Train Derailment: Minot, ND

The Peril:

• At about 1.39 am on January 18th, 2002 a Canadian Pacific train, carrying at several tank cars full o anhydrous ammonia, derailed 2 miles west of the town of Minot, ND.

• The anhydrous ammonia was leaking covering the valley city of Minot with a cloud of anhydrous ammonia, which vaporized in the sub zero air and held close to the ground

TRAIN DERAILMENT:

• This CP railway train derailed 7 out of the 15 tank cars rupturing that carried anhydrous ammonia. This released more that 750, 000 liters (200,000 U.S. gallons).
• 30 of 112 Derailed
• Destroyed nearby power lines, compromised 3,000 residences/business

THE WARNING

• 13 minutes after receiving the 911 call, the fire chief had established a field incident command site.

• The Emergency Command Center had been established one hour after the accident. Reports confirming thick vapor cloud encompassed the residential subdivision close to the accident site and the city of Minot;

• Reports detailed that the cloud was preventing the safe evacuation of residents in those areas.

• Two Alternatives: "shelter in place" or evacuate

• Residents were instructed to “… stay in their homes and shut down their furnaces and air handling systems, go into their bathroom and use large amounts of water—turn on their shower and breathe through a wet cloth.”

• Most of the town was evacuated once it was safe.

• Anhydrous ammonia is described the Centers for Disease Control as, “a colorless gas with pungent, suffocating fumes, is used as an agricultural fertilizer and industrial refrigerant. When handled improperly, anhydrous ammonia can be immediately dangerous to life or health

• Formed a large cloud that acts like a heavier-than-air gas for a period of time. The vapors hug the ground initially, the chances for humans to be exposed are greater than with other gases.

• In this case, it was to be as fertilizer, one of its many uses.

HEALTH RISKS: EXPOSURE TO ANHYDROUS AMMONIA

The U.S. Department of Health and Human Service(DHHS) Anhydrous Ammonia has the following health effects:

•Irritating to the eyes and respiratory tract. Swelling and narrowing of the throat and bronchi, coughing, and an accumulation of fluid in the lungs can occur.

•Causes rapid onset of a burning sensation in the eyes, nose, and throat, accompanied by lacrimation discharge of tears, runny nose and coughing.

•Upper airway swelling and pulmonary edema may lead to airway obstruction.

•Prolonged (more than a few minutes) skin contact can cause pain and corrosive injury

TREATMENT:

Large amounts of water can be applied to anhydrous ammonia burns on the skin (15 minutes)

To treat inhalation issues: move to an area with fresh air and administer oxygen if needed.

Exposure to eyes, rise with water or saline solutions for 15 minutes

severe exposure has occurred, blood and urine analysis, chest x-rays, pulmonary function testing and other tests may show whether the lungs have been injured

Sir, we have a Problem!!!

Delayed Warning

• Minot emergency response plan included contacting the local emergency radio and television broadcast networks. At time of the derailment only 1 radio station was on air and most of the population was asleep.

• Many residents did not hear the emergency broadcasts due to the power outages

The proximity of the warning sirens:

• The outdoor sirens were “positioned to be heard within the city limits of Minot.”

• Plume reaching 11,600 people threatening health and lives

THE DAMAGES:

334 injuries, including the freight train crew, emergency responders, and residents of Minot and the surrounding rural areas.

One resident was fatally injured

11 people sustained serious injuries, and 322 people, including the two train crew members, sustained minor injuries.

The physical damages were were estimated at $2,486,000;

8 million in environmental remediation

Some of the Players

Freight Rail Network:

• National Transportation Safety Board (NTSB)
• Federal Rail Association (FRA)
• Canadian Pacific Railroad (CP)
• Chemical Suppliers

Federal/State Agencies:

• Health and Human Services (HHS)
• Environmental Protection Agency (EPA)
• Minnesota National Guard
• Department of Transportation (DOT)

Local Agencies:

• Sheriffs Department
• Minot Fire Department
• Trinity Hospital & Local EMS

ANALYSIS:

The NTSB Accident Report identified a joint bar fracture in the Continuous Welded Rail (CWR) as the cause of the derailment at Minot.

Operational elements needing modification to enhance readiness and response.

