps identify a location proximate to Graniteville as New Hope, but local residents consider 

the locality to be Graniteville.

2 Canal Street is also known locally as Main Street.
Factual Information 2 Railroad Accident Report

Graniteville lies in a shallow valley that encompasses a stream, known as Horse 

Creek, which is about 1,000 feet west of the NS main line and somewhat parallels it. The 

terrain adjacent to Horse Creek generally gains elevation as it extends to the east and to 

the west of the streambed. The Horse Creek streambed is about 190 feet above sea level. 

The main line track at the accident location is about 225 feet above sea level, with the 

terrain moderately increasing in elevation as the track extends toward the north. The 

industry track elevation is also about 225 feet at the turnout, with the elevation moderately 

decreasing as the track extends north and west toward the plant.

The industry track where the accident occurred serves facilities of Avondale Mills, 

Inc., a manufacturer of textiles. (See figure 2.) The facilities include the millís Woodhead, 

Hickman, and Gregg Division plants as well as the Stevens steam plant. The Avondale 

Mills industry track (hereinafter referred to as ìindustry trackî), upon diverging from the 

NS main line, immediately traverses Canal Street at a roadway at-grade crossing and 

Figure 1. Accident location.

Columbia

Greenville

Anderson

Rock Hill

North Charleston

SOUTH CAROLINA

NORTH CAROLINA

GEORGIA

Summit

Aiken

Augusta

Graniteville

Warrenville

Railway System

Norfolk Southern Facilities

Graniteville

DIAGRAM NOT TO SCALE 

Aiken

Warrenville

Augusta
Factual Information 3 Railroad Accident Report

continues in a northwesterly direction. The track then traverses Hickman Street at a 

roadway at-grade crossing before continuing in a northwesterly direction toward several 

industrial facilities and additional track turnouts. The portion of the industry track between 

the Canal Street grade crossing (edge of pavement) and the Hickman Street grade crossing 

(edge of pavement) measures about 328 feet in length. 

Events Preceding the Accident

NS local train P22 (full designation P22P005) operated Monday through Friday 

out of the NS yard at Aiken, South Carolina. The train crew (engineer, conductor, and 

brakeman) normally went on duty at 7:00 a.m. and spent the day placing and picking up 

cars at local industries along the main line.

On January 5, 2005, the day before the accident, the regularly assigned train P22 

conductor was on vacation. During his absence, the trainís regularly assigned brakeman 

was working as conductor, and the brakemanís job was filled from the extra board.3

 Both 

the conductor and brakeman went on duty in Aiken at 7:00 a.m. on January 5. The 

regularly assigned engineer for train P22 had taken the day off, and his job was also being 

Figure 2. NS main line and Avondale Mills facility industry track in Graniteville. ìP.S.î 

identifies the point of switch from the main line onto the industry track.

3 The extra board is a list of qualified employees available to work in the absence of a regular 

employee or to work unscheduled assignments. At the time of the accident, temporary job vacancies on train 

P22 were filled from among extra board employees working out of Columbia, South Carolina, about 58 

miles from Aiken.

Fence Line

Trolley Line Road

Canal Street

Aiken Road

Aiken Road

Hickman Street

65’

65’

Hard Street

Church

0’ 50‘ 100’ 150’ 200’

Industry Gate

N

P.S.

NS Right of Way (Property Line)

NS Right of Way

Parking Lot

Hickman Mill

Building

Data Processing Office

Avondale Mills

Source: NTSB
Factual Information 4 Railroad Accident Report

filled from the extra board. Because of rest requirements,4 the only available extra board 

engineer could not begin work until 8:32 a.m.

The NS trackage in this area is non-signaled, and authority to use various track 

segments is via track warrants issued by the train dispatcher in Greenville, South Carolina. 

At 8:11 a.m., the train P22 conductor was given a track warrant authorizing train P22 to 

occupy and work on the east-west main line (designated the SA line) between milepost 

(MP) SA51.0 and Warrenville, South Carolina (MP SA63.4). The SA main line connects 

Aiken with the north-south main line (designated the R line) on which the accident 

occurred. (See figure 3.) 

The brakeman said that after the engineer arrived, the conductor held a job briefing 

with the crew in which he advised them of specific movements that were to be made 

during the shift.5 After the briefing, the crew boarded its locomotive, coupled to eight 

freight cars, and departed the Aiken Yard.

4 Required off-duty time between assignments, generally referred to as ìrest,î is governed by Federal 

regulations and union agreements.

Figure 3. NS main lines in the accident area. Mileposts are referenced by letter and 

number designations.

5 At the time of the accident, the Federal Railroad Administration had recommended, but had not 

required, that railroads mandate such job briefings. The NS Safety and General Conduct Rules required that 

job briefings be held ìto review the planned itinerary, procedures, and necessary safeguards for the task to be 

performed.î The rule specified that such a briefing ìmust always precede the task at the work site, be clearly 

understood, and be updated or modified as conditions change.î

COLUMBIA, SC

Bridgestone

Vaucluse Siding

R 175

Warrenville Siding

R 179.3

SA 63.45

AIKEN 

SA 57.29

Point of Switch

R 178.3

AB 17.3

AUGUSTA, GA

R 109.0

R 171.8

R 191.4

N

POINT OF 

COLLISION

Avondale Mills / 

Gregg Industry

AB 23.75

SA 51

SA-Line

R-Line

AB-Line

GRANITEVILLE, SC
Factual Information 5 Railroad Accident Report

The crew spent the first part of the day servicing industries along the SA line 

before returning to the Aiken Yard about 1:00 p.m. for lunch. After lunch, the crew reboarded the train, and about 2:10 p.m., the conductor received a second track warrant 

authorizing the train to occupy and operate on the R main line track between MP R185.0 

and MP R171.0. Train P22 then proceeded east to the junction of the SA and R main lines.

During the afternoon, the crew worked various industries along the R line from 

Bath, South Carolina, (MP R185.0) north to the Bridgestone industrial lead (MP R171.8). 

The engineer said that about 4:00 p.m., the crewmembers realized that they would be 

ìpressed for timeî to complete their planned work. The crewmembers completed their 

duties at the Bridgestone lead at 5:50 p.m. After leaving Bridgestone, the crew intended to 

place two cars of sodium hydroxide solution (caustic soda) at the Avondale Mills plant at 

MP R178.3, after which they planned to proceed south to Warrenville (MP R179.3) and tie 

down the train for the night. The conductor had arranged with a taxi service under contract 

to the NS to have a taxi waiting at Warrenville at 6:15 p.m. to take the crew back to Aiken.

Train P22, now with 12 freight cars, reached the industry track about 6:10 p.m. 

According to the engineer, although the conductor and brakeman had conducted job 

briefings at other work sites during the day, no job briefing was held before the work 

began at the Avondale Mills plant. When he was later asked why he believed no job 

briefing was held, the engineer said, ìIt could have been they [the conductor and 

brakeman] were in a hurry.î

The train stopped on the main track with its locomotive about 6 car lengths north 

of the main track switch for the industry track.6

 (See figure 4.) The conductor said that he 

told the brakeman to bring in the train on the industry track, after which the conductor 

dismounted the locomotive and walked west to open the facility gates and make sure the 

tracks were clear. (See figure 5.) The conductor also lined the industry track switches for 

the move. The train then pulled south, stopping just north of the switch, at which point the 

brakeman dismounted. The train pulled south again and stopped when the last car was 

clear of the industry track switch. The brakeman lined and locked the switch7

 (see figure 

6) to allow the train to move from the main track onto the industry track, then walked back 

to flag the first road crossing. After the conductor had prepared the route, the engineer 

shoved the train from the main line onto the industry track. Once the train occupied the 

first crossing, the brakeman radioed the engineer to stop. The brakeman mounted the 

leading end of the last freight car, and the train shoved back again, with the conductor 

flagging the next road crossing. 

6 The information in this section regarding crew actions and train movements is based on postaccident 

interviews with the crewmembers.

7 Main line switches have locks that deter tampering by unauthorized persons. Railroad employees 

have keys for the locks, and they are expected to relock a switch after it has been repositioned.
Factual Information 6 Railroad Accident Report

Figure 4. Looking north at the switch and turnout from the NS R main line onto the 

Avondale Mills industry track at Graniteville. The switch banner, or target, shows white, 

indicating that the switch is in the ìnormalî position, that is, aligned for movement along 

the main line track. (The banner shows red when the switch is set for the industry track.) 

North of the turnout and to the right of the main line is the wayside light indicating the 

position of the switch for the Vaucluse Siding.

Figure 5. The Avondale Mills industry track and gates to the Avondale Mills facility at 

Graniteville.
Factual Information 7 Railroad Accident Report

Train P22 had to pull out and set aside two empty cars before it could place the two 

loaded caustic soda cars at the facility. (According to the engineer, these moves did not 

require that the train pull out as far as the main line, and no part of the train moved over 

the main line switch after the train was backed onto the industry track.) The conductor said 

that he was aware that the Federal hours-of-service limitation of 12 on-duty hours8 would 

occur for himself and the brakeman at 7:00 p.m., and he told the engineer and the 

brakeman that they would not have time to continue to Warrenville as planned. At 

6:20 p.m., he radioed the taxi driver waiting at Warrenville and told him to come to the 

industry track (about 1 mile north of Warrenville) to pick up the crew.9

After placing the two caustic soda cars at the Avondale Mills plant, the crew 

prepared to leave the train on the industry track for the night. Because of the length of the 

train and the need to avoid blocking the road crossings or the plant gate, the crew had to 

uncouple 8 cars from the 10-car train and place them on two tracks within the plant gates. 

The engineer then moved the locomotive and the remaining two empty freight cars onto 

the industry track between the main line and the industry gate, stopping the locomotive in 

the clear about 5 to 6 car lengths from the main line switch.10 About this time, the taxi 

arrived and parked on the grass on the east side of the industry track near the locomotive.

Figure 6. The switch stand for the Avondale Mills turnout switch at Graniteville showing 

the switch locked in position.

8 Title 49 Code of Federal Regulations Part 228.

9 The vehicles used by the contracted taxi service have radios that allow them to communicate with 

train crews.

10 The length of train P22 as parked on the siding was about 172 feet. Based on this measurement, crew 

statements, and other documentation obtained during the investigation, the head end of train P22 was 

estimated to be about 342 feet from the switch stand for the main line track switch.
Factual Information 8 Railroad Accident Report

The engineer applied the locomotive handbrake and began shutting down and 

securing the locomotive. The brakeman said that he closed one of the two sides of the 

swinging gate at the entrance to the plant and walked toward the locomotive to tie down 

the train and retrieve his personal belongings. He said they had been ìpushed for the 

[hours-of-service] lawî as they worked, and he noted the time and was ìin a hurry to get 

everything done that I needed to do.î The brakeman said he looked at his watch and noted 

that it was about 6:59 p.m. when he reached the locomotive. The brakeman set handbrakes 

on the train and retrieved his bag from the locomotive.

Meanwhile, the conductor noted that it was about 6:57 p.m. when he closed the 

other side of the plant gate and began walking toward the locomotive. He said he 

remembered thinking to himself, ìLord, mission accomplished. Everybodyís happy. Letís 

get our stuff and go in.î He said he saw the brakeman at the locomotive when he arrived. 

He said he retrieved his clipboard and bag and placed them in the back of the taxi, then 

went back to help the engineer with his bag. The three crewmembers then got in the taxi, 

and the taxi departed.

During the time the crew was working at the Avondale Mills facility, the main line 

switch remained lined for the industry track. NS Operating Rule 104, in effect at the time, 

required that the train P22 crew return the switch to its ìnormalî position (lined and 

locked for the main line) when the work was complete. Rule 104(a) states that, while the 

position of a switch is the responsibility of the employee handling it, ìthisÖdoes not 

relieve other crewmembers of the responsibility if they are in place to observe the position 

of switches.î

In postaccident interviews, the brakeman said he was aware that whenever a job is 

completed, any main line switch that was used must be lined and locked for the main 

track. He said,

in my mind, when I left [the industry track], everything was properly lined back to 

the main line. I had no doubts in my mind when I left there.

He also said, ìI am not 100 percent sure that I did [reline the main line switch]. I 

would say I might have made a mistake.î

The engineer said that he was on the ìoff sideî of the locomotive and could not see 

the main line switch while working on the industry track. He said that he did not know 

ìhow the brakeman handled it.î

The conductor stated:

While we [were] working in the plant, I was off in the field and I never got near 

the switchÖ. We usually have job briefings, but I never told my brakeman to 

make sure that the switch was lined and locked for the main line movement. I 

never told him, and I never touched the switch myself. It was in my mind when I 

arrived at the mill. I should have done a briefing to ensure that the switch was 

lined back.
Factual Information 9 Railroad Accident Report

The conductor also stated that because the industry track was curved, the main line 

switch banner11 was not illuminated by the locomotive headlight while the train was in the 

industry track, nor was it otherwise visible to the crewmembers while they worked.

The conductor said he had no conversations with the engineer or the brakeman 

about the way the switch was lined. The conductor also said, and the taxi driver 

confirmed, that the subject of the switch did not come up during the ride back to the 

terminal. The conductor said, ìOnce we got in that taxi, we went back toward the depot; 

and in my mind, everything was all right.î As it left the area, the taxi traveled south along 

Canal Street and over a grade crossing within 21 feet of the main track switch, but neither 

the driver nor his passengers noted its position.

The taxi arrived at the Aiken Yard office at 7:15 p.m. After the crewmembers 

gathered their belongings, the engineer departed the yard while the conductor and 

brakeman proceeded to the yard office. About 7:50 p.m., as the conductor was completing 

his paperwork, he asked the brakeman to contact the train dispatcher and clear the two 

track warrants that had been issued to train P22. The brakeman cleared the two track 

warrants with the dispatcher at 7:53 and 7:54 p.m., respectively. The brakeman said later 

that he would not have cleared the track warrants for the conductor if he had thought he 

had not left everything lined properly at the industry track.12 The conductor and brakeman 

completed the paperwork at 8:11 p.m.13

The Accident

The train dispatcher on duty when local train P22 finished its work said that no 

trains occupied the main line track in the Graniteville area from the time the localís track 

warrants were cleared at 7:54 p.m. until he went off duty at 11:00 p.m. The dispatcher who 

came on duty at 11:00 p.m. said that he gave no authority for train operations over that 

section of track until after 2:00 a.m. on January 6, 2005, when he issued a track warrant 

for NS freight train 192 (full designation 192P005) to operate from Augusta, Georgia (MP 

R191.4), to Summit, South Carolina (MP R132.8).

Train 192 originated in Macon, Georgia, on January 5, 2005, and was destined for 

Columbia, South Carolina. The NS records indicate that the train received an initial 

terminal air brake test in Macon at 10:50 a.m. The train departed Macon at 1:30 p.m. on 

January 5 with 2 locomotives, 16 loads, and 14 empties.

11 A switch banner, sometimes termed a switch indicator or switch target, is typically a reflectorized 

metal flag-like device connected to the switch stand. (See figure 4.) It consists of one or two flags of 

different colors that indicate the position of the switch.

12 NS Operating Rule 181, regarding track warrants, states, in part, ìWhen clearing [a track warrant] at 

a point where a switch must be returned to the normal [main line] position, ëclearí must not be given until 

such switch has been locked in the normal positionÖ.î

13 Although the crew completed train operations within the 12-hour Federal hours-of-service limit, the time 

required to complete paperwork for the train caused the on-duty time of the conductor and brakeman to exceed 12 

hours. The NS subsequently filed excess service reports with the Federal Railroad Administration for this time.
Factual Information 10 Railroad Accident Report

While en route, the head-end train telemetry device on the lead locomotive failed 

to communicate properly with the end-of-train telemetry device.14 At McBeam, Georgia, 

the train crew switched the two locomotives, after which reliable communications were 

established. No other problems were encountered en route. The train arrived at 10:50 p.m. 

at the NS Nixon Yard in Augusta, Georgia, where the inbound crew went off duty.

The outbound train 192 crew (engineer and conductor), who would continue the 

trip toward Columbia, South Carolina, went on duty at 12:30 a.m. on January 6, at Nixon 

Yard. The conductor said that after taking control of train 192 at Nixon Yard and receiving 

the necessary track warrant, he and the engineer took the train about 4 miles across town 

to the NS Augusta Yard, where they performed switching duties and added cars to the 

consist. After a successful brake test, train 192 departed Augusta Yard about 2:10 a.m. on 

January 6. The train consisted of two locomotive units (operating short hood forward) 

pulling 25 loads and 17 empties. The train had a trailing tonnage of 3,520 tons and a 

length of 2,553 feet. The NS consist list for the train showed 14 cars containing hazardous 

materials or hazardous materials residue.15

About 30 minutes and 13 miles after departing Augusta, train 192 approached the 

industry track at Graniteville. According to event recorder data, the train was traveling 44 

mph at this time (recorder time 2:36:30 a.m.). The engineer moved the throttle handle to 

notch 8 (maximum throttle), and the throttle remained in this position until 2:38:11, when 

the train speed indicated 47 mph. As the speed continued to increase to 48 mph, the 

engineer decreased the throttle to notch 6. At recorder time 02:38:37, the throttle handle 

was placed in notch 4, with the speed remaining at 48 mph.

