The agency said Conrail actions - allowing the train to move across the swing-style bridge over the Mantua Creek despite the fact that locks to hold it in place were not intact, and the company's insufficient training of the train crew to inspect such a mechanism - were the probable causes.
The derailment occurred about 7 a.m. on a cold Friday morning at the troubled East Jefferson Street Bridge. The 82-car freight train had reached a red light, meaning the bridge had not been properly locked, but a conductor "erroneously" determined it was safe to proceed, which Conrail dispatch approved. Seven cars derailed, four into the creek, causing one to rupture and leak 20,000 gallons of vinyl chloride. Nearly 700 residents were eventually evacuated from their homes, and about 30 sought medical attention.
"We regret that this incident occurred, and its impact on those that it affected," Conrail said in a statement Tuesday. The company is facing a number of lawsuits. "We will evaluate the NTSB findings and final report and will implement all appropriate measures."
The statement, from company spokesman Michael Hotra, also said the company has "redoubled" its efforts to work with first responders in addressing hazardous materials.
The derailment remains an unfortunate memory, marked by misinformation, in the minds of many residents.
"They didn't make an effort to make the community aware," said borough resident Andre Campbell, 36. Campbell, a painter and tow-truck driver, said he and his family were evacuated from their home the night of the derailment. "People just didn't have information."
In staff presentations Tuesday, the NTSB outlined what some called a systemic "breakdown" - from the company's ensuring bridge safety prior to the accident, to responders' lacking readiness. Conrail personnel, the board determined, did not immediately provide "critical" information on the hazardous materials to responders.
Many responders did not use protective gear on scene, and air-monitoring devices were not immediately utilized. The situation caused Washington Township and Deptford members of the Gloucester County hazmat team to quit the squad, claiming faulty and insufficient equipment. The county denied that claim, instead blaming unfamiliarity with the resources, but is overseeing changes to the team and its training regimen.
NTSB board member Robert Sumwalt called the emergency response system "abysmal." He said many accident responses are "organized chaos."
"On this day, there was chaos," he said, "but it was certainly not organized."
Paulsboro Fire Chief Al Giampola, in attendance at the NTSB meeting, rebuked Sumwalt's statements after the meeting: "I think that was absolutely disrespectful to the first responders."
"It came out of nowhere," Giampola said of the derailment. "I made all the proper notifications."
Giampola, former borough emergency management coordinator Glenn Roemmich, and Councilman Gary Stevenson all said the immediate half-mile evacuation suggested by federal officials remains infeasible, even today. The borough lacks resources to shuttle and house thousands of residents, so the decision to institute a shelter-in-place until evacuating residents later was the most practical plan, they maintained.
"That's what the NTSB doesn't understand about book sense vs. common sense," said Stevenson, who was deputy fire chief at the time and lives next to the accident site. Conrail is currently replacing the bridge with another, vertical-lift one that will continue to support rail. It is expected to open in 2015.
The bridge had received two dozen "trouble tickets" in the year preceding the derailment - nearly half of which were issued in the month before, following Hurricane Sandy - officials said. A consultant's recommendation before the accident that the company leave the bridge closed to marine traffic to assess its issues was not heeded, the NTSB said.
The board also called on a number of state and federal bodies to introduce reforms. The U.S. Department of Transportation should require railroads to provide local and state officials with information on hazardous materials in transit, the board said. It also recommended that the Federal Railroad Administration create a regulation that would ensure inspection by a "qualified employee" before allowing a train to pass a movable bridge with a red light.
"This conductor basically had no clue," NTSB board member Mark Rosekind said. The conductor had not inspected a bridge in several years.
The NTSB said New Jersey "firefighter certification and training requirements were not effective," in ensuring responders operate in compliance with U.S. hazardous waste and emergency response standards. The findings also criticized the state's review of local emergency response plans; Paulsboro's updated plan was two years past due at the time of the derailment, meaning some information was outdated.
Mary Goepfert, spokeswoman for the state Office of Emergency Management, said the office ties grant availability to municipalities' compliance with emergency operation plan requirements.
She said the office would review the recommendations and "ensure that the towns and the counties are fully scanning and being aware of new hazards."
Officials have estimated that 25,000 to 30,000 railcars with hazardous materials pass through Paulsboro each year. Stevenson, the councilman, said it's imperative such an accident "never happen again on that bridge."
After being out of his home for a month because of the spill, he said, he was displaced periodically as repairs were made to cracks in the foundation.
"The shock waves," he said, "broke the house."
Paulsboro residents fear lingering health effects. A3.
Inquirer staff writer Clark Mindock contributed to this report.