Norfolk Southern and its contractors botched the decision to blow open five vinyl chloride tank cars after last year’s disastrous derailment in East Palestine, Ohio, and trackside detectors that might have prevented the crash failed to accurately detect the temperature of a burning wheel bearing 20 miles (32.19 kilometers) beforehand, according to the National Transportation Safety Board.

Area residents, rail industry representatives and local and state officials packed East Palestine High School’s auditorium Tuesday to hear the NTSB’s investigation findings and recommendations to prevent similar disasters.

“On behalf of the entire agency I want to recognize the significant impact this derailment has had,” NTSB Chair Jennifer Homendy said at the beginning of the hearing. She added that while some have tried to minimize the wide-reaching effects of the crash because there were no deaths, “the absence of fatality or injury doesn’t mean the presence of safety.”

Dozens of freight cars derailed Feb. 3, 2023, on the outskirts of East Palestine near the Pennsylvania border, including 11 carrying hazardous materials. Some residents were evacuated that night but then days later more had to leave their homes amid fears of an imminent explosion. Despite potential health effects, officials intentionally released and burned toxic vinyl chloride from five railcars three days after the crash, sending flames and smoke into the air.

The NTSB had said early on that an overheated bearing on one of the railcars that was not caught in time by trackside sensors had likely caused the crash. Investigative hearings since then also highlighted other possible contributors including widespread rail job cuts and rushed inspections. Investigators also delved into why officials chose to deliberately blow open the vinyl chloride cars and burn what is a key ingredient for making PVC pipes.

After confirming on Tuesday the trackside detector failure, NTSB investigators also said that Norfolk Southern and its contractors compromised the integrity of the vent-and-burn decision by withholding accurate information from OxyVinyls, the company that made the vinyl chloride. They added that Norfolk Southern contractors repeatedly recommended blowing open the tank cars and burning the contents despite available evidence that the tank cars were cooling after the crash.

“Norfolk Southern and its contractors continued to assert the necessity of a vent-and-burn, even though available evidence should have led them to re-evaluate their initial conclusion,” investigator Paul Stancil said.

The railroad defended the decision again Tuesday and said it was based on more than just temperature readings. Officials also had concerns about the way the pressure relief devices malfunctioned on the tank cars. Plus, Norfolk Southern said nothing kept OxyVinyls from joining the discussion in the command center and sharing its opinion that the tank cars wouldn’t explode.

Earlier this year, Homendy told Congress that the agency’s investigation had determined that the controversial operation that prompted evacuations wasn’t necessary. OxyVinyls experts testified at earlier NTSB hearings they were certain a feared chemical reaction that could have caused those tank cars to explode wasn’t happening.

But Ohio’s governor, first responders and the hazardous materials experts who made that decision have said the information they had that day made them believe an explosion was likely imminent, making the burn the best option despite the risks of unleashing cancer-causing dioxins in the area.

OxyVinyls has declined to comment publicly beyond what its experts testified to last spring, and the company didn’t immediately respond Tuesday.

NTSB staff said Tuesday that no federal standards currently exist for how railroads should respond to bearing failure alarms and they recommended that the Federal Railroad Administration establish rules governing railroad responses to such alarms. They also recommended that new guidance be developed for deciding when first responders use the vent-and-burn tactic that was deployed last year and that federal standards should be developed for trackside detectors.

At the time of the East Palestine derailment, only one person in Atlanta was monitoring alerts from all the detectors across Norfolk Southern and doing so from home. That person didn’t see the Salem alert about the elevated temperature of the bearing, but under the railroad’s rules, no action would have been taken because there was only one elevated reading.

Homendy said the analyst that night said he did not get formal lunch or bathroom breaks, but numerous times would run to get his lunch and quickly return to monitoring. She said that’s “certainly not a way to run a railroad.”

Norfolk Southern has since put two people on duty and is trying for three, NTSB investigators said.

The company also announced last week that it will lead an industrywide examination of how to improve the way vent-and-burn decisions are made in future derailments. That was part of its settlement with the federal government.

Though NTSB recommendations aren’t binding, Congress may be willing to enforce some of them because of the crash’s spotlight on rail safety.

More than a year ago, a bipartisan group of lawmakers led by Ohio’s two senators proposed a package of reforms including requiring two-person crews and setting standards for the inspections and detectors that help prevent derailments. The bill ultimately stalled in the U.S. Senate under resistance from Republicans and the railroads. GOP House leaders have said they didn’t want to consider new rail safety regulations until after the final NTSB report was released.

With limited success, federal regulators also pushed for the railroads to make changes like signing onto an anonymous government hotline to report safety concerns. The industry responded to the crash by promising to install more trackside detectors, review the way they are used and help first responders improve their handling of derailments with more training and better access to information about the cargo.

Norfolk Southern CEO Alan Shaw pledged to “make things right” in East Palestine with more than $100 million in aid to residents and the community. Shaw also hired a consultant from the nuclear power industry to recommend changes and tried to work with labor. Still, critics said Norfolk Southern was too often satisfied in the past with doing only the minimum required for safety and workers reported no big changes in day-to-day operations.

After the derailment, all the major freight railroads pledged work to improve safety by adding hundreds more trackside sensors to help spot problems like overheating bearings and by re-evaluating how they analyze the data from those detectors. The Association of American Railroads trade group said the industry will review the NTSB report and look for additional ways to improve safety. But so far the industry’s efforts haven’t resulted in a significant boost in its safety record in the FRA statistics.

The NTSB has also looked at the struggles of first responders who didn’t immediately know exactly what was on the train after 38 cars jumped off the tracks, many spilling their contents and catching fire. Investigators said Tuesday that firefighters didn’t learn what was on the train for roughly an hour and didn’t order an evacuation or tell their firefighters to pull back to a safe distance until about two hours after the derailment.

Federal officials finalized a new rule Monday that will require railroads to inform first responders about what is on a train immediately after a derailment. The industry says more than two million first responders now have immediate access to that information via an AskRail app that allows them to look up any train’s cargo.

—Josh Funk, Tom Krisher and Patrick Orsagos, Associated Press