The conductor stated that about this time he heard the trainís emergency brakes 

activate. He said he recalled the engineer saying, ìThe target [switch banner] is wrong,î16

but the conductor said he did not observe the switch target himself. He said that his train 

was diverted onto the industry track, where it struck another train, throwing him to the 

floor of the locomotive. He said he recalled smelling chemicals after the impact. Event 

recorder data indicated that the speed of the train at 2:39:00 a.m., approximately 467 feet 

from the final resting point, was 47 mph. At 2:39:20, the speed registered 0 mph.

According to dispatcher radio transcripts, at 2:40:11 a.m., a radio emergency tone 

sounded at the desk of the NS dispatcher on duty in Greenville. When the dispatcher 

responded to the emergency tone, a caller (believed by the dispatcher to be the train 192 

engineer) reported:

14 The end-of-train telemetry device (EOTD) transmits pertinent information, including brake pipe 

pressure at the rear of the train, to the head-end telemetry device (HOTD) on the lead locomotive.

15 These included three tank cars of chlorine (the 6th, 7th, and 9th cars from the locomotives); two tank 

cars of sodium hydroxide (the 8th and 31st cars); two tank cars containing residue of elevated temperature 

rosin (the 16th and 17th cars); one tank car of cresols (the 18th car); four tank cars containing methanol 

residue (the 24th through 27th cars); and two tank cars of aniline (the 34th and 35th cars).

16 The investigation revealed that the switch target was on the engineerís side (the west side) of the 

locomotive as the train proceeded north.
Factual Information 11 Railroad Accident Report

Dispatcher, this is trainÖ192Ö. We need emergency assistance in Graniteville. 

We justÖhit a switchÖat GranitevilleÖ. It was lined off the main line and we 

went around there andÖhit an engine that was in the track. ÖWe went through 

the switch at 45 mph. We need help.

Asked by the dispatcher if the crew was all right, the caller said, ìIt just 

happenedÖ. We need an ambulance. I think Iím bleeding.î

According to NS records, the dispatcher reported the collision and possible injury 

to the NS police command center. An employee of the command center subsequently 

reported the accident to the Aiken County Sheriffís Department and requested emergency 

medical services.

In a Safety Board interview, the conductor said that he attempted to get off the 

locomotive from his side (the east side) of the locomotive, but was unable to do so because 

the window and door were jammed. He said that he exited the locomotive from the other 

side, followed by the engineer. The conductor said that he and the engineer then walked 

about 100 yards, at which point they ìmet up with some people.î He recalled the engineer 

saying that they needed to get ìdownwindî of the area. He also recalled seeing white or 

gray smoke, but no fire. He said they walked a little farther, and then lay on the ground.17

Emergency Response

When train 192 struck train P22, both locomotives and the first 16 cars of train 192 

derailed. (See figure 7.) The ninth car from the locomotive units, containing 90 tons of 

chlorine, was punctured during the derailment and released chlorine gas. Winds were light 

at the time of the accident, and the chlorine vapor cloud settled in the low-lying valley 

along the tracks.18 Based on emergency responder observations and the locations of those 

receiving fatal injuries, the cloud extended at least 2,500 feet to the north; 1,000 feet to the 

east; 900 feet to the south; and 1,000 feet to the west. The sudden release and expansion of 

the escaping gas caused the product remaining in the tank to auto-refrigerate and remain in 

the liquid state, slowing the release of additional gas.

17 The conductor said that he was subsequently informed in a hospital that an Avondale Mills employee 

placed him on the back of his truck and transported him to a hospital after he and the engineer walked away 

from the collision. A motorist reported picking up the engineer and transporting him to a hospital.

18 Because chlorine gas is heavier than air with a vapor density of 2.5 at 32° F, it will seek the lowest 

point in the immediate area.
Factual Information 12 Railroad Accident Report

Figure 7. Distribution of wreckage after the derailment and collision. ìP.C.î indicates estimated point of collision

Fence Line

Trolley Li

ne Road

Canal Street

Aiken Road

Aiken Road

Hickman Street

65’

65’

Hard Street

Church

1

2

3

S2

S1

17

0’ 50‘ 100’ 150’ 200’

16

7 6

4 5

Industry Gate

N

KEY

8

9 10

15

P.S.

655’

771’

NS Ri

ght of Way (Property Line)

NS Ri

ght of 

Way

P

236’

342’

P1

P2

136’

0.0 (Ref.)

H

H

H

14

11

12

13

Ascen

ding 

Grade

Parking Lot

Hickman Mill

Building

Data Processing Office

P. Locomotive 4622P1. PPGX 12119

P2. WITX 4760

S1. Locomotive 6653

S2. Locomotive 6593

1. NS 473153

2. NS 269182

3. SOU 6774 4. ACFX 0512135. NAHX 551307

6. SBLX 141467. GATX 171058. GATX 583269. UTLX 900270

10. NAHX 551599

11. CSXT 496430

12. CSXT 49690413. CSXT 495573

14. NS 41117815. NS 403130

16. GATX 31941 (One end off)H. Coil Car HoodsP.S. Point of Switch & Switch Stand Location

P.C. Point of Collision

Source: NTSB

564’

Avondale Mills

Average 1.14% Descending Grade

719’

P.C.
Factual Information 13 Railroad Accident Report

Immediately after the collision, at 2:39:43 a.m. on January 6, a female employee 

on duty at one of the Avondale Mills facilities (about 200 feet from the collision site) 

placed a 911 call to the Aiken County Sheriffís Office 911 Emergency Call Center. The 

caller identified herself and reported, ìI think thereís been a train wreckÖat 

GranitevilleÖat Hickman Mills.î She said that she was alone and that when she went 

outside to investigate, she could ìsee smokeî but could not discern exactly what had 

happened. She further indicated that the accident was at the Hickman Street railroad grade 

crossing. Near the end of the 48-second call, the caller appeared to become increasingly 

agitated, saying, ìI smell smoke.î The caller then exclaimed, ìI got to get out of here,î at 

which point the call abruptly ended.

Over the next 10 minutes, about a dozen additional calls were made to 911, with 

callers reporting that there had been a train wreck. Some callers reported a low-lying 

yellow haze that smelled like bleach. Within about an hour after the accident, more than 

100 additional 911 calls were received. By 6:00 a.m., more than 200 calls had been 

received. Also commencing about 2:40 a.m. were calls on the non-emergency telephone 

lines of the emergency call center. About 80 calls were received on these lines within the 

first hour, and by 5:40 a.m., about 200 calls had been received. 

Fire Department Response

At 2:40:40 a.m., resources of the Graniteville, Vaucluse, and Warrenville Volunteer 

Fire Department were dispatched to the scene, with the first responding unit reported to be 

en route less than a minute later.19 At 2:42 a.m., upon hearing a report from the dispatcher 

that a smell of chemicals was reported in the area, the initially responding fire department 

senior officer (the fire chief) advised further responding fire department personnel to stand 

by at their locations away from the scene until the situation could be further assessed.

At 2:45 a.m., emergency dispatch advised the fire department that it had confirmed 

the possibility that two trains had collided head on. Additional confirmation came from 

the NS about 3 minutes later. The fire chief, upon approaching the scene, smelled an 

intense chemical odor and experienced difficulty breathing. At 2:46 a.m., a hazardous 

materials team was requested. At 2:48 a.m., the fire chief advised dispatch that he could 

not breathe and was withdrawing from the area. At 2:49 a.m., the fire department asked 

dispatch to initiate the Aiken County Reverse 911 Emergency Notification System, with 

instructions for residents to shelter indoors.

Commencing about 2:50 a.m., additional resources⎯ambulances, hazardous materials 

personnel and equipment, Aiken city and other mutual aid services⎯were asked to respond. At 

2:52 a.m., dispatch advised responders that three persons were trapped inside the Hickman 

plant. At 2:54 a.m., fire department personnel asked dispatch to advise Aiken Hospital that 

persons overcome by chemical fumes were en route from the scene. At 2:57 a.m., the fire 

department asked that approach roads be blocked (which effectively initiated a 1-mile-radius 

buffer around the accident site) and reiterated the earlier reverse 911 request to shelter indoors.

19 Information in this section is based on incident response data and communications information 

provided by the responding agencies, as well as on interviews with key emergency response personnel.
Factual Information 14 Railroad Accident Report

At 3:05 a.m., while awaiting delivery of train consist information that had been 

faxed from NS, the fire chief directed that an incident command center be established; the 

fire chief would become incident commander for the search and rescue effort. About this 

time, firefighters also asked dispatch to obtain wind direction information (from Bush 

Field in Augusta), which was received about 3 minutes later.

At 3:06 a.m., firefighters were informed that the sixth through ninth cars on the 

train contained chlorine and sodium hydroxide and that additional information would be 

forthcoming. At 3:08 a.m., the fire department began staging equipment and personnel at 

the incident command center, which had been set up at a nearby car dealership. At 

3:10 a.m., firefighters asked that all Aiken County emergency medical services 

ambulances be placed on standby.

At 3:13 a.m., an Avondale Mills employee told firefighters that workers on duty at the 

Stevens steam plant could not be contacted. The employee expressed concern about a possible 

explosion if the workers had departed the plant without properly shutting down the boilers.

At 3:21 a.m., personnel from the Aiken County hazardous materials team arrived 

at the incident command center. At 3:24 a.m., a copy of the faxed train 192 consist list was 

delivered, and fire department authorities advised all responding personnel to report with 

their equipment to the command center. At 3:30 a.m., the fire department requested all 

available self-contained breathing apparatus.

At 3:33 a.m., a report was received of a ìsteady streamî of individuals departing 

the Ascauga Lake Road area. At 3:35 a.m., authorities established the first of four 

decontamination stations to treat individuals exposed to the chlorine gas. At 3:37 a.m., 

dispatch advised firefighters that it had received reports of people ìdownî inside the 

Avondale Mills facility. At the same time, a firefighter and a mill supervisor entered the 

steam plant to prevent a possible boiler explosion. A decision was made to shut down and 

evacuate the plant.

At 3:38 a.m., a second decontamination station was set up. At 3:39 a.m., the 

incident commander, concerned that the incident command center was too close to the 

accident site, directed that it be moved from the car dealership to a location about a mile 

away. Some emergency response apparatus remained at the initial site as a ìforward 

commandî location. At 3:40 a.m., a firefighter wearing personal protective equipment got 

close enough to the accident site to note the number on the tank car that had been 

breached. He also encountered an individual suffering from gas inhalation and discovered 

another individual trapped in an automobile beneath a fallen tree near the derailment site. 

(Both these individuals were later successfully rescued.)

Beginning at about 3:50 a.m., several entry teams, consisting of firefighters 

wearing personal protective equipment and riding in privately owned pickup trucks, were 

organized and dispatched to the accident site for search and rescue operations. Upon 

locating individuals or groups affected by the chlorine gas, the teams transported them to 

one of the decontamination sites. The entry teams then returned to the site to repeat the 

search and rescue cycle for several hours.
Factual Information 15 Railroad Accident Report

At 3:53 a.m., a third decontamination station was established at a local high 

school. At 4:10 a.m., an entry team reported a downed electrical power line near the 

wreckage site, and a request was made to the utility company to respond to the scene to 

disconnect the power feed. Also at 4:10 a.m., an entry team reported no visible fire in the 

derailment wreckage. This report was revised at 4:24 a.m., when responders reported 

seeing ìbright orange smokeî20 emanating from one railcar and ìgreen smokeî21 from 

another.

At 4:55 a.m., an entry team entered the steam plant to shut down the facility. 

Moments later, the mission was revised when ìfive or sixî individuals were reported to be 

trapped in a room at the plant. One person was found and rescued, after which the team 

completed the shutdown of the steam plant at 5:07 a.m. and performed a final sweep of the 

plant. Several additional entry teams began missions to assess the condition of the railroad 

equipment.

The immediate area around the accident site remained relatively stable until 

1:00 p.m., when a fire was reported at the steam plant. A fire department entry team 

entered the plant and found that a fire had ignited in coal chutes feeding several of the 

boilers. A pumper truck supplied water to an unmanned waterline-fed monitor nozzle that 

discharged a spray on all the coal feeders. At this point, the fire was under control but not 

extinguished. The discharging monitor nozzles were left in place while workers evacuated 

the area. The scene remained relatively stable for the balance of the day.

For the next several days, fire department entry teams monitored and contained the 

fire in the steam plant coal feeders while a cleanup of the railroad wreckage continued. At 

8:00 a.m. on January 14, with the report that the hazardous materials had been removed 

from the unbreached railcars, support operations were concluded, and hazardous materials 

response personnel were released. At about noon, fire department personnel returned to 

the steam plant to extinguish the remaining fire in the coal feeders. The fire was reported 

extinguished at about 4:00 p.m., which concluded the fire departmentís operations for the 

incident.

Sheriffís Office Response

After the initial 911 call, patrol units of the Aiken County Sheriffís Office were 

dispatched to the scene. The first sheriffís office responder arrived on the scene about 

2:42 a.m., followed shortly thereafter by several other officers. When they approached the 

scene, the officers began experiencing respiratory difficulties because of the chlorine gas. 

They immediately withdrew to a safe distance and awaited further instruction. Several of 

the responding officers were taken to a local medical facility for treatment.

20 According to technical experts, the appearance of ìorange smokeî is consistent with entrained ferric 

chloride in the released liquid chlorine. Light appears red as it passes through the ferric chloride that forms 

as chlorine reacts with steel in an oxygen-deprived environment. The absence of fire damage in proximity to 

the chlorine tank puncture indicates that the derailment did not result in a fire.

21 The appearance of ìgreen smokeî is consistent with a discharge of chlorine gas.
Factual Information 16 Railroad Accident Report

Workers and residents in the immediate vicinity of the gas release began to 

evacuate the area within moments of the accident. They were assisted in this evacuation 

by fire department and sheriffís office personnel on scene.

Later in the morning, the sheriffís office directed the evacuation of those who had 

been sheltering in place within a 1-mile radius of the site. This mandatory evacuation 

affected about 5,400 people. Sheriffís office personnel, assisted by mutual aid from a 

number of other area law enforcement agencies, conducted a house-to-house evacuation. 

Approach roads were closed at key intersections. The sheriffís office also instituted a 

300-meter buffer zone around the site and restricted access to only those individuals 

wearing the appropriate personal protective equipment. The evacuation was lifted in 

phases, beginning on January 13, with the last evacuees permitted to return to their homes 

on January 19.

Hazardous Materials Response

About 11:00 p.m. on January 6, responders inserted a temporary polymer patch in 

the opening of the punctured ninth tank car. At 7:00 p.m. on January 8, responders began 

unloading sodium hydroxide from the eighth tank car. At 8:50 p.m., the temporary 

polymer patch in the ninth tank car failed, releasing chlorine vapors and causing the 

unloading of the eighth tank car to be temporarily discontinued. By 8:37 a.m. on 

January 9, responders had inserted a second polymer patch in the opening in the punctured 

ninth tank car. Chlorine vapor was then drawn from the car to create a vacuum that would 

reduce the amount of chlorine gas escaping. The chlorine vapor removed from the tank 

was transferred into a sodium hydroxide solution to neutralize it. Following these 

measures, the unloading of the eighth tank car was resumed and completed by 3:30 p.m. 

While the eighth car was being unloaded, construction began on a permanent lead patch 

for the punctured ninth car.

At 9:30 a.m. on January 10, the punctured chlorine tank car was rotated so the 

puncture was at the highest elevation on the tank car. This rotation disturbed the liquid 

chlorine in the tank and caused a delay in efforts to unload other tank cars.

At 12:10 p.m. on January 10, responders began unloading the chlorine from the 

derailed sixth car in the train. On the morning of January 11, responders rejected the plan 

for a lead patch on the punctured ninth tank car and decided to use a steel patch instead. 

Unloading of the sixth car was completed by 2:00 p.m. on January 11.

About 1:10 a.m. on January 12, responders began unloading chlorine from the 

derailed seventh car. By 9:30 a.m., the steel patch was in place on the punctured tank car, 

and the unloading was started. Because the punctured tank car had extensive damage, the 

remaining chlorine could not be removed as it had been from the unbreached cars. The 

chlorine in this car had to be vaporized and transferred from the tank as a gas, after which 

it was bubbled through a sodium hydroxide solution held in a separate tank. This process, 

which converted the chlorine into a relatively safe and easily transportable liquid bleach 

and salt solution, required several days to complete.
Factual Information 17 Railroad Accident Report

By 2:10 p.m. on January 12, the unloading of the seventh car was complete. By the 

early morning hours of January 13, the two unbreached chlorine tank cars had been 

unloaded, placed on railroad flat cars, and moved from the site.