The safety issues identified in this accident were as follows:

• CP programs and inspection practices of joint bars in CWR

• FRA oversight on CWR maintenance programs

• Tank car crash worthiness

• Minot ND Disaster Management

EMERGENCY RESPONSE

Mutual Aid Activated (assistance from nearby fire departments)

The chief arrived on-scene within 10 minutes of the accident. Upon his arrival, he assumed incident command and set up a field command post and EOC at the Minot City Fire Station

Chief appropriately kept emergency responders from entering the accident area until the area was deemed safe so as not to put more persons at risk from the effects of the anhydrous ammonia.

As soon as they could, emergency responders entered the neighborhood and went door-to-door to provide medical treatment and evacuate the residents.4

The local Minot Emergency Responders, the City of Minot, and the CPR hosted an emergency response exercise on September 7, 2001. Trinity Hospital also participated in this exercise to test its own procedures for managing a hazardous materials accident.

Before the accident, the Minot emergency responders, the city of Minot and the Canadian Pacific Railway had conducted a disaster preparedness exercise that enhanced the effectiveness of the emergency response to the anhydrous ammonia release on January 18, 2002.

DISASTER MANAGEMENT: MINOT, ND

• EAS was not activated for several hours after incident
• Poor management of Public Communication (Power Outage & location of Sirens
• EM weren't readily available (contact list)
• Minot Rural Fire Department volunteer program resulting in 6 firefighter injured during the disaster
• After adequate notification, evacuation, communication and emergency response of population operations improved and went well
• Trinity Hospital activated Emergency Plan and handled surge of patients very well.

Adequate Emergency Response

•The Ward County 911 dispatchers provided accurate and timely information to the Residents of Minot

•The decision by the chief of the Minot Rural Fire Department to shelter the residents of Minot in their homes.

•Trinity Hospital was prepared to handle a hazardous materials disaster; hospital staffs were able to treat more than 300 persons

Canadian Pacific Railway Policy and Procedures

Overview: Track Maintenance and Training

CWR territories typically are associated with higher speed operations, higher tonnage, and greater hazardous materials density, as well as passenger train operations

It was mandatory that the class of track (CWR) at Minot be inspected at least twice weekly with one calendar day between inspections according to the FRA.

The Federal Railway Association’s guidelines provided that these inspections could be completed “by walking or by using a Hy-Rail vehicle”. Per the Railroad Accident Report

CP had “inspected the track four to five times a week using a Hy-Rail vehicle” during the colder weather.

Most of the inspection was visual/noise from the HY-Rail vehicle.

• Shells of the 5 tank cars were built before 1989 & fabricated from low grade steel.

• Standard for materials of containers carrying hazardous materials have improved since then and no FRA requirements were in place to retire substandard cars.

Rail Maintenance Standard Practices

• The CP track maintenance and standard practices were fully reviewed by the NTSB

• Repairs were not done according to new standards of FRA and ignored new FRA guidelines.

• Training records indicated that the section foreman and the track maintenance supervisor had attended an average of five training classes each year between 1997 and 2002, with most of them being 1 day or less, including roll out training directly from the FRA

RECOMMENDATIONS

TO THE FRA:

Require all railroads with CWR track to include procedures and programs are to file with the Federal Railroad Administration

Maintenance techniques for identifying cracks in rail joint bars should be standardized

Compliance review

Continued improvement of tank shell standards.

Mandatory installation of global positioning systems (GPS) in locomotives

To the Emergency Response and Preparedness of Minot

Need multiple contacts outlets for emergency broadcasts on both radio and television.

Minot Central Dispatch needs to have the phone numbers of key media staff at all Minot area stations and can contact them when necessary.

Emergency Alert Systems (EAS) lessons learned

Regular and frequent testing of EAS is essential to identify mitigation strategies

First

make sure system can notify your designated target audience.

Second

Coordinated effort with all the players; at multiple levels (Fed, State and Local) Training/Exercises

Third

Mutual Aid: Know Your Resources

Other local emergency response departments could have been better trained and equipped to deal with this event. Goal is to prevent further injury and preservation of life in disaster

Improving Initial Response Operations

Response needs to include layered notification option due to the area and frequent power outages.

Need backup generator options for critical infrastructure

Emergency Alert System needs to include a notification system, capable of sending voice and text messages to cellular phones, SMS text messaging, and email.

Law Enforcement Door to Door response and evacuation procedures should be implemented and practiced for future disaster response.

Better Placement of Emergency Sirens

Canadian Pacific Derailment

Minot North Dakota

By Nick Anzalone

FRA OVERSIGHT: TANKER STANDARDS

Questions???