The derailment itself was caused by a defective wheel bearing, but the NTSB found other factors contributed to the release of hazardous materials, potentially endangering the public and emergency responders. Those factors included problems with a tank car and a controlled burn decision after the wreck, a delay in telling emergency responders what the train was carrying, and insufficient training of volunteer firefighters.

Norfolk Southern, in its written response said it has already moved to improve safety. “We will move quickly to compare the NTSB’s recommendations to our current protocols and will implement those that advance our safety culture,” it said.

But the railroad and the agency are at odds over one of the most consequential actions of the disaster: the railroad’s recommendation that toxic vinyl chloride in some of the rail cars undergo a controlled burn.

The NTSB criticized Norfolk Southern for recommending the controlled burn and for not relaying dissenting opinions to the incident commander.

Vinyl chloride manufacturer OxyVinyls told Norfolk Southern that there was not a chemical reaction in the cars posing risk of an explosion, but key officials on the Unified Command of officials led by the East Palestine fire chief were not told that before they decided to do a “vent and burn” operation, according to remarks during hearings.

The toxic chemical burn caused a large and noxious black smoke plume over the town, and necessitated the evacuation of thousands of residents. It has also caused lasting fears among some in the area about the potential for long-term health effects. Exposure to vinyl chloride, which is used to make PVC pipes, is associated with an increased risk of cancer.

Norfolk Southern and its contractors continued to assert a “vent and burn” operation was necessary, “even though available evidence should have led them to reevaluate their initial conclusions,” according to NTSB investigator Paul Stancil. He told NTSB members that there was “a misunderstanding or confusion” between OxyVinyls’ support team and and Norfolk Southern’s expert contractors.

“The decision-making process was very much flawed,” said NTSB member Thomas Chapman during the hearing. “I think it’s really unfortunate.”

Norfolk Southern on Tuesday said along with its expert contractors, its “only motivation in recommending the vent and burn to the Unified Command was the health and safety of the community and first responders.”

The railroad said several factors “indicated the strong possibility of a catastrophic, uncontrolled explosion.” Norfolk Southern also said it “received conflicting information from OxyVinyls’ personnel” and that OxyVinyls could have made its views known to decision makers.

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