By midnight on January 18, the unloading of the punctured tank car was complete. 

(See figure 8.) On January 19, by 9:00 a.m., the tank car was cleaned and purged on site. It 

was then loaded on a flat car and moved to the Augusta Yard the following morning, 

January 20.

Injuries

Nine persons, including the train 192 engineer, died from chlorine gas inhalation 

as a result of the accident.22 Of the eight civilians who received fatal injuries, six were 

employees of Avondale Mills facilities to the west and north of the accident site, one was a 

truckdriver at one of the plant facilities to the west of the site, and one was in a residence 

south of the site.

Figure 8. Ruptured chlorine tank car during unloading. The tank has been rotated so 

that the patched puncture is at the top. Hoses attached to the patch are drawing off 

chlorine vapors that are then bubbled through a sodium hydroxide solution to reduce 

their hazard.

22 The death of another Graniteville resident on April 19, 2005, was initially reported by media sources 

to have occurred as a result of exposure to the chlorine gas released in the accident. The final autopsy report 

for this individual listed the death as natural due to pulmonary thromboemboli. Regardless of the 

circumstances, this death would not have met the criteria for death reporting under 49 Code of Federal 

Regulations 830.2, because it did not occur within 30 days of the accident.
Factual Information 18 Railroad Accident Report

About 554 people, among them civilians, railroad crew, and emergency 

responders, were taken to local hospitals complaining of respiratory difficulties. Of these, 

75 were admitted for treatment. Six firefighters were treated and released; one firefighter 

was admitted to the hospital and remained there for several days. Two sheriffís department 

officers were also treated and released.

The coronerís investigation reports for the eight deceased civilians all listed the 

probable cause and mechanism of death as asphyxia, which occurred within ìminutesî of 

exposure, with secondary/contributing factors that included exposure to chlorine gas. The 

locomotive engineer survived the collision but died several hours later. The coronerís 

investigation report listed the probable cause and mechanism of death of the engineer as 

lactic acidosis with secondary/contributing factors that included exposure to chlorine gas.

Damages

Hazardous Materials Cars

Of the 16 derailed cars, 5 contained hazardous materials or hazardous materials 

residue. The hazardous materials cars included three tank car loads of chlorine (the 6th, 7th, 

and 9th cars from the locomotives), one tank car load of sodium hydroxide (the 8th car), and 

one empty tank car containing residue of elevated temperature rosin (the 16th car). The ninth 

car was the only derailed hazardous materials tank car that was breached and released its 

cargo. The other four tank cars were damaged, but their tanks were not breached.

The sixth car (chlorine) sustained a severe dent just to the right of center in the 

lower half of the B-end head. The appearance and location of the dent was consistent with 

its having been made by a coupler from another car. The bottom of the tank sustained 

some flattening, and the jacket was substantially damaged.

The seventh car (chlorine) sustained a severe dent on the left side (from the B-end) 

between the center of the tank and the A-end, just below the midline of the tank. A severe dent 

was also found on the A-end to the left of the coupler, and the coupler had been torn out. The 

jacket had several dents, with the most severe occurring between the B-end and the top fittings.

The eighth car (sodium hydroxide) sustained extensive jacket damage, and the 

jacket was torn from almost one-third of the tank on the A-end. Two smaller dents were 

observed in the shell near the A-end on the right side (from the B-end). The coupler and 

draft gear were missing from the B-end, and the stub sill was bent upwards.

The ninth car (chlorine) had a puncture and a tear on the right side near the middle 

and slightly toward the A-end of the tank. The opening was 34 inches long and 5 inches 

wide at its widest point. The area around the puncture was crushed inward, and there were 

severe dents on either side of it. These dents ranged in depth from 15 to more than 20 

inches. The car came to rest angled slightly to one side with the puncture opening 

extending below the midline of the resting tank. The left side of the tank had some 
Factual Information 19 Railroad Accident Report

flattening, and there was a dent on the shell near the A-end head weld at about the 

2 oíclock position. Emergency responders on the day of the accident measured the liquid 

level of the chlorine remaining in the tank and found that about one-third of the original 

load, or 30 tons (4,609 gallons), remained in the tank.23 The responders also noted that the 

B-end coupler24 of a steel coil car (the 11th car in the train) was in contact with the 

damaged tank jacket near the puncture and that it had frost on its surface. Metallurgical 

examination of the puncture area revealed that the dents in the puncture area mated with 

damaged protrusions on the 11th-car coupler.

Other Railroad Equipment

The lead locomotive unit of train 192 derailed but remained upright (leaning to the 

east at about a 12° angle) and positioned somewhat aligned with and about 4 feet from the 

centerline of the industry track. (See figure 9.) The locomotive unit appeared not to have 

lost overall structural integrity or to have sustained significant loss of occupant survival 

space. The cab windows were not broken. The unit sustained severe impact damage to the 

front end, with the front coupler, pilot plate structure, and stepwell elements severely 

mangled and with various components bent and displaced in an upward and aft direction 

by about 2 feet. Except for the front impact damage, the carbody of this unit did not 

exhibit substantial collision damage.

23 The NS estimated the amount remaining in the tank at 44 tons, or about 1/2 the original load of 90 tons.

24 A standard E-type bottom-shelf coupler.

Figure 9. The lead locomotive of train 192 (left) and the lead locomotive of train P22 

(right) showing collision damage.
Factual Information 20 Railroad Accident Report

The second locomotive unit on train 192 derailed but remained coupled to the lead 

locomotive, upright and positioned with the aft end skewed from alignment with the track 

by about 15 feet. The unit showed impact damage at the aft end on the right side of the 

frame, including a segment of missing handrail. The aft right corner pilot plate structure 

and stepwell elements were severely bent and displaced in an aft direction. The aft left 

corner pilot plate structure sustained impact damage. Except for the aft end frame and 

pilot plate structure damage and several carbody panel separations, this unit did not show 

substantial collision damage. There was visible evidence of a diesel fuel spill beneath the 

fuel tank, but there was no apparent fire.

Train P22 consisted of one locomotive and two empty freight cars at the time of 

the accident. It was propelled about 217 feet northward (along the track) by the impact. 

The locomotive derailed but came to rest upright and positioned somewhat longitudinally 

aligned with the track about 3 feet to the east of the track centerline. The unit sustained 

impact damage to the front end, with the front coupler, pilot plate structure, and stepwell 

elements severely mangled. Various components were bent and displaced in an upward 

and aft direction by about 5 feet.

The P22 locomotive unit sustained severe impact damage to the front carbody 

cowl (short hood), which was displaced in an aft direction by about 2 feet. The right sidesill was buckled downward several inches, proximate to the area above the fuel tank. The 

left side-sill was also buckled, but to a lesser degree than the right. Except for the front 

impact damage and the damaged side-sills, the carbody of this unit did not exhibit 

substantial collision damage. There was visible evidence of a diesel fuel spill beneath the 

fuel tank but no evidence of fire. The cab compartment appeared to be relatively intact and 

did not lose overall structural integrity or sustain significant loss of survival space. One 

window on the left side of the cab was shattered.

The first railcar on train P22 was a covered hopper. It did not derail and remained 

coupled to the locomotive. The second railcar, also a covered hopper, uncoupled from the 

first car and came to rest about 81 feet away along the industry track. Both truck 

assemblies separated from the carbody. The leading truck assembly was found on the 

ground adjacent to the carís front coupler; the aft assembly was found wedged against the 

underside discharge door beneath the center of the car. The leading end of the car was on 

the ground; the aft end had overridden and was wedged against and resting upon the 

leading end-sill of a tank car that had been on the industry track west of train P22.

Some main line and industry track was damaged in the derailment or removed to 

facilitate cleanup. A total of 14 track panels (39 feet each) were installed: 6 panels on the 

main track and 8 panels on the industry track. In addition, 10 carloads of ballast stone 

were spread. Total damage to the rolling stock and track was estimated in excess of $2.19 

million. The NS reported total damages to exceed $6.9 million.

Emergency Response Equipment

The Graniteville, Vaucluse, and Warrenville Volunteer Fire Department reported 

that two pumper trucks, one medical unit vehicle, and one service truck, all of which had 
Factual Information 21 Railroad Accident Report

been parked at the departmentís Station No. 1 for the duration of the gas release, had been 

destroyed or damaged beyond economical repair as a result of chlorine gas contamination. 

Total cost for the damaged or destroyed equipment was estimated in excess of $630,000.

Wreckage

Wreckage and debris of the derailed railroad equipment extended more than 500 

feet, beginning at the industrial turnout switch and continuing in a northerly direction 

along the industry track. Investigators were not able to perform a detailed documentation 

of the wreckage because of the continuing potential of a hazardous gas release and 

because of the wreckage cleanup efforts that prevented access to the site.

Personnel Information

Train P22

Engineer. The train P22 engineer was originally hired on July 25, 1979, as a car 

retarder operator.25 On September 3, 1979, he was promoted to yard foreman, helper, and 

trainman. On July 7, 1986, he was promoted to conductor. He became an engineer on 

September 12, 1990. His most recent engineer re-certification was on August 16, 2004.26

The engineer stated that he was not preoccupied or distracted during his shift. He 

also said he was not aware that either his brakeman or conductor was preoccupied or 

distracted during their shift. He said that other than intermittent problems with his 

locomotive radio, he experienced no problems with any of his equipment.

The engineer characterized his health as good. His most recent physical 

examination before the accident was in August 2004. The engineer explained that he 

underwent two physicals at that time: one conducted by his personal physician and one as 

part of his engineer re-certification. He said that he had no problem with his hearing or 

vision, although he wore prescription reading glasses. He said he had not used any overthe-counter or prescription medications, but said he periodically took vitamins. He also 

said he had not used alcohol or illicit drugs on the day before the accident.

As an extra-board employee, the engineer was called to work as needed. He said 

he was called at 1:00 a.m. on Tuesday, January 4, for a 2:30 a.m. on-duty time. He worked 

from that time until about 12:30 p.m. on January 4. He said he went to bed about 7:00 p.m. 

on January 4. At 10:32 p.m., the engineer was called to work as the engineer on train P22 

the next day, January 5. He was authorized to deadhead (by taxi or other means) from his 

25 A car retarder operator remotely operates a brake device built into the rails to reduce the speed of 

cars being switched into a classification yard (where cars are grouped before being made up into trains).

26 Engineer certifications are valid for 3 years at time of issuance and include an evaluation of vision 

and hearing.
Factual Information 22 Railroad Accident Report

home in Columbia to Aiken to arrive at 12:32 a.m. so that he would be in place and ready 

for work the next morning. Because the engineer was required to be given 8 hours rest 

time after arriving in Aiken, he could not report for train P22 until 8:32 a.m., more than 

1 1/2 hours after the conductor and brakeman had gone on duty.27 He went off duty at 

8:11 p.m. and had been off duty for about 6 1/2 hours when the accident occurred.

Conductor. The train P22 conductor (who was the regularly assigned P22 

brakeman but who was working in place of the vacationing conductor on the day before 

the accident) was originally hired as a trainman on April 4, 1978. On May 18, 1978, he 

was promoted to yard foreman, helper, and trainman. On January 2, 1992, he was 

promoted to conductor.

The conductor said he had no problems with any equipment as he worked the day 

before the accident. Similarly, he had experienced no problems related to the weather, nor 

was he distracted or preoccupied while he performed his duties. He stated his overall 

health was ìin good shape.î He said he had not used prescription medications but that he 

sometimes took medicine for allergies. The conductor said that he believed he had taken 

two Benadryl28 tablets about 1:00 p.m. on the day before the accident. He said he took no 

additional over-the-counter medications, nor did he consume any illicit drugs or alcohol 

that day. The conductor recalled that his most recent physical examination before the 

accident was in January or February 2004, adding that he undergoes a physical 

examination annually.

The conductor traveled about 50 miles from his home to the work site Monday 

through Friday, arriving in time to go on duty at 7:00 a.m. He said that on the Monday 

before the accident, he went off duty about 7:40 p.m. and retired about 9:50 p.m. On 

Tuesday, he awoke at 5:15 a.m., went on duty at 7:00 a.m., went off duty about 8:00 p.m., 

and retired about 9:45 p.m. He said he arose on Wednesday, January 5, the day before the 

accident, at about 5:00 a.m. and reported for work at 7:00 a.m. He went off duty about 

8:11 p.m. and had been off duty for about 6 1/2 hours when the accident occurred.

Brakeman. Records revealed that the brakeman was originally hired on 

October 18, 1978. On November 26, 1978, he was promoted to yard foreman, helper, and 

trainman. On January 2, 1992, he was promoted to conductor.

The brakeman said he had not been distracted or preoccupied during his shift. 

Likewise, he said he was not aware that his engineer or conductor had been distracted or 

preoccupied while working.

The brakeman reported that he was ìin good healthî and that his most recent 

physical examination was conducted by his personal physician in December 2004. The 

27 The engineer would have had to have been called by 9:00 p.m. on January 4 to be able to start work 

at 7:00 a.m. on January 5 in Aiken. The NS representatives said that the job vacancy did not occur in time to 

allow a call by 9:00 p.m.

28 Benadryl, an over-the-counter antihistamine containing diphenhydramine, relieves red, irritated, 

itchy, watery eyes; sneezing; and runny nose caused by hay fever, allergies, and the common cold. The 

medication can have sedating effects.
Factual Information 23 Railroad Accident Report

brakeman said he took multivitamins and a vitamin B complex. He also said he took a 

green tea supplement called MSM29 as well as a supplement known as Laye.30 He said 

both supplements were used to help alleviate pain in his joints. He said he was not sure 

whether he had taken either product the day before the accident. He said he had not used 

over-the-counter or prescription medications or alcohol or illicit drugs on the day before 

the accident.

The brakeman was an extra-board employee who was called to work as needed. He 

had not worked the Saturday or Sunday before the accident. He said that on Monday, he 

awoke at 4:25 a.m., reported for duty in Newberry, South Carolina, at 7:00 a.m., and went 

off duty at 1:30 p.m. He said he retired at 9:45 p.m. that evening. The brakeman worked 

train P22 on Tuesday. He said he awoke about 4:25 a.m. and reported for work at Aiken at 

7:00 a.m. He went off duty at 7:31 p.m. and retired about 10:30 p.m. On Wednesday, the 

day before the accident, he said he awoke at 4:25 a.m., went on duty in Aiken at 7:00 a.m., 

and went off duty at 8:11 p.m. At the time of the accident, he had been off duty for about 

6 1/2 hours.

Train 192

Engineer. Records revealed that the engineer was originally hired on April 7, 

1997. On August 25, 1997, he was simultaneously promoted to yard foreman, helper, 

trainman, and conductor. On December 12, 2001, he was promoted to engineer. His most 

recent engineer re-certification was issued on March 20, 2002. The engineerís most recent 

evaluation was on August 16, 2004. In the comments section, the examining officer noted, 

ìDid well, no exceptions.î

On Monday, January 3, 2005, he had been called for duty at 1:24 a.m. for an 

on-duty 3:00 a.m. start time. He went off duty later that morning at 8:30 a.m. He was 

called later that day, at 4:02 p.m., for an on-duty start time of 5:30 p.m. He went off duty 

the following morning, Tuesday, January 4, at 1:25 a.m. At 10:49 p.m., he was called for 

an on-duty start time of 11:59 p.m. He went off duty the following day, Wednesday, 

January 5, at 11:45 a.m. He was called at 11:07 p.m. that evening for an on-duty start time 

of 12:30 a.m., Thursday, January 6, for train 192. At the time of the accident, he had been 

on duty for about 2 hours 10 minutes.

Conductor. Records revealed that the conductor was originally hired on 

February 22, 1999. On August 30, 1999, he was simultaneously promoted to yard 

foreman, trainman, helper, and conductor.

On Sunday, January 2, the conductor had been called at 9:45 p.m. for an 11:10 p.m. 

on-duty start time. He went off duty the following day, Monday, January 3, at 4:34 a.m. He 

29 Methylsulfonylmethane (MSM) is also known as methyl sulfone or dimethylsulfone. It is advertised 

for relief of pain from arthritis, back pain, or muscle pain. No published research studies link MSM to any of 

the health claims made for it.

30 Subsequent contact with the brakeman determined this product to be L-Lysine. L-Lysine is used by 

the body in building new tissue. It also promotes the body's protective substances, such as enzymes and 

antibodies. L-Lysine is a natural constituent in foods, with no known toxic effects.
Factual Information 24 Railroad Accident Report

was called the following day, Tuesday, January 4, at 1:00 a.m. for an on-duty start time of 

2:30 a.m. He went off duty later that day at 12:33 p.m. He was called later that evening at 

10:49 p.m. for an on-duty start time of 11:59 p.m. He went off duty the following day, 

Wednesday, January 5, at 11:46 a.m. He was called at 11:07 p.m. that evening for an 

on-duty start time of 12:30 a.m. on Thursday, January 6, for train 192. At the time of the 

accident, he had been on duty for about 2 hours 10 minutes.

Toxicological Testing

In accordance with Federal requirements,31 specimens were obtained from the 

engineer and conductor of train 192 and submitted for toxicological testing. The results 

were negative for alcohol and the screened substances.32 Based on the circumstances of 

the accident and the fact that the crew of train P22 had been off duty for several hours 

when the accident occurred, the NS determined, in consultation with representatives of the 

Federal Railroad Administration (FRA), that neither the P22 crew nor dispatching 

employees were required by Federal regulations to undergo required postaccident 

chemical testing.

Meteorological Information

The nearest National Weather Service reporting station to Graniteville, South 

Carolina, was about 17 miles away, in Augusta, Georgia. Sunset was at 5:34 p.m. Augusta 

weather at 6:53 p.m. on January 5, 2005, (the approximate time the P22 crew was 

preparing to depart Graniteville and return to Aiken) was as follows: winds from the south 

at 5 mph; visibility unrestricted at 10 miles; skies mostly cloudy; temperature 60°

Fahrenheit (F); dew point 57° F. No precipitation was reported.

Augusta weather at 2:32 a.m. on January 6, 2005, (minutes before the collision and 

derailment) was as follows: winds from the south-southwest at 7 mph; visibility 5 miles; 

skies clear; temperature 55° F; dew point 54° F. No precipitation was recorded between 

7:00 p.m. on January 5 and 3:00 a.m. on January 6.

Operations and Track Information

The NS, which owns and operates the track in the accident area, is a subsidiary of 

the Norfolk Southern Corporation, headquartered in Norfolk, Virginia. The NS operates 

approximately 21,300 route miles of track in 22 eastern and southeastern States, the 

District of Columbia, and Ontario, Canada.

31 Title 49 Code of Federal Regulations Part 219, Subpart C.

32 These substances included cannabinoids, cocaine, opiates, amphetamines, methamphetamines, 

phencyclidine, barbiturates, benzodiazepines, and ethyl alcohol.
Factual Information 25 Railroad Accident Report

The NS is the product of various railroad combinations, reorganizations, and 

consolidations. The largest NS predecessors were Norfolk & Western Railway and 

Southern Railway. The NS subsequently acquired a portion of the assets of Conrail, and 

the holdings of these former carriers make up the majority of the NS today.

The area in which the accident occurred is within the NS Piedmont Division. The 

R main line is a 190.52-mile track segment that extends from a junction to a main line near 

Charlotte, North Carolina, south through Columbia, South Carolina, to Augusta, Georgia. 

Numerous small towns and industries are near this track segment.

The segment of the R line at Graniteville is a non-signaled single main track 

controlled by a train dispatcher using a track warrant control system from Greenville, 

South Carolina. According to the terminal superintendent in charge of the territory, at the 

time of the accident, five trains were being operated daily over the track at Graniteville. 

These included two through freight trains in each direction operating between Augusta, 

Georgia, and Columbia, South Carolina, in addition to local train P22. The NS timetable 

speed from Columbia to Augusta at the time of the accident was 49 mph, in accordance 

with FRA limits for the territory, except in areas with reduced speeds because of curves.

The closest curve to the accident site is a left hand, 1o curve beginning at MP 

R178.45 and ending at MP R178.65. At MP R178.3 is the turnout to the industry track. 

The turnout uses a No. 10 switch33 that is of similar construction and material to the main 

track. When lined for the diverging track, the maximum authorized speed through the 

switch is 15 mph. The switch was equipped with a 14-inch-diameter red and white 

reflective banner atop a 7-foot long banner shaft secured to the switch stand.

Postaccident Inspections

Switch and Track

The chlorine release that occurred as a result of the accident prevented Safety 

Board investigators from immediately entering the accident site. Because the Federal 

Bureau of Investigation (FBI) had trained hazardous materials teams with the equipment 

necessary to enter the site safely, the Safety Board requested the assistance of the FBI to 

document switch alignment, equipment, and other information. After being advised as to 

what to look for by Safety Board investigators, FBI representatives inspected the switch at 

the industry track turnout on January 7, 2005, the day after the accident. The switch was 

found to be lined and locked for the industry track. It showed no evidence of having been 

moved or tampered with. The switch points were in the proper position for the turnout, 

and the switch banner was in the red position, indicating that the switch was lined for the 

diverging track. No defects were noted with the switch points, switch throw rods, switch 

33 The number designation of a turnout switch refers to the angle at which the turnout track diverges 

from the main track, with higher numbers representing a more gradual angle. The investigation determined 

that the turnout into the Avondale Mills industry track led a train from the main line into an approximate 8o 

curve.
Factual Information 26 Railroad Accident Report

lugs, heel blocks, switch stand (base), or the switch lock. FBI investigators removed the 

switch handle and lock and the mast and banner and assisted the Safety Board in its 

investigation of these items.

On January 14, 2005, Safety Board investigators were able to inspect the accident 

site. A track inspection was performed on the industry track turnout and the track north 

and south of the turnout for approximately 1/10 mile. No main line track damage was 

incurred due to the accident, although a portion of the track north of the turnout had been 

removed to allow for cleanup.

The industry track turnout and the track south of it were intact and had no defects 

under Federal track standards. A section of the industry track near the switch had been 

damaged in the accident and had also been removed to allow for cleanup. The remainder 

of the industry track was intact. The NS maintains the track in the turnout to a limit of 295 

feet, beginning at the switch points and extending into the industry track. An FRA 

inspection on January 14, 2005, identified no defects in this section of track.

Investigators reviewed track inspection records for the R line between Columbia, 

South Carolina, and Augusta, Georgia, for the time period between November 9, 2004, 

and January 5, 2005. NS inspection records for the track segment where the accident 

occurred, between MP R178 and MP R179, showed no defects for the 2-month period. 

The FRA requires that this class of track (class 4) be inspected twice weekly, and the 

records showed that the NS was in compliance with this requirement. The FRA also 

requires a monthly switch inspection. NS records showed the switch to have been last 

inspected on December 7, 2004. Records of a postaccident (January 8, 2005) FRA 

inspection of this track segment showed no defects.

Railcars

After the derailment, the 26 cars from train 192 that had not derailed were 

decontaminated and moved to the Augusta Yard. On January 8, 2005, two locomotive 

units were coupled to that train, and an air brake test was performed. Both automatic and 

emergency brake applications were performed successfully.

After the brake tests, the cars were inspected by Safety Board investigators along 

with representatives of the NS, the State of South Carolina, and the FRA. A number of 

FRA safety appliance defects were found. In addition, inspectors found two broken brake 

shoes, one knuckle pin (coupler) defect, one leaking roller bearing seal, two piston travel

defects, and one brake shoe that failed to center. The brakes also cut out on one car.34 The 

identified defects would not have affected the performance of the train.

Train 192 was equipped with an automatic two-way end-of-train device (EOTD). 

Movement by the engineer of the automatic brake handle to the emergency position would 

automatically (via telemetry) cause the EOTD to activate emergency braking from the rear 

34 Freight car brakes are ìcut outî when the branch pipe from the train air brake line to the carís air 

brake system is closed off, nullifying the brakes on that car without affecting the brakes of adjacent cars.
Factual Information 27 Railroad Accident Report

of the train, as well as from the head end. This system is designed to provide a more rapid 

brake application throughout the train and to ensure a complete brake application even in the 

event of a blockage in the air brake line. The postaccident inspection of the control stand in 

the cab of the lead locomotive of train 192 showed the automatic brake handle in the 

emergency position. The EOTD from train 192 was tested and found to function as designed.

Tank Car and Hazardous Materials Information

Tank Cars

A review of Association of American Railroads (AAR) certificates of construction 

for the derailed tank cars, as well as the postaccident inspection, revealed that each tank 

car was equipped with double-shelf couplers. These couplers are designed to resist vertical 

movement between joined couplers and thereby remain engaged during switching 

operations or accidents.

The sixth car in the train (SBLX 14146), containing chlorine, was built in 1997 by 

Trinity Industries, Inc., as a U.S. Department of Transportation (DOT) specification 

105J500W tank car. The last periodic qualification of the car was in February 2004. The 

tank heads (the curved ends of the tank) were manufactured from 13/16-inch plate, and the 

shell was manufactured from 0.7874-inch carbon steel plate. Head and shell plates were 

specified as AAR specification TC-128-B normalized steel.35 This car had a thermal 

protection system consisting of 2 inches of ceramic fiber covered with 2 inches of 

fiberglass. The AAR certificate of construction indicated that the 13/16-inch tank head, in 

combination with the insulation and the 0.1196-inch steel jacket, met the DOT tank-head 

puncture-resistance performance standards of 49 Code of Federal Regulations 179.16.

The seventh car in the train (GATX 17105), also containing chlorine, was built in 

1979 by General American Transportation Corporation. It was a DOT specification 

105J500W tank car that was originally built as a specification 105A500W tank car. The 

last periodic hydrostatic test was in January 2000. The tank heads were manufactured 

from 13/16-inch plate, and the shell was manufactured from 0.7874-inch carbon steel 

plate. Head and shell plates were non-normalized AAR specification TC-128-B steel. This 

car had a thermal protection system consisting of 4 inches of foam insulation. The tank car 

also met the DOT tank-head puncture-resistance performance standards of 49 Code of 

Federal Regulations 179.16.

The eighth car in the train (GATX 58326), containing sodium hydroxide solution, 

was built in June 1980 by ACF Industries, Inc., as a DOT specification 111A100W1 tank 

car. The last periodic hydrostatic test was in January 1998. The tank heads and shell were 

manufactured from 7/16-inch carbon steel plate. Head and shell plates were non35 Normalized steel has undergone a heat treatment process that lowers the temperature at which the 

material transitions from ductile to brittle. The process also increases the amount of energy required to cause 

fracture. Since 1989, pressure tank car shells have been required to be fabricated from normalized steel.
Factual Information 28 Railroad Accident Report

normalized ASTM36 specification A-515 grade 70, except for the center section of the 

shell, which was non-normalized AAR specification TC-128-B steel. This car had a total 

of 6 inches of fiberglass insulation.

The ninth car in the train (UTLX 900270), the punctured chlorine car, was built in 

1993 by Union Tank Car Company. It was a DOT specification 105J500W tank car that 

was originally built as a specification 105S500W tank car. The last periodic qualification 

was in July 2004. The tank heads were manufactured from 53/64-inch plate, and the shell 

was manufactured from 0.777-inch carbon steel plate. Head and shell plates were 

specified as AAR specification TC-128-B normalized steel. This car had a thermal 

protection system consisting of 2 inches of ceramic fiber covered with 2 inches of 

fiberglass. This car was equipped with 1/2-inch full head shields.37

Chlorine tank cars such as the punctured car are pressure tested to 500 pounds per 

square inch, gauge (psig), compared to 300 psig for tank cars used to transport anhydrous 

ammonia and liquefied petroleum gas. Because of the higher test pressure, chlorine tank 

car walls are thicker than those of lower-rated pressure tank cars.

Hazardous Materials

Four of the five tank cars that derailed (three car loads of chlorine and one car load of 

sodium hydroxide) were shipped by Olin Chlor Alkali Products (Olin) of Augusta, Georgia. 

The three tank cars containing chlorine were loaded between December 31, 2004, and 

January 4, 2005. Loading of the tank car that was punctured in the derailment had been 

completed at 3:10 a.m. on January 4. The recorded loading pressure for each car was 22 

psig, which equates to a chlorine temperature of about 12o F. The estimated temperature of 

the chlorine (and the tank car steel) at the time of the derailment was 26o F.

The cars each contained 180,000 pounds (about 13,830 gallons)38 of chlorine. 

According to Olinís material safety data sheet, chlorine is a poisonous gas, an oxidizer,

and a marine pollutant. It has an IDLH value39 of 10 parts per million (ppm). If inhaled, 

chlorine will react with moisture in the respiratory tract and lungs to form hydrochloric 

acid, resulting in inflammation of these tissues. Severe exposure can result in pulmonary 

edema, suffocation, and death. Chlorine has a vapor pressure of 31 psig at 26o F and a 

vapor density of 2.5 (heavier than air). At atmospheric pressure, chlorine changes from a 

36 ASTM International is a voluntary standards organization originally known as the American Society 

for Testing and Materials.

37 A head shield is a supplemental heavy steel plate required by Federal regulation on the ends of some 

hazardous materials tank cars to reduce the likelihood that a tank head will be punctured by the coupler of an 

adjacent car in the event of excessive end impact or derailment.

38 Calculations made using a specific gravity for chlorine of 1.56.

39 The IDLH (immediately dangerous to life and health) value is an atmospheric concentration of any 

toxic, corrosive, or asphyxiate substance that poses an immediate threat to life, or would cause irreversible 

or delayed adverse health effects, or would interfere with an individualís ability to escape from a dangerous 

atmosphere. The Environmental Protection Agency uses 10 percent of the IDLH value when determining 

that a release has reached a level of concern for public exposure.
Factual Information 29 Railroad Accident Report

liquid to a gas at ñ29o F. It is miscible40 in water. It is considered corrosive because it 

forms hypochlorous acid and/or hydrochloric acid when combined with water.

The sodium hydroxide car contained 191,750 pounds (15,340 gallons)41 of a 

50-percent solution of sodium hydroxide in water. The solution is corrosive, and 

prolonged contact can cause permanent skin damage.

The fifth derailed tank car was shipped by Westvaco Corporation from De Ridder, 

Louisiana. The car was listed as empty but contained a residue of rosin, which is 

transported as an elevated temperature liquid. Rosin is normally a solid, and in this form is 

not regulated by the DOT as a hazardous material. The material is heated to 212° F or 

more for loading and unloading and at such temperatures is considered a burn hazard.

Tests and Research

Sight Distance Tests

On March 29, 2005, Safety Board investigators conducted sight distance tests at 

the accident scene using locomotive equipment similar to that in use on train 192 at the 

time of the accident. The tests were conducted at the same time of day as the accident and 

under similar weather and lighting conditions. During the tests, the test engineer was 

seated on the left (west) side of the locomotive, as had been the accident engineer. A test 

conductor was seated on the right (east) side of the locomotive.

The test determined that the red reflection from the switch banner could be first 

observed from the engineerís seat at a distance of 1,461 feet from the switch as the train 

transitioned from curved to tangent (straight) track. The red reflection was first visible on the 

conductorís side of the locomotive at 1,339 feet from the switch. The test also determined, 

however, that the red reflection could not be identified by either crewmember as a switch 

banner until the train was within 566 feet of the switch when the train headlight illuminated the 

banner. The test revealed that the position of the switch points (which indicate which way the 

switch is lined) could not be seen by the crew until the train was 220 feet from the switch stand.

The tests showed that a number of warning and signal lights were visible to the 

crew of a train approaching the industry track switch. Canal Street and Trolley Line Road 

intersected with Aiken Road about 393 feet north of the switch on either side of the NS 

main line. The grade crossing at these intersections was protected with flashing lights and 

bells. A total of eight pairs of red flashing lights at the intersections activated when a train 

was 1,927 feet south of the crossing, or 1,534 feet from the switch. Additionally, about 

281 feet north of the switch and just east of the main track was a wayside light indicating 

the switch position at the Vaucluse Siding.42

40 Miscibility refers to the ability of a liquid or gas to dissolve uniformly in another liquid or gas.

41 Calculations made using a specific gravity for a 50-percent solution of sodium hydroxide of 1.5.

42 See the ìOther Informationî section of this report for more information on switch position indicator lights.
Factual Information 30 Railroad Accident Report

The driver of the taxi that transported the P22 crew on January 5 said that as he left 

the area with the crew, he drove along Canal Street, on the west side of the main line. The 

distance from the centerline of that roadway to the industry track switch stand measured 

21 feet. Investigators determined that the position of the switch would have been clearly 

visible to an occupant of a vehicle proceeding along the road.

Event Recorder Data

Each of the three locomotive units involved in the accident was equipped with an 

event data recorder. The lead locomotive of train 192 used magnetic tape as a recording 

medium; the trailing unit and the single locomotive of train P22 were equipped with solidstate devices. Magnetic tape data were read on scene; the solid-state units were shipped to 

Safety Board headquarters in Washington, D.C., where the information was downloaded 

and analyzed by the Safety Boardís Vehicle Recorders Division.

The clock from each event recorder was correlated to the approximate reported 

time of the collision. Using the Safety Boardís data analysis software, the data were 

verified for accuracy by comparing the data recorded before the collision against the 

operating range and limitations of the locomotives and against the known preaccident 

operation of the train. The data recorded for traction motor current from the trailing 

locomotive of train 192 was found to be inconsistent with the operation of the train. No 

evidence was found of damage or recorder malfunction. Because damage from the 

accident prevented the testing of the locomotive, the reason for the anomalous data 

readings could not be determined. The remaining data from the trailing locomotive were 

found to be consistent with the operating range and limitation of the equipment.

Train P22. The crew of local train P22 stated that the train arrived at the industry 

track about 6:10 p.m. on January 5. Event recorder data indicate that the train came to a 

stop at approximate recorder time 6:08:51 p.m. The train remained at a stop until recorder 

time 6:09:57, after which the train made a series of forward and reverse movements with 

the throttle handle and automatic brake handle being manipulated. The speed during these 

movements remained below 11 mph. At recorder time 6:52:57 p.m., the speed indicated 0 

mph; the throttle was in idle; and the automatic brake was in the 26-pound application 

position. No further operational control changes were recorded.

Train 192. Event recorder data from the magnetic tape recorder on the lead 

locomotive indicated that at approximate recorder time 2:10:41 a.m., consistent with the 

reported time of departure from Augusta, the train brake was released and the speed began 

to increase. Train speed continued increasing with the throttle handle in the idle position 

until 2:12:36, when the throttle handle was moved to notch 3 and the speed indicated 9 

mph. The train continued north with the throttle manipulated between the idle and notch 3 

positions while the speed fluctuated between 9 and 12 mph.

At recorder time 2:22:30 a.m., the throttle handle was placed in notch 4, and the 

speed began increasing. The speed continued increasing while the throttle handle was 

manipulated between notch 3 and notch 8, and at 02:29:47, the data indicated a speed of 49 

mph, which was the maximum speed attained during the trip from Augusta to Graniteville.
Factual Information 31 Railroad Accident Report

The train continued northbound with the speed fluctuating between 44 and 47 mph. 

At recorder time 2:36:30 a.m., the throttle handle was increased to notch 8 while the train 

traveled at 44 mph. Data indicated that the throttle handle remained in notch 8 until 2:38:11 

with the train speed indicating 47 mph. The throttle was decreased to notch 6 with the speed 

continuing to increase to 48 mph. At recorder time 2:38:37, the throttle handle was placed in 

notch 4 with the speed remaining at 48 mph. At 2:39:00, approximately 467 feet from the 

final resting point of the train,43 the speed indicated 47 mph. At 2:39:03, approximately 268 

feet from the final resting point, traction motor current rose sharply, indicating an increase in 

load on the motors. The indicated speed at that point was 42 mph, and the train was 

decelerating rapidly. At 2:39:06, approximately 117 feet from the final resting point, the 

automatic brake (train brakes) indicated an emergency; the independent (locomotive) brake 

toggled on; the throttle was in the idle position; and the speed was 26 mph. A second, larger 

spike in traction motor current occurred at 2:39:15. At 2:39:20 a.m., speed indicated 0 mph.

Laboratory Examination and Testing

The Safety Boardís Materials Laboratory examined a portion of the tank from the 

ruptured ninth car on the train. This examination revealed that a 2 1/2-inch-long fracture 

area in the center of the tank shell impact area, including the origin of the crack, separated 

in a ductile mode. The remaining portions of the crack on either side of the ductile fracture 

area separated in a brittle mode.

The Safety Board performed Charpy impact testing of the steel from the tank car 

shell. The Charpy testing showed that the ductile-to-brittle transition temperature of the steel 

plate from the shell of the ruptured tank was 40o F for specimens oriented transverse to the 

rolling direction of the steel plate and 0o F for specimens oriented parallel to the rolling 

direction of the steel plate. The estimated temperature of the chlorine (and the tank car steel) 

at the time of the derailment was 26o F. The chemical composition and tensile properties of 

the head and shell material met the specifications for AAR TC-128-B normalized steel.

Other Information

Accidents Involving Improperly Lined Switches

According to FRA safety data, ìHuman factors constitute the largest category of 

train accident causes, accounting for 38 percent of all train accidents over the last 5 years.î 

The data show that the leading cause [of human factor accidents] for 2004 was improperly 

lined switches, which alone accounted for 16 percent of human factor accidents in the last 

4 years.î44

43 Distance estimates are based on time and speed calculations; they do not account for any wheel 

sliding or skidding that may have occurred during the accident sequence.

44 Douglas Taylor (Staff Director Operating Practices, FRA Office of Safety), ìFRAís Operating Rules 

Working Group Spurs Action to Address Critical Safety Issues,î American Short Line Railroad Association 

Safety Bulletin No. 9, August 2005, p. 2.
Factual Information 32 Railroad Accident Report

In 1999, the P22 conductor in the Graniteville accident was dismissed from service 

for his failure to ìproperly restore the main track switchÖresulting in your endangering 

the safety and lives of other employees.Öî Documentation pertaining to this incident, 

which occurred on March 10, 1999, disclosed that a train, traveling about 30 mph, 

encountered the misaligned switch at 3:05 a.m. the following morning. The engineer saw 

the red switch target and placed the train in emergency braking, coming to a stop about 5 

car lengths from the switch. The NS suspended the conductor from service on the day of 

the incident and dismissed him from service after an investigation on March 31, 1999. The 

conductor was reinstated on April 11, 1999.

On January 8, 2005, two days after the Graniteville accident, a Burlington 

Northern Santa Fe Railway Company (BNSF) freight train was unexpectedly diverted 

onto an industrial track in Bieber, California. The BNSF train struck two loaded grain 

cars, derailing 7 locomotives and 14 cars. Two railroad employees were injured.

On September 15, 2005, during the preparation of this accident report, a southbound 

Union Pacific (UP) freight train was unexpectedly diverted into a passing siding at Shepherd, 

Texas, where it struck a northbound local train that had been parked on the siding track to 

allow the southbound train to pass. The conductor of the parked train had earlier lined the 

northernmost siding switch to allow the local to back from the main line into the siding where 

it was to await the southbound train. To avoid violating Federal hours-of-service regulations, 

the local train crew secured the train in the siding and, without relining the switch at the north 

end of the siding, departed in a contracted taxi. When the taxi was about 20 miles from 

Shepherd, the conductor realized he had left his keys in the switch lock at the siding and 

insisted that the driver return to Shepherd. Meanwhile, a 3-person relief crew had boarded the 

local train. As the southbound train approached, the local trainís engineer remained aboard the 

locomotive while the other two crewmembers dismounted to inspect the passing train from 

the ground. Instead of proceeding down the main line, the southbound train entered the siding 

via the improperly lined switch and struck the standing train. The engineer of the local train 

was killed, and four other crewmembers of the two trains were injured.

Postaccident FRA Safety Advisory

In response to the Graniteville accident, the FRA, on January 13, 2005, issued 

Safety Advisory 2005-01, ìPosition of Switches in Non-Signaled Territory,î to

advise all railroads to review their operating rules and take certain other action 

necessary to ensure that train crews who operate manual (hand-operated) main 

track switches in non-signaled territory restore the switches to their normal 

position after use.

The advisory informed railroads of the circumstances of the Graniteville accident 

as well as of the January 8, 2005, BNSF accident.

The safety advisory referenced rules promulgated by the UP and the BNSF 

railroads regarding the relining of switches. On October 1, 2004, the UP adopted a 

requirement that before reporting clear of the limits of a track warrant, the crewmember 

releasing the track warrant must first inform the train dispatcher that main track switches 
Factual Information 33 Railroad Accident Report

have been restored to their normal positions. If the crew does not provide this information, 

the train dispatching system prompts the train dispatcher to ask for it. The change was 

made because of a September 29, 2004, collision that occurred at Thomaston, Texas, in 

which a Texas Mexican Railway Company (TM) crew released a track warrant without 

verifying that a siding switch was properly lined for the main track. A southbound UP 

train entered the siding and collided with an unattended TM train.

On October 31, 2004, the BNSF adopted a requirement that before releasing a 

track warrant, a train crew must report to the train dispatcher the position of any switch the 

train has used. The dispatching system will not allow a track warrant to be cleared until the 

dispatcher confirms the switch position through a job briefing with the crew. According to 

the FRA advisory, this change was made as the result of a recommendation from a BNSF 

division safety team. The safety team was concerned about incidents in which crews in a 

particular subdivision had forgotten to reline main line switches. The BNSF rules 

department issued this change across the BNSF system.

In the safety advisory, the FRA ìstrongly urgedî railroads to (1) ensure that their 

operating rules contain a provision similar to those of the UP and the BNSF that require train 

crews who manually operate main line switches in non-signaled territory to report to the 

dispatcher that the switches have been restored to the normal position before the crews 

report clear of the main track, (2) require that the conductor of a crew working in nonsignaled territory, before reporting clear of main track, sign a switch position awareness 

form that lists the name and location of any switch operated by any member of the crew and 

the time each switch was relined for the main line, (3) require that the switch position 

awareness form be submitted to a designated railroad official at the completion of each tour 

of duty, (4) require that railroad officials review the forms for accuracy and to use the results 

in the railroadsí testing and proficiency programs, and (5) ensure that the revised rules, 

procedures, and forms are immediately disseminated to all affected operating personnel.

The advisory stated that the FRA is considering the need for additional measures, 

such as regulatory action or further advisories.

FRA Human Factors Working Group

On May 18, 2005, the FRAís Railroad Safety Advisory Committee45 established an 

operating rules working group to review the primary human factor causes of train 

accidents and incidents and to recommend methods of reducing those accidents/incidents 

and the resulting employee injuries. The working group was tasked with reporting its 

findings and recommendations to the full committee by February 10, 2006.

FRA Emergency Order

In follow-up to Safety Advisory 2005-01, the FRA, on October 20, 2005, issued 

Emergency Order No. 24, ìEmergency Order Requiring Special Handling, Instruction and 

45 The Railroad Safety Advisory Committee is made up of representatives of government, industry, and 

other entities having an interest in railroad safety. The FRA established the committee in 1996 to advise the 

FRA and develop consensus recommendations on safety issues.
Factual Information 34 Railroad Accident Report

Testing of Railroad Operating Rules Pertaining to Hand-Operated Main Track Switches.î 

The order states that:

Öpublic safety compels issuance of this Emergency Order (EO) requiring 

railroads to modify their operating rules and take certain other actions necessary 

to ensure that railroad employees who dispatch non-signaled territory or who 

operate hand-operated main track switchesÖin non-signaled territory ensure the 

switches are restored to their proper (normal) position after use.

In the ìBackgroundî section of the order, the FRA notes that the year 2004 saw a 

marked increase in the ìfrequency and severity of collisions resulting from improperly 

lined main track switchesÖ.î The order states that after the issuance of the January safety 

advisory, and with the exception of two accidents that occurred shortly after the advisory 

was promulgated, ìthere was a respite of nearly six months in accidents resulting from 

improperly lined switches in non-signaled territory.î However, in July 2005, two such 

accidents occurred, and within a 28-day period in August and September, according to the 

emergency order, three additional, more serious accidents occurred:

On August 19, 2005, a Kansas and Oklahoma Railroad freight train, operating at 

26 mph in Nickerson, Kansas, encountered an improperly lined switch, entered a siding, 

and struck a standing cut of cars. The trainís engineer was severely injured.

On August 21, 2005, a UP freight train, operating at 30 mph, was unexpectedly 

diverted into a siding in Heber, California, where it struck a standing cut of cars. The control 

compartment of the lead locomotive was destroyed. The three crewmembers ìsurvived only by 

quickly throwing themselves on the floor of the locomotive immediately before impact.î

The third serious accident was the previously described September 15, 2005, 

accident on the UP railroad in Shepherd, Texas.

The July-through-September accidents, according to the FRA in its emergency 

order, were a ìclear indication that the Safety Advisory ha[d] lost its effectiveness.î The 

emergency order was thus issued:

Öto accomplish what the Safety Advisory could not: implement safety practices 

that will abate the emergency until [the] FRA can complete rulemakingÖ.

The FRA states that, using the advice contained in the February 2006 report of the 

previously referenced Railroad Safety Advisory Committee human factors working group, 

its ìgoal is to publish a proposed rule in 2006, and a final rule soon thereafter.î

The emergency order identifies certain actions that must be taken by railroad 

employees who operate hand-operated main line switches in non-signaled territory or who 

dispatch in non-signaled territory. Those actions may be summarized as follows:

ï All employees subject to the emergency order must receive both initial and 

periodic instruction on the emergency order and on the railroadsí operating 

rules related to hand-operated switches in non-signaled territory. Railroads 

must maintain records of the training.
Factual Information 35 Railroad Accident Report

ï Employees who operate the switches are responsible for restoring them to their 

normal positions.

ï Employees releasing track authority must report to the dispatcher that all main 

line switches have been restored to their appropriate positions. Additionally, 

the dispatcher must confirm that the conductor and engineer have initialed the 

switch position awareness form (which the FRA recommended in its safety 

advisory that railroads adopt).

ï Employees operating hand-operated switches must complete a switch position 

awareness form, and all the information required by the form must be entered 

before an employee reports clear of the limits of track authority.

ï Job briefings must be held by employees in connection with the operation of 

hand-operated main track switches in non-signaled territory. A briefing must 

be conducted before the work is done, each time the work plan is changed, and 

when the work is complete.

ï Each time a train crewmember changes the position of a hand-operated main 

line switch in non-signaled territory, the crewmember, while at the switch, shall 

inform the engineer by radio of the switch name, location, and position. The 

engineer must acknowledge the information before any movement can occur.

ï Operational tests and inspections must incorporate the requirements of the 

emergency order.

ï Every affected employee will be provided a copy of the emergency order, and 

receipt must be acknowledged in writing.

The emergency order provides relief for railroads that provide a level of safety the 

FRA considers equivalent to the emergency order. As outlined in the order, relief is 

automatically granted when (in reference to hand-operated switches in non-signaled 

territory):

ï A railroadís operating rules require that trains approaching the switches be 

prepared to stop;

ï The switches are protected by distant switch indicators; or

ï The switches are automatic or self-restoring and are protected by switch point 

indicators [described in the next section of this report], unless those switches 

are operated by hand.

The emergency order provides for a civil penalty of up to $27,000 for any person 

(including individuals or corporate entities) violating the requirements of the order. Steps 

to implement the order must begin immediately, with full implementation required by 

November 22, 2005.

Switch Position Indicators

Some railroad switches, even in non-signaled territory, are equipped with switch 

circuit controllers that can detect the switch position and alert the crew of an approaching 
Factual Information 36 Railroad Accident Report

train if the switch is improperly lined. In signaled territory, the position of the switch is

conveyed to the train crew through a corresponding wayside signal. In non-signaled

territory, depending on the type of switch system in use, the crew can be alerted by

wayside indicator lights or by a radio message broadcast on the train crewís radio channel.

The switches for the siding at Vaucluse,46 about 1.1 miles north of the industry track,

are equipped with switch position indicator lights. One wayside light at the switch signifies

the switch position, and if the switch is not lined for the main line, another wayside light

farther along the track alerts an oncoming train in time for it to slow and stop short of the

switch. Unlike the hand-operated switch at the industry track, the switches at Vaucluse are

ìspringî switches.47 If a train is to use one of these switches to enter the siding from the main

line, a crewmember must still line the switch by hand and reline it for the main line after the

train is in the siding. But while the switch is lined for the main line, a train may move from

the siding onto the main line without the need to reposition the switch. As the train moves

through the switch, the train wheels force open the switch points for the movement. Once the

last wheels of the train have cleared the switch, a powerful spring, hydraulically assisted,

automatically returns the switch points to their normal position (lined for the main line).

Because a crew can move their train through a spring switch onto the main line

without manually manipulating the switch, no crewmember tends the switch after the train

has passed through. If the spring switch is equipped with a switch circuit controller, the

controller will detect the switch position and if, for example, an obstruction has prevented

the switch from returning to the normal position or if the switch has been left lined for the

siding, the lights at and in advance of the switch will display the appropriate aspect to the

next train approaching that location.

Postaccident Action by NS

Immediately after the accident, the NS amended its Operating Rule 181 to address

manually operated main track switches in non-signaled territory. Under the new rule

(Operating Rule 181a), train and engine crews, when reporting clear of track authority

limits in non-signaled territory, must advise the dispatcher or control operator of:

ï The total number of hand-throw main track switches operated within the track

authority;

ï The name and location of each main track switch operated;

ï The restoration and securement of main track switches in their normal (main

line) position.

The rule states that train dispatchers or control operators within non-signaled

territory are not to clear a track authority until notified by the train or engine crew that each

hand-throw main track switch that has been operated has been locked in normal position.

46 This is a passing siding paralleling the main line with a switch at the north and south ends.

47 The NS has not equipped switches other than spring switches with switch position indicator lights or

other methods of alerting train crews of improperly lined switches.
Factual Information 37 Railroad Accident Report

Hours of Service Act

Congress enacted the original Hours of Service Act in 1907. The intent of the act 

was to promote railroad safety by limiting the number of hours train crewmembers may 

remain on duty and by requiring railroads to provide them with a minimum rest period 

between shifts. The act, which has been revised and amended since its enactment, is 

codified in FRA regulations at 49 Code of Federal Regulations Part 228 and applies to any 

railroad employee engaged in or connected with the movement of a train. The act provides 

that train employees may not remain on duty for more than 12 consecutive hours or 16 

hours in an emergency.48 The Hours of Service Act further provides that a covered 

employee must be given at least 8 consecutive hours off after a tour of duty of less than 12 

duty hours, and 10 consecutive hours off after a tour of duty of 12 hours or more.

When a train crew cannot reach a scheduled or convenient crew change point 

within 12 duty hours, the train must stop so that a replacement crew can take over. The 

crewmembers being relieved are paid for any time they spend ìdeadheadingî back to the 

terminal; however, this time is referred to as ìlimbo time,î as it is not considered to be 

time on duty or time off duty.49

The hours-of-service limits for the conductor and brakeman of train P22 expired at 

7:00 p.m. After the crew arrived at the Aiken Yard, the conductor and brakeman finished 

the required paperwork, and the entire crew was shown off duty at 8:11 p.m. Records 

showed that on 10 of the 30 working days before the accident, train P22 crews had spent 

time on paperwork after having been on duty for 12 hours in train or engine service. An 

FRA representative responsible for enforcing the Hours of Service Act told the Safety 

Board that any work, including paperwork, done on behalf of the railroad beyond the 

allotted 12 hours is considered a violation of the act.

In Safety Board interviews, the P22 crew working the day before the accident said 

that they were not aware that doing paperwork after 12 hours of operating a train could be 

considered a violation of the Hours of Service Act. They indicated that they understood 

the law covered only the movement of railroad equipment, not subsequent time spent in 

administrative duties. NS managers told the Safety Board that they were unaware that 

train crews were working outside the time limits. The computer time submissions by train 

crews were used primarily for accounting and pay purposes and were not used by 

operations managers to audit train crew activities. The FRA requires railroads to file 

excess-service reports when covered employees exceed the 12-hour limit. The NS had 

submitted no such reports for service performed by the P22 crew before the accident. 

After the accident, the FRA cited the NS for violations of the Hours of Service Act.

48 The Hours of Service Act does not specifically refer to ìemergencyî or ìemergencies,î but to 

ìcasualties, unavoidable accidents, Acts of God,î and is interpreted by the FRA as ìa cause not known to the 

carrier or its officer or agent in charge of the employee at the time the said employee left the terminal, and 

which could not possibly be foreseen.î

49 The amount of time that a train crew spends deadheading to (as opposed to from) an assignment is 

considered on-duty time and is included when calculating total duty time.
38 Railroad Accident Report

Analysis

The Accident

NS train 192 was operating under track warrant authority on January 6, 2005, 

when it departed Augusta, Georgia, bound for Columbia, South Carolina. The crew had 

every reason to believe that no other trains would be occupying their track and that all 

switches would be set for the main line. The 30-minute trip was uneventful from Augusta 

to Graniteville.50

Train 192 continued operating at near the maximum authorized speed of 49 mph as 

it approached the industry track switch, which was improperly lined for the industry track 

instead of the main line. Event recorder data indicated that the train was traveling about 47 

mph just before it encountered the switch and was diverted into the industry track. At a 

point north of the turnout switch, as the train entered the 8o left-hand curve of the industry 

track, the first car aft of the locomotives rolled toward the right and derailed. As the car 

toppled to the right, it became uncoupled from the locomotives, and the trainís emergency 

brakes applied. The movement of the first car off the rails also caused the aft end of the 

second locomotive to derail.

Almost simultaneously with the separation of the first railcar, the front of the lead 

locomotive of train 192 struck the front end of the locomotive of standing train P22, which 

had been left on the industry track the previous evening. The derailment and impact likely 

accounted for the spike in traction motor current recorded at 2:39:03 by the event recorder 

in the lead locomotive of train 192. The speed of the locomotives, which were rapidly 

decelerating, was about 42 mph at that point.

With the collision and derailment, the cars coupled behind the first railcar were 

carried onward toward the derailed first railcar as a result of ìrun-inî momentum. The 2nd 

through 14th cars in the consist then progressively derailed as they made contact with the 

preceding derailed cars, with the individual cars coming to rest in a wreckage pileup. The 

15th and 16th cars in the consist derailed but did not become entangled in the pileup.

The collision of the two locomotives derailed the standing train P22 locomotive 

and propelled it about 217 feet northward (along the track). The P22 locomotive came to 

rest about 5 feet south of the Hickman Street pavement edge, remaining upright and 

somewhat aligned with the track.

The lead locomotive of train 192 traveled about 145 feet after the collision and 

came to rest an estimated 77 feet south of the Hickman Street pavement edge, which is 

about 487 feet to the north of the switch for the industry track turnout.

50 The accident scenario outlined in this section is based on postaccident inspections, physical evidence, 

and event recorder data.
Analysis 39 Railroad Accident Report

The investigation revealed that the improperly lined switch had most recently been 

used by the crew of local train P22 about 8 hours before the accident. The crew had lined 

the switch for the industry track in order to place two cars at the Avondale Mills plant. No 

crewmember remembered relining the switch for the main line before they boarded a taxi 

and returned to the terminal.

Exclusions

Inspection records and postaccident examination revealed that the track and switch 

in the derailment area were in good condition on the day of the accident. The non-derailed 

cars from train 192 were tested, and no defects were found that would have affected the 

operation of the train or altered its performance. The train 192 crewmembers were 

qualified for their duties; they had received adequate time to rest before being called for 

work; and they had been on duty for only about 2 hours 10 minutes when the accident 

occurred. Postaccident toxicological testing was negative for the train 192 engineer and 

conductor. The Safety Board therefore concludes that neither train equipment defects nor 

track condition were causal or contributory to this accident. The Safety Board further 

concludes that, in regard to the crew of train 192, fatigue, crew training and qualifications, 

and drugs and alcohol were not factors in this accident.

The train P22 crew was experienced and qualified for the position each 

crewmember held on the day before the accident. Each crewmember had had sufficient 

off-duty time to have been well-rested before reporting for duty on January 5, 2005. 

Because about 6 1/2 hours elapsed from the time the P22 crew went off duty until the 

accident occurred, toxicological testing of the train P22 crew was not required or 

performed. Crewmembers said they had not used alcohol or illicit drugs before or during 

duty on January 5, and no evidence was found to suggest such use. The Safety Board 

therefore concludes that, in regard to the crew of train P22, neither crew qualifications and 

training nor fatigue were causal or contributory to this accident, and no evidence was 

found to suggest drug or alcohol use.

Emergency Response

Local emergency response agencies were notified via 911 calls within about 1 

minute of the accident. The fire chief and other resources of the Graniteville, Vaucluse, and 

Warrenville Volunteer Fire Department were en route to the scene about 1 minute thereafter. 

When the first-arriving responders reported breathing difficulties, the fire chief ordered his 

resources to stand by and not approach the scene, which proved to be a prudent action. When 

the fire chief arrived and was himself almost overcome by the toxic fumes, he directed a 

mass evacuation of the area. Within about 13 minutes of dispatch, the fire chief began 

marshaling his firefighting personnel and equipment at a staging area upwind of the toxic 

gas release site. The fire chief also began establishing incident command, requested mutual 

aid from nearby communities, requested weather information, and asked that the reverse 911 
Analysis 40 Railroad Accident Report

system be activated. Within about 27 minutes of dispatch, equipment and personnel were 

being successfully staged at what was later identified as a ìforward commandî site. Within 

about 34 minutes of dispatch, all Aiken County fire resources were placed on standby.

Within 53 minutes of the initial dispatch, the first of four decontamination stations 

was being organized. Within 69 minutes of dispatch, several firefighter entry teams, 

wearing personal protective equipment and riding in privately owned pickup trucks, were 

dispatched to the accident site. The teams transported individuals or groups of people who 

had been exposed to the gas vapor to one of the decontamination stations before returning 

to the scene to repeat the search and rescue cycle. The technique used by the entry teams, 

which allowed them to rapidly cycle into and out of the ìhot zone,î proved to be a 

particularly efficient and expeditious means of evacuating those individuals who were in 

the most danger because of their proximity to the accident site.

A review of the causes of death of the fatalities occurring in the field revealed that 

the mechanism of death for all the fatalities was asphyxia that occurred within minutes of 

exposure to the chlorine gas. This finding suggests that many, if not all, of the civilian 

fatalities in this accident occurred within the minutes that elapsed before emergency 

responders arrived on the scene or were able, because of the toxic fumes, to begin a safe 

search and rescue effort.

Based on the promptness of the dispatch of emergency response resources to the 

scene; the immediate implementation of the incident command system; the timely request 

that additional mutual aid emergency response resources be dispatched to the scene; and 

the relatively prompt search and rescue, evacuation, and decontamination efforts, the 

Safety Board concludes that the execution of the emergency response to this accident was 

timely, appropriate, and effective.

Performance of Train P22 Crew

The crew of local train P22, working out of Aiken, South Carolina, completed their 

work along the NS main line in the Graniteville area about 7:00 p.m. on January 5, 2005. 

No other trains or crews occupied or worked along the main line between the time the P22 

crew left the industry track and the arrival of train 192 about 7 1/2 hours later.

The P22 conductor stated that his crew arrived at the industry track about 6:10 

p.m. the day before the accident. Because the brakeman and conductor had been on duty 

since 7:00 a.m., they had only 50 minutes to complete their work at the mill and safely 

secure their train before reaching the maximum 12-hour limit imposed by Federal hoursof-service regulations. The brakeman recalled being ìpushed for the [hours of service] 

lawî as he worked in the Avondale Mills area. The engineer said that throughout the 

workday, both the brakeman and conductor held job briefings at various places they 

worked, but no such job briefing was held once the crew arrived at the industry track. The 

engineer later speculated that the reason no job briefing was held might have been that the 

conductor and brakeman were ìin a hurry.î
Analysis 41 Railroad Accident Report

The brakeman told investigators he was sure ìin his mindî that everything was 

lined properly when he left the Avondale Mills area the evening before the accident. But 

he also said he was not ì100 percentî sure that he had relined the main line switch before 

departing. Postaccident inspection revealed that the switch was lined and locked for the 

industry track, as it had been when train P22 used the switch on the evening of January 5. 

The switch showed no evidence of tampering, and no other trains used the track in the area 

from the time the train P22 crew left until the accident the next morning. The Safety Board 

therefore concludes that the crew of train P22 failed to reline a main line switch after using 

it, leading to the subsequent and unexpected diversion of train 192 into an industry track 

where it struck train P22 and derailed.

Perhaps the most vexing question when considering the circumstances of this 

accident is how an experienced train crew could fail to execute a simple action⎯relining a 

switch⎯that they had performed many times before and that, in fact, was a routine part of 

their jobs. As the crew wrapped up their work at the industry track and departed the area, 

none of them realized that a critical final task had been omitted.

One expert who studies the nature of errors is James Reason, professor emeritus of 

psychology at the University of Manchester in Manchester, UK. Reason has characterized 

errors of omission as a ìparticularly worthwhile target since the failure to carry out 

necessary steps in the performance of a task is probably the single most common human 

error type.î51

In a paper,52 Reason discusses the nature of omissions and how they occur. He 

identifies a number of task features that are likely to increase the probability that a 

particular step in a task will be omitted. The task features Reason identified are as follows:

ï The greater the informational loading of a particular task stepóthat is, the 

higher the demands imposed upon short-term memoryóthe more likely it is 

that items within that step will be omitted.53

ï Procedural steps that are functionally isolated, that is, ones that are not 

obviously cued by preceding actions nor follow in a direct linear succession 

fromthem, are more likely to be left out.

ï Recursive or repeated procedural steps are particularly prone to omission. In 

cases where two similar steps are required to achieve a particular goal, the 

second step is the one most likely to be neglected.54

51 J. Reason, ìHow Necessary Steps in a Task Get Omitted: Revising Old Ideas to Combat a Persistent 

Problem,î Cognitive Technology. 1998; 3:24-32.

52 J. Reason, ìCombating Omission Errors Through Task Analysis and Good Reminders,î Quality and 

Safety in Health Care. 2002; 11:40-44.

53 D. A. Norman, The Psychology of Everyday Things. New York: Basic Books, 1988.

54 C. Baber and N. A. Stanton, ìTask Analysis for Error Identification: A Methodology for Designing 

Error-Tolerant Consumer Products,î Ergonomics. 1994; 11:1923ñ41.
Analysis 42 Railroad Accident Report

ï Necessary steps that follow the achievement of the main goal of a task are 

likely to be omitted. This is an instance of a general principle: Steps near the 

end of a task sequence are more prone to omission. Such ìpremature exitsî are 

due in part to the actorís preoccupation with the next task, particularly when the 

current activity involves largely routine actions.55

ï Steps in which the item to be acted upon is concealed or lacking in conspicuity 

are liable to omission.

ï Steps following unexpected interruptions are especially prone to omission. 

This can occur because the person loses his or her place in the action sequence 

or because some unrelated action is unconsciously ìcounted inî as part of the 

task sequence.56

ï In tasks that involve departures from standard operating procedures or from

habitual action sequences, the intended actions may be supplanted by themore 

frequently used routine in that context and thus omitted.

ï Actions that are triggered by weak, noisy, or ambiguous signals are likely to be 

omitted.

Reason discussed a study involving frequent users of office copiers that illustrated 

the potential for omission errors created by the above task features. Based on these 

features, researchers correctly predicted that the most common error reported by copier 

users who manually copied multi-page documents would be the failure to remove the last 

page of the original after copying was complete. This failure was predictable because:

ï The emergence of the last copy page is a strong, but false, signal that the job is 

complete. That is, the main goal of the activity (copying) is achieved before 

completion of all the necessary steps.

ï This false completion signal gains influence because of its proximity to the 

presumed end of the activity. As the last page is copied, attention to the

subsequent task increases.

ï As the last sheet is copied, it is no longer necessary to insert another original. 

This leaves removing the last original page a functionally isolated act. Up until 

this point, removal of an original page has been cued by the need to place the 

next one.

ï The closed copier lid conceals the last sheet of the original, so there is no

visible reminder to remove it.

The primary purpose of the exercise was to demonstrate that task features that are 

likely to provoke frequent omissions can be identified and, once they are identified, steps 

can be taken to reduce the frequency of such errors.

55 J. Reason, Human Error. New York: Cambridge University Press, 1990.

56 J. Reason, Human Error.
Analysis 43 Railroad Accident Report

Some of the task features that have been identified as leading to omission errors 

were evident in the Graniteville accident. Some of the more important of these features are 

as follows, illustrated by events from the accident sequence:

Procedural steps that are functionally isolated, that is, ones that are not obviously 

cued by preceding actions nor follow in a direct linear succession from them, are 

more likely to be left out.

When the crew arrived at the Avondale Mills plant, they immediately undertook a 

series of steps that would permit them to achieve their objective of placing two cars at the 

industry track. This included the conductorís getting off the locomotive and leaving the 

train to unlock gates and prepare switches near the industry track, the brakeman and 

engineerís continuing on toward the switch, the brakemanís dismounting the train and 

lining the switch for the industry track, the engineerís backing the train into the industry 

track, and the brakeman and conductorís continuing with their switching and placement of 

cars.

In this sequence of actions, each step proceeded in a direct linear fashion, one step 

leading naturally to the next. Had the initial plan called for moving the train onto the 

industry track and leaving it there without returning to the main line, relining the switch 

after the train was on the industry track would have been a natural next step. Similarly, had 

the crew been able to finish their work at the industry track and take the train to 

Warrenville as they planned, relining the switch once the train returned to the main line 

would have followed naturally in an organized sequence.

As it was, the 12-hour duty limit interrupted the process of planned, deliberate, 

sequential steps. Now, instead of completing their job at the mill, continuing southbound, 

and securing their train, the crew had to secure the train in place. This required that the 

crew switch and place cars to get the train clear of the main line and road crossings and do 

it within a strict time limit. They were just able to complete this work before their 

maximum on-duty time expired.

The last-minute change in plans created a new sequence of events that left one 

critical step functionally isolated⎯that of relining the main line switch. Because the train 

did not return to the main line, relining the main line switch was no longer part of an 

organized process of sequential steps and was thus neglected.

Necessary steps that follow the achievement of the main goal of a task are likely 

to be omitted. This is an instance of a general principle: Steps located near the end 

of a task sequence are more prone to omission.

The main objective for the crew once they arrived at Avondale Mills was to place 

two cars within the plant. This objective was realized once the last car had been placed. 

The conductor expressed relief that they had completed the job within their allowable 

hours of service. In the minds of the crewmembers, the only task remaining was to secure 

the equipment, retrieve their gear, and depart, which they did. The task of relining the 

main line switch was a necessary step in terms of safety and efficient train operations, but 
Analysis 44 Railroad Accident Report

it was not part of the immediate job at hand. In other words, the crew forgot to reposition 

the switch, something that had been done many times before, because the primary 

objective (switching cars) had been achieved, and they had already begun to focus on the 

next task (securing the train and departing).

Steps in which the item to be acted upon is concealed or lacking in 

conspicuity are liable to omission.

When the crew completed securing the train, the head end was about 342 feet from 

the main line switch. Both the engineer and the conductor said the switch banner was not 

visible at that point. Had the switch banner been conspicuous, it might have been detected 

by a crewmember who would likely have realized that the switch was not properly lined. 

And even though the switch position could have been detected as the crew passed along 

the adjacent road on the way to the terminal, they had no reason to observe it and 

apparently did not.

The Safety Board concludes that the crew of train P22 failed to reline the main line 

switch for one or more of the following reasons: (1) the task of relining the switch was 

functionally isolated from other tasks the crew was performing, (2) the crewmembers 

were rushing to complete their work and secure their train before reaching their hours-ofservice limits, (3) the crew had achieved their main objective of switching cars and were 

focused on the next task of securing their equipment and going off duty, and (4) the switch 

was not visible to the crew as they worked, leaving them without a visual reminder to 

reline the switch.

The conductor stated that he did not hold a job briefing at the industry track that 

specifically addressed the switches at that location. Furthermore, he said that he did not 

tell the brakeman to ensure that the switch was lined and locked for the main track. NS 

rules require that a job briefing be held in this circumstance. Had a job briefing been held, 

it would likely have included a discussion of the switches and specifically who was 

responsible for ensuring that they were properly positioned. Had such a briefing taken 

place, the relining of the switch might not have been overlooked. The Safety Board 

concludes that had the conductor of train P22 held a comprehensive job briefing at the 

Avondale Mills industry track, as required by NS operating rules, the crew may have 

attended to the main line switch, and the accident may not have occurred.

After the accident, the FRA issued Safety Advisory 2005-01, which urged 

railroads to review their operating rules and take certain steps to ensure that crews using 

manually operated switches leave those switches in the proper position when their work is 

complete. The advisory referenced rules already implemented by the BNSF and UP 

railroads requiring that crews inform dispatchers of switch positions or inform them that 

switches had been properly relined before reporting clear of main line track. These rules 

were developed because of accidents similar to the one at Graniteville. The FRA also 

urged the use of a switch position reporting form to be filled out by the conductor before 

reporting clear of main line track.
Analysis 45 Railroad Accident Report

While any operating rule change designed to enhance safety is welcomed, the 

Safety Board does not believe that rule changes or the use of forms is sufficient to prevent 

recurrences of accidents such as the one at Graniteville. The Safety Board notes that only 

2 days after the Graniteville accident, a BNSF freight train was unexpectedly diverted into 

an industrial siding in California where it struck two loaded cars and derailed. This 

accident occurred less than 3 months after the BNSF implemented the rule referenced in 

the FRA advisory, a rule similar to those the FRA is urging other railroads to adopt and to 

the rules adopted by the NS after the accident. The Safety Board further notes that the UP 

had also adopted such a rule before the issuance of the advisory, but this did not prevent 

the September 15, 2005, collision of a southbound UP freight train with a standing local 

train in Shepherd, Texas, that resulted in a fatality and several injuries.

At Graniteville, the brakeman whose job it was to reline the switch said that he 

believed everything was correct when he left the scene, and there is no reason to believe 

that, even in his haste to return to the terminal, he would knowingly have left the switch 

improperly lined. While it is possible that a discussion with the dispatcher specifically 

regarding switches would have caused him to think through his actions and remember that 

he had neglected the switch, it is also possible that during such a discussion he would 

simply have confirmed his belief that he had left the site properly secured. He was 

certainly aware that when he cleared the track warrants with the dispatcher he was 

certifying that the main line was ready for use by other trains. He would not likely have 

done this if he had any doubt about how he had left the track. Finally, under normal 

conditions, the conductor would have cleared the track warrants with the dispatcher. He 

likely would have assumed that the brakeman had relined the switch and would have 

reported it to the dispatcher accordingly, especially if the brakeman had already departed.

Similarly, the use of forms, such as the switch position awareness form, has not 

been shown to be particularly effective in preventing railroad accidents. For example, 

some railroads, in order to lessen the chance that a traffic control signal will be missed or 

misinterpreted by a crew, require that conductors record signal indications as they are 

encountered en route. But the Safety Board has investigated a number of accidents in 

which such forms, although required and used, did not prevent crews from missing signals 

and causing accidents.

The FRA itself acknowledged the ineffectiveness of the safety advisory when, in 

October 2005, it issued Emergency Order 24 in response to a number of accidents 

involving improperly lined switches that occurred after promulgation of the advisory. 

While the Safety Board acknowledges the timeliness with which the FRA has addressed 

this safety issue, the Board is concerned about the effectiveness of the emergency order in 

preventing future accidents. The primary concern of the Board is that the emergency order 

largely requires what the previous safety advisory had recommended, which has been 

shown to be of questionable effectiveness.

For example, it is not likely that a railroad employee qualified and authorized to 

operate a hand-operated switch is unaware of the rules requiring that the switch be 

returned to its proper position after work is complete. It is therefore unclear how 

additional instruction on rules will improve employee performance. The emergency order 
Analysis 46 Railroad Accident Report

also directs that an employee who operates a switch is responsible for returning it to its 

normal position; however, NS operating rules placed responsibility accordingly, and this 

did not prevent the Graniteville accident. The shortcomings of requiring the completion of 

a switch position awareness form and of requiring that switch positions be confirmed with 

the dispatcher have already been discussed. The additional operational tests required by 

the emergency order may be expected merely to confirm that employees know their 

responsibilities and that they fulfill those responsibilities most of the time. Such tests can 

perhaps prevent errors of ignorance, but not of omission.

The emergency order goes beyond the safety advisory recommendations and 

current regulations in at least two respects: by directing that job briefings be held at the 

completion of work and by requiring that a train crewmember who repositions a main line 

switch in non-signaled territory communicate with the engineer regarding the switch 

position. The Safety Board welcomes these requirements as worthy additions to existing 

requirements that could provide an additional layer of safety. As previously noted, a 

comprehensive safety briefing was not held before the work at Graniteville. Had such a 

briefing been held before and, more importantly, after the work (as required by the FRA 

emergency order), the accident might have been avoided.

A significant element of the emergency order is the provision for a civil penalty of 

up to $27,000 for violations of the order. The penalty may apply to the individual at fault 

and/or to the company or other corporate entity. The magnitude of this penalty reflects the 

seriousness with which the FRA views violations of this kind; however, it does not, in the 

view of the Safety Board, address the cause of the violations. That is, the Safety Board 

does not believe that employees forget to reline switches because the existing penalties are 

inadequate. Employees are acutely aware that an improperly lined switch, in addition to 

being a rule violation that could lead to removal from service, is likely to result in 

significant property damage or the injury or death of fellow employees or innocent 

bystanders. A substantial financial penalty is unlikely to be more effective than this 

sobering prospect in preventing these types of accidents.

Moreover, the Safety Board is concerned that the significant civil penalty may 

have an unintended impact on safety under some circumstances. That is, an employee 

who, after leaving a work site, realizes that a switch has been left improperly lined may be 

made more reluctant than in the past to immediately report the error to train dispatchers. 

The threat of the severe fine may prompt the employee to attempt a remedy (such as 

returning later to reline the switch) before the mistake can become known. As happened in 

the September 2005 fatal collision in Shepherd, Texas, such action on the part of the 

employee could contribute to an accident that might otherwise have been avoidable.

Clearly, measures beyond added or enhanced operating rules or additional forms, 

or even severe penalties, are needed to ensure that accidents such as the one at Graniteville 

do not recur. For example, a conspicuous visual stimulus associated with the switch at 

Graniteville might have alerted the P22 crew to the position of the main line switch 

despite any distractions.
Analysis 47 Railroad Accident Report

A conspicuous visual stimulus could take one of many forms. It could be a steady 

or flashing strobe light (such as those used on some school buses and traffic signals) of a 

color that would not be confused with other railroad signals. This would be analogous to 

the ìblue flagî procedures mandated by the FRA to draw particular attention when 

personnel are working on, under, or between rail cars. The crew would probably have seen 

a highly conspicuous light before leaving and would have relined the switch. Assuming 

they had tied down the train out of sight of the switch (and had not traveled past it in 

leaving) and had therefore left the switch improperly lined despite its conspicuity, a 

unique flashing strobe or other obvious light might have alerted the train 192 crew to the 

switch position in time to slow the train.

Alternatively, a device could be installed that would use electronic technology to 

draw the crewís attention to an improperly lined switch. Once an employee moved a 

switch to a non-normal position, the device could monitor the employeeís proximity to the 

switch. Should the employee leave the vicinity without relining the switch, a notification 

could be sent to the employeeís pager or cell phone. If the employee failed to respond 

within a specified time, the system could alert the railroad dispatcher or other designated 

railroad employee.

The foregoing examples represent two possible means, one visual and one 

electronic, of capturing an employeeís attention, but the Safety Board recognizes that 

there are likely additional ways by which this objective could be achieved. The Safety 

Board therefore believes that the FRA should require that, along main lines in nonsignaled territory, railroads install an automatically activated device, independent of the 

switch banner, that will, visually or electronically, compellingly capture the attention of 

employees involved with switch operations and clearly convey the status of the switch 

both in daylight and in darkness.

Train Speeds in Non-Signaled Territory

The maximum authorized speed along the NS main line through Graniteville was 

49 mph, and according to all available evidence, train 192 did not exceed this speed from 

the time it left Augusta until it reached Graniteville. However, sight distance tests 

demonstrated that the banner indicating the misaligned switch was not identifiable (by 

investigators who were specifically looking for it) until the train was within about 566 feet 

of the switch. To the crew of train 192, this distance might have been even less because of 

the other lights and signals within the train crewís visible range that may have created a 

perceptual conflict. The Safety Board concludes that at the speed train 192 was traveling 

as it entered Graniteville, the distance required for the train crew to perceive the banner of 

the misaligned switch, react to it, and bring the train to a safe stop was greater than the 

distance available.
Analysis 48 Railroad Accident Report

The Safety Board was concerned as early as 1974 about the issue of train speeds in 

areas not under a form of centralized traffic control. As a result of its investigation of a 

fatal accident in Cotulla, Texas, involving a misaligned switch in non-signaled territory,57

the Safety Board made the following safety recommendation to the Missouri Pacific 

Railroad (now part of the Union Pacific Railroad):

R-74-22

Review your operation on main tracks that are not equipped with automatic 

block signals and take appropriate action to ensure the capability of 

engineers to stop trains in advance of misaligned switches. This action 

could include reducing the size or speed of trains, installing automatic 

block signals or advance-position indicators, or improving the visibility of 

switch stand targets.

This recommendation was classified ìClosed⎯No Longer Applicableî after the 

Safety Board was provided with information indicating that the Missouri Pacific Railroad 

would continue to evaluate territories for the possible installation of automatic block 

signals or centralized traffic control.

At the time of the Cotulla accident, Interstate Commerce Commission (ICC) Order 

29543 was in effect, which established a speed limit of ìless than 50 mphî for freight 

trains operating in non-signaled territory.58 The Safety Boardís investigation of the Cotulla 

accident revealed that Order 29543 was inadequate in that the maximum allowable speed 

was established without consideration of factors, such as visibility and stopping distances, 

that at times may require lower speeds for safe operation. Therefore, the Safety Board 

made the following safety recommendation to the FRA:

R-74-26

Determine and assess the current risks of train accidents involving 

misaligned switches, collisions, broken rail, and other route obstructions on 

main track where automatic block signal systems do not exist. Promulgate 

regulations to replace Interstate Commerce Commission Order 29543. 

These regulations should detail the major risks and controls assumed, set 

guidelines for safe operations below the maximum operating speed, and 

assign responsibility to the carrier for safe operations.

When the FRA issued regulations for signal and train control systems in January 

1984, the wording of ICC Order 29543 was incorporated, unchanged, into the new 

regulations. The Safety Board had intended that the new regulations specify circumstances 

57 National Transportation Safety Board, Collision of Missouri Pacific Railroad Company Freight 

Train Extra 615 South With a Standing Locomotive, Cotulla, Texas, December 1, 1973, Railroad Accident 

Report NTSB/RAR-74/03 (Washington, D.C.: NTSB, 1974).

58 This speed limit does not apply along non-signaled track where train movements are governed by a 

manual block system permanently in effect. See 49 Code of Federal Regulations 236.0(c).
Analysis 49 Railroad Accident Report

that required that trains be operated below the allowable maximum speed. Because the 

FRAís actions did not satisfy the Safety Boardís intent, Safety Recommendation R-74-26 

was classified ìClosed⎯Unacceptable Action.î

As acknowledged by the FRA, the frequency and severity of accidents involving 

misaligned switches in non-signaled territory appear to be increasing. While at least some 

of the measures the FRA has directed through its emergency order may aid in reducing the 

number of switching mistakes, they are unlikely to eliminate such mistakes entirely. 

Additional measures are therefore needed to help ensure that such mistakes, when they do 

occur, do not result in accidents.

The Safety Board therefore believes that the FRA should require railroads, in nonsignaled territory and in the absence of switch position indicator lights or other automated 

systems that provide train crews with advance notice of switch positions, to operate those 

trains at speeds that will allow them to be safely stopped in advance of misaligned switches.

Hazardous Materials Release

During the derailment, the ninth car in the train, a tank car loaded with chlorine, was 

punctured. Emergency responders observed that the B-end coupler of the 11th car in the 

train, a car transporting steel coils, was in contact with the damaged tank jacket near the 

puncture in the tank shell and was covered with frost. Leaking chlorine, which boils at 

-29o F at atmospheric pressure, vaporizes rapidly from a liquid to a gas as it escapes 

through an opening such as a puncture, thereby freezing water vapor in the air and causing 

frost to form on nearby objects. Metallurgical examination of the damage on the shell 

around the puncture documented several impression marks on the shell that matched 

damage found on projecting surfaces of the coupler. The Safety Board therefore concludes 

that the chlorine gas release that occurred in this accident resulted when the shell of the 

9th car on the train was punctured by the coupler of the 11th car.

Photographs show that the punctured tank car came to rest angled slightly to one side 

with the puncture opening extending below the midline of the resting tank. With the tank car 

in this position, it is likely that the liquefied chlorine above the level of the puncture was 

released within minutes and pooled on the ground. Measurements by emergency responders 

of the liquid level of the chlorine remaining in the tank on the day of the accident revealed 

that the tank car retained only about one-third of its original load of 180,000 pounds (13,830 

gallons) of liquefied chlorine. Thus, approximately 120,000 pounds (9,218 gallons) of 

liquefied chlorine were released before the responders arrived on scene.

The liquefied chlorine rapidly vaporized and expanded when it spilled from the tank 

car. (The vaporization of liquefied chlorine at 32o F at atmospheric pressure can generate a 

gaseous cloud with a volume 450 times greater than the volume of the liquid released.59) 

As a result, the released chlorine created a large toxic cloud around the derailment site. 

59 Richard J. Lewis, Jr., Hawley Condensed Chemical Dictionary-Thirteenth Edition. New York: John 

Wiley & Sons, Inc., 1997.
Analysis 50 Railroad Accident Report

Because gaseous chlorine is 2 1/2 times heavier than air, the toxic cloud tended to settle in

low areas around the railroad tracks and remain more concentrated in these areas. Judging

from the locations of the fatalities, the cloud likely expanded to the west and into the plant,

followed the local topography running downhill to the south and west, and was blown to the

north by light winds. All fatalities resulting from the accident were caused by inhalation of

chlorine gas. Given that both train 192 crewmembers survived the collision (the engineer

died later from exposure to the gas), no fatalities or serious injuries would have resulted from

this accident had a tank car of chlorine not been punctured.

Tank Car Performance

Tank Car Crashworthiness

As previously noted, the 9th of 42 cars in the train was struck and punctured by the

coupler of the 11th car transporting steel coils. The combined weight of the striking steel

coil car and the rest of the trailing cars in the train was about 2,618 tons. The estimated

impact speed was determined to be about 42 mph. This combination of mass and velocity

subjected the punctured chlorine tank car to severe impact forces during the derailment,

with the most concentrated forces being applied in the area struck by the coupler.

The punctured tank car was built in 1993, and therefore was required to have both

the tank heads and the tank shell constructed of normalized steel. The normalizing heat

treatment typically increases the fracture toughness and lowers the ductile-to-brittle

transition temperature of steel plate. Thus, for a given composition of steel, normalized

steel is less susceptible to catastrophic brittle fractures and requires more energy to

fracture than non-normalized steel.

Charpy impact testing showed that the normalized steel in the tank shell of the

punctured chlorine car had a fracture toughness that was significantly greater than the

fracture toughness of the non-normalized steels of the catastrophically ruptured tank cars

involved in the derailment of a Canadian Pacific Railway freight train in Minot, North

Dakota, in January 2002.60 The steel in the Minot tank cars exhibited relatively low

fracture toughness, and cracks propagated rapidly around the circumference of each tank.

The higher fracture toughness in the Graniteville tank car contributed to the relatively

quick arrest of the crack even though there was brittle fracture in its outer portions.

Chlorine tank cars such as the punctured ninth car are tested to a pressure of 500 psig

compared to a test pressure of 300 psig for tank cars used to transport anhydrous ammonia and

liquefied petroleum gas. To be rated for the increased operating pressure, the tanks of chlorine

tank cars must have greater tank wall thicknesses than tanks of the lower pressure cars.

Because of the improved properties of normalized steel and the increased wall thickness, the

60 National Transportation Safety Board, Derailment of Canadian Pacific Railway Freight Train 292-

16 and Subsequent Release of Anhydrous Ammonia Near Minot, North Dakota, January 18, 2002, Railroad

Accident Report NTSB/RAR-04/01 (Washington, D.C.: NTSB, 2004).
Analysis 51 Railroad Accident Report

punctured car was among the strongest tank cars currently in service. The Safety Board 

therefore concludes that, as shown in the Graniteville accident, even the strongest tank cars in 

service can be punctured in accidents involving trains operating at moderate speeds.

The Safety Board addressed the improvement of crashworthiness of railroad tank 

cars in its Minot, North Dakota, accident report. The Board stated in its report:

Improvements in the crashworthiness of pressure tank cars can be realized 

through the evaluation of alternative steels and tank car performance standards. 

The ultimate goal of this effort should be the construction of railroad tank cars that 

have sufficient impact resistance and that eliminate the risk of catastrophic brittle 

failures under all operating conditions and in all environments. Achieving such a 

goal does not necessarily require the construction of a tank car that is punctureñ

proof; it may only require construction of a car that will remain intact and slowly 

leak its contents if it is punctured.

To address these concerns, the Board recommended that the FRA:

R-04-6

Validate the predictive model the Federal Railroad Administration is 

developing to quantify the maximum dynamic forces acting on railroad 

tank cars under accident conditions.

R-04-7

Develop and implement tank car design-specific fracture toughness 

standards, such as minimum average Charpy value, for steels and other 

materials of construction for pressure tank cars used for transportation of 

U.S. Department of Transportation class 2 [gases] hazardous materials, 

including those in low-temperature service. The performance criteria must 

apply to the material orientation with the minimum impact resistance and 

take into account the entire range of operating temperatures of the tank car.

On August 9, 2004, the FRA responded and described the actions being taken to 

address each recommendation. In response to Safety Recommendation R-04-6, the FRA 

stated that it has identified ongoing programs at the Volpe National Transportation 

Systems Center and the University of Illinois at Chicago to evaluate in-train forces 

associated with train derailments. The FRA said it anticipates that the modeling program 

will be completed in early 2006. Regarding Safety Recommendation R-04-7, the FRA 

stated that further research in this area is required and that it may require a ìthree-year 

effortî to develop adequate tank car design-specific fracture toughness standards.

On June 22, 2005, in addressing the FRAís response to Safety Recommendation R04-6, the Safety Board noted that programs to analyze in-train forces have already been 

identified and that it expects validation of the models to be a standard part of any model 

development. Based on FRAís response, Safety Recommendation R-04-6 was classified 

ìOpen⎯Acceptable Response.î In addressing the FRAís response to Safety 

Recommendation R-04-7, the Safety Board stated that implementation of tank car design-
Analysis 52 Railroad Accident Report

specific fracture toughness standards, such as Charpy impact value, can be achieved for 

standard manufacturing processes without waiting for the results of the modeling effort 

associated with Safety Recommendation R-04-6. The Safety Board added that evaluation 

and analysis of the dynamics of the Minot accident can provide data about the levels of 

fracture toughness that may be necessary for pressure tank cars and that data from 

subsequent accidents in Macdona, Texas, on June 28, 2004, and Graniteville will provide 

additional information. Based on the FRAís response, Safety Recommendation R-04-7 

was classified ìOpen⎯Unacceptable Response.î

Congress also recognized the significance of the Safety Boardís safety 

recommendations to the FRA by incorporating them into the ìSafe, Accountable, Flexible, 

Efficient Transportation Equity Act,î which was signed into law in August 2005. Section 

20155 of the act stipulated that the FRA was to validate the predictive model within 1 year 

of enactment and initiate a rulemaking to implement appropriate design standards for tank 

cars within 18 months of enactment.

The Macdona and Graniteville accidents, both of which have occurred since the 

Minot report was issued, resulted in the puncturing of two chlorine tank cars and the death 

of 12 people from chlorine inhalation. When a liquefied gas such as chlorine, which is 

poisonous by inhalation, is released, large clouds at lethal concentrations can be generated 

within minutes. There is often little or no time to alert citizens and to take effective action. 

Based on AAR data on tank car shipments in the United States for 2002, chlorine and 

anhydrous ammonia ranked as, respectively, the fourth and seventh most commonly 

shipped hazardous materials by tank car. Furthermore, these products routinely travel 

through communities of varying size, including large metropolitan areas.

Reduction of Tank Car Vulnerability

It is the belief of the Safety Board that modeling of accident forces and the 

application of fracture toughness standards as recommended in the Minot report will 

provide the most effective improvements in the crashworthiness of tank cars. However, at 

best, it will be several years before a significant percentage of pressure tank cars in service 

will have been so designed and constructed. Therefore, the most expedient and effective 

means to reduce the public risk from the release of highly poisonous gases in train 

accidents is for railroads to implement operational measures that will minimize the 

vulnerability of tank cars transporting these products.

Supplemental operational measures are already imposed for the transportation of 

certain high-risk materials. For example, the DOTís Pipeline and Hazardous Materials 

Safety Administration requires that pipeline operators have an integrity management plan 

for high-consequence areas, which are identified on the basis of population densities and 

environmentally sensitive areas. The regulations are designed to identify high-risk areas and 

to develop a process for evaluating the risks within areas identified as high-consequence.61

61 Under the regulations, a high-consequence area may include an urban area with a population greater 

than 50,000, or a population density of 1,000 people per square mile, or other area (an unincorporated town 

or village, for example) that contains a concentrated population.
Analysis 53 Railroad Accident Report

The integrity management plan for pipeline operators describes both preventive 

and mitigative measures that a pipeline operator must take to protect a high-consequence 

area. Such measures include implementing enhanced damage prevention practices, better 

monitoring, shorter inspection intervals, improved system monitoring and detection, and 

additional personnel training/drills with emergency responders.

For rail transportation of hazardous materials, the AAR since 1990 has published 

Circular No. OT-55, Recommended Railroad Operating Practices for Transportation of 

Hazardous Materials. This circular contains recommended operating practices for 

member railroads that include speed restrictions for ìkey trainsî and enhanced track 

inspection standards for ìkey routes.î62 Because the train involved in the Graniteville 

accident was not a key train and the main line track was not on a key route, neither the 

operational restrictions nor additional inspections applied. Further, even if train 192 had 

met the definition of a key train, Circular No. OT-55 would not have restricted its speed 

below that at which it was already operating.

Two research studies have also been conducted that address operational measures 

to reduce the vulnerability of tank cars transporting hazardous materials. The 1992 FRA 

report, Hazardous Materials Car Placement in a Train Consist,

63 concluded that the rear 

one-quarter of a train is the most desirable location for cars containing hazardous 

materials and that reducing the speed and size of trains can reduce the number of cars 

derailed in an accident. The second study, ìMinimizing Derailments of Railcars Carrying 

Dangerous Commodities Through Effective Marshaling Strategies,î64 prepared for the 

Transportation Research Board, reached similar conclusions and provided some additional 

statistical information to validate those conclusions.

Both these reports address operational measures that might have made a difference 

in the Graniteville accident. Placement of the three tank cars transporting chlorine near the 

front of the train and ahead of most of the trailing tonnage increased the probability that 

the cars would be damaged and would release chlorine in an accident. Had the chlorine 

cars been placed behind the other loaded cars in the train, the reduction in the trailing 

tonnage would have reduced the impact forces on the tank cars. A reduction in train speed 

would also have significantly reduced the derailment forces on the tank cars. These 

operational measures, taken individually or collectively, may have been sufficient to 

prevent the puncture of the tank car and the release of the chlorine.

While the FRA report notes that car placement might be detrimental to train 

handling and dynamics and that switching cars to change their order in the train might 

62 Under the recommended practices, a key train includes any train with five tank car loads of poison 

inhalation hazard (PIH) cargo; or 20 carloads of a combination of PIH, flammable gas, explosives, and 

environmentally sensitive chemicals; or one or more carloads of high-level radioactive waste. A key train 

cannot exceed 50 mph.

63 R. E. Thompson, E. R. Zamejc, and D. R. Ahlbeck, Hazardous Materials Car Placement in a Train 

Consist, Vol. 1 (Review and Analysis). Report DOT/FRA/ORD/18.I. Federal Railroad Administration, U.S. 

Department of Transportation (Washington, D.C., 1992).

64 F. F. Saccomanno and S. El-Hage, ìMinimizing Derailments of Railcars Carrying Dangerous 

Commodities Through Effective Marshaling Strategies,î Transportation Research Record 1245. 

Transportation Research Board, National Research Council (Washington, D.C., 1989).
Analysis 54 Railroad Accident Report

result in exposing these cars to additional dangers, railroads should be able to take these 

factors into account and still reduce the vulnerability of tank cars transporting chlorine, 

anhydrous ammonia, and other liquefied gases that are poisonous by inhalation. Given the 

risks involved in the transportation of such liquefied gases, the Safety Board believes that 

the FRA should require that railroads implement operating measures, such as positioning 

tank cars toward the rear of trains and reducing speeds through populated areas, to 

minimize impact forces from accidents and reduce the vulnerability of tank cars 

transporting chlorine, anhydrous ammonia, and other liquefied gases designated as 

poisonous by inhalation.

Train Crew Protection From Inhalation Hazards

The Safety Board has found that freight train crews may survive collisions and 

derailments only to be injured or killed by hazardous materials released in the accident. 

Although the crew of NS train 192 survived the collision and exited the locomotive 

unassisted, they could not escape exposure to the chlorine gas. The conductor said that 

after getting out of the locomotive, he and the engineer were able to walk some distance 

from the collision site. The two were transported to hospitals. The conductor was treated 

and released; the engineer died several hours later from inhalation of the toxic gas.

The consequences of this accident are remarkably similar to those of the June 28, 

2004, collision of two freight trains near Macdona, Texas. A tank car on the striking train 

was punctured and released chlorine gas. Once again, the crew of the striking train 

survived the collision and exited the locomotive unassisted into a chlorine-laden 

atmosphere. The conductor and engineer had walked about 1,400 feet away from the 

collision site when the conductor collapsed and died from exposure to chlorine gas. The 

engineer was hospitalized with severe injuries due to his exposure.

Emergency breathing apparatus is commercially available that would give 

crewmembers in these circumstances an opportunity to escape a hazardous atmosphere. 

According to the manufacturers, many of these devices are approved for use to escape 

certain chemical atmospheres, including chlorine and ammonia, as well as fire and smoke. 

Emergency escape breathing devices are typically effective for a period of time (5 to 50 

minutes) that allow the user to escape and reach a safe location. The devices are used in a 

variety of industrial settings. They must also be carried on merchant and passenger vessels 

under the Safety of Life at Sea protocols. The Safety Board concludes that had the 

engineer of train 192 been wearing appropriate, fully functioning emergency escape 

breathing apparatus when he walked away from the collision site, he may not have 

succumbed to the effects of chlorine gas inhalation.

The Safety Board therefore believes that the FRA should determine the most 

effective methods of providing emergency escape breathing apparatus for all 

crewmembers on freight trains carrying hazardous materials that would pose an inhalation 

hazard in the event of unintentional release, and then require railroads to provide these 

breathing apparatus to their crewmembers along with appropriate training.
55 Railroad Accident Report

Conclusions

Findings

1. Neither train equipment defects nor track condition were causal or contributory to this 

accident.

2. In regard to the crew of train 192, fatigue, crew training and qualifications, and drugs 

and alcohol were not factors in this accident.

3. In regard to the crew of train P22, neither crew qualifications and training nor fatigue 

were causal or contributory to this accident, and no evidence was found to suggest 

drug or alcohol use.

4. The execution of the emergency response to this accident was timely, appropriate, and 

effective.

5. The crew of train P22 failed to reline a main line switch after using it, leading to the 

subsequent and unexpected diversion of train 192 into an industry track where it 

struck train P22 and derailed.

6. The crew of train P22 failed to reline the main line switch for one or more of the 

following reasons: (1) the task of relining the switch was functionally isolated from 

other tasks the crew was performing, (2) the crewmembers were rushing to complete 

their work and secure their train before reaching their hours-of-service limits, (3) the 

crew had achieved their main objective of switching cars and were focused on the 

next task of securing their equipment and going off duty, and (4) the switch was not 

visible to the crew as they worked, leaving them without a visual reminder to reline 

the switch.

7. Had the conductor of train P22 held a comprehensive job briefing at the Avondale 

Mills industry track, as required by Norfolk Southern operating rules, the crew may 

have attended to the main line switch, and the accident may not have occurred.

8. At the speed train 192 was traveling as it entered Graniteville, the distance required 

for the train crew to perceive the banner of the misaligned switch, react to it, and 

bring the train to a safe stop was greater than the distance available.

9. The chlorine gas release that occurred in this accident resulted when the shell of the 

9th car on the train was punctured by the coupler of the 11th car.

10. As shown in the Graniteville accident, even the strongest tank cars in service can be 

punctured in accidents involving trains operating at moderate speeds.
Conclusions 56 Railroad Accident Report

11. Had the engineer of train 192 been wearing appropriate, fully functioning emergency 

escape breathing apparatus when he walked away from the collision site, he may not 

have succumbed to the effects of chlorine gas inhalation.

Probable Cause

The National Transportation Safety Board determines that the probable cause of 

the January 6, 2005, collision and derailment of Norfolk Southern train 192 in 

Graniteville, South Carolina, was the failure of the crew of Norfolk Southern train P22 to 

return a main line switch to the normal position after the crew completed work at an 

industry track. Contributing to the failure was the absence of any feature or mechanism 

that would have reminded crewmembers of the switch position and thus would have 

prompted them to complete this final critical task before departing the work site. 

Contributing to the severity of the accident was the puncture of the ninth car in the train, a 

tank car containing chlorine, which resulted in the release of poisonous chlorine gas.
57 Railroad Accident Report

Recommendations

As a result of its investigation of the January 6, 2005, collision and derailment of 

Norfolk Southern train 192 in Graniteville, South Carolina, the National Transportation 

Safety Board makes the following safety recommendations:

To the Federal Railroad Administration:

Require that, along main lines in non-signaled territory, railroads install an 

automatically activated device, independent of the switch banner, that will, 

visually or electronically, compellingly capture the attention of employees 

involved with switch operations and clearly convey the status of the switch 

both in daylight and in darkness. (R-05-14)

Require railroads, in non-signaled territory and in the absence of switch 

position indicator lights or other automated systems that provide train 

crews with advance notice of switch positions, to operate those trains at 

speeds that will allow them to be safely stopped in advance of misaligned 

switches. (R-05-15)

Require railroads to implement operating measures, such as positioning 

tank cars toward the rear of trains and reducing speeds through populated 

areas, to minimize impact forces from accidents and reduce the 

vulnerability of tank cars transporting chlorine, anhydrous ammonia, and 

other liquefied gases designated as poisonous by inhalation. (R-05-16)

Determine the most effective methods of providing emergency escape 

breathing apparatus for all crewmembers on freight trains carrying 

hazardous materials that would pose an inhalation hazard in the event of 

unintentional release, and then require railroads to provide these breathing 

apparatus to their crewmembers along with appropriate training. (R-05-17)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER ELLEN ENGLEMAN CONNERS

Acting Chairman Member

DEBORAH A. P. HERSMAN

Member

Adopted: November 29, 2005

59 Railroad Accident Report

Appendix A

Investigation

The National Response Center notified the National Transportation Safety Board 

of the accident about 4:15 a.m. on January 6, 2005. The investigator-in-charge and other 

members of the Safety Board investigative team were launched from the Washington, 

D.C., headquarters office and from the Atlanta, Georgia, field office. Investigative groups 

were established to study operations, track, signals, mechanical, survival factors, human 

performance, and hazardous materials issues. No hearings or depositions were held in 

conjunction with this accident. Member Deborah A. P. Hersman was the Board Member 

on scene.

Parties to the investigation included the Federal Railroad Administration, Norfolk 

Southern Railway Company, the Brotherhood of Locomotive Engineers and Trainmen, the 

United Transportation Union, General American Transportation, Union Tank Car 

Company, Trinity Industries, Olin Corporation, the Graniteville, Vaucluse, and 

Warrenville Volunteer Fire Department, and the Aiken County Sheriffís Office.