Graniteville, South Carolina: Jan. 5, 2005

In Graniteville, South Carolina, the industrial part of town is known as The Valley. On the evening of Jan. 5, 2005, a 10-car Norfolk Southern freight train making deliveries to local factories ran into problems that forced the crew to pull onto a siding, near a textile plant, Avondale Mills.

Unfortunately, said Don Turno, chief of the Aiken County Hazmat Team, the crew failed to complete a critical safety procedure.

"They forgot to verify that the [rail] switch had been put back into the main line configuration," Turno said.

At 2:40 a.m., Jan. 6, a second Norfolk Southern freight traveling north from Augusta, Georgia, to Columbia, South Carolina, came through Graniteville. Despite the light to moderate fog, the engineer saw the switch in the wrong position andattempted to stop. It was too late. Only 17 seconds later the 42-car second train traveling at 47 mph diverted onto the siding and hit the locomotive of the parked freight head on.

As a result, nearly 60 tons of chlorine gas spewed from a ruptured tank car, the second largest chlorine accident in U.S. history. Nine people died. Another 554 people, among them residents, railroad crew and emergency responders, sought medical attention after exposure, complaining of respiratory distress. Ofthese, 75 were admitted to hospitals for treatment.

Ultimately, the accident forced more than 5,400 residents within a one-mile radiusof the wreck to leave their homes for five days or longer. Property damage from the corrosive gas proved so extensive that one of the community's leading industries shut down permanently.

Emergency response to the disaster was almost immediate. The headquarters ofthe Graniteville-Vaucluse-Warrenville (GVW) Volunteer Fire Department lies only 500 feet south of where the two trains met.

"When (the volunteers) were dispatched, some of their responders headed to the station, driving through the plume," Turno said. "The chlorine was so concentrated that it choked out their vehicles."

Six firefighters were treated and released; one firefighter was admitted to the hospital and remained there for several days. Two sheriff's department officers were also treated and released.

Aiken County, covering 1,073 square miles, ranks as South Carolina's second largest county. Aiken, the county seat, is part of the Augusta, Georgia, metroplex. County-operated emergency responders include the sheriff's office and, under the heading of Aiken County Emergency Services, EMS, emergency management and hazmat.

The hazmat team includes 40 members, both paid and volunteer, working out of one station. In addition, 23 local fire departments operate in AikenCounty, three of which are career and the rest volunteer.

Less than 10 miles northeast of Augusta and only 4½ miles west of Aiken is the unincorporated community of Graniteville. The GVW Volunteer Fire Department consists of 40 members and three stations serving about 12,000 residents. A county emergency services fire team also covers the area.

Owned by Aiken County, the 1,115-acre Sage Mill Industrial Park is located in Graniteville. It was home to eight divisions of Avondale Mills, Inc., one of the largest denim manufacturers in the U.S.

The industrial park was also occupied by SKF USA, a roller bearings manufacturer, and a Bridgestone/Firestone tire plant. The industrial area extends to the west and northwest of the main railroad line. To the east and southeast of the line is primarily residential property. Next to and north of the main line right-of-way, about 1,000 feet from the accident site, is as mall commercial/retail district.

A Norfolk Southern local train designated P22P005 — P22 for short — operated Monday through Friday out of the railroad's yard in Aiken. The train crew, including an engineer, conductor and brakeman, normally went on duty at 7 a.m. and spent the day placing and picking up cars at local industries along the main line.

According to a National Transportation Safety Board report, the original plan for the 12-hour work shift on Jan. 5 called for parking P22 in Warrenville, about a mile from Graniteville, for the night. However, the crew found itself seriouslybehind schedule by the time it reached Graniteville. Norfolk Southern requires that conductors hold a job briefing at each stop covering the work to be done. Because of the rush to finish by 7 p.m., the conductor skipped the briefing for the Avondale Mill stop. That briefing would have covered realigning the switch to allow use of the main track.

Unable to accomplish the assigned tasks before the conductor and brakeman reached their regulatory limit for hours on duty, the crew decided to leave the locomotive and remaining 10 railroad cars in Graniteville. They uncoupled eight of the cars, parking them inside the gates at Avondale Mill. The locomotive and two empty freight cars were left on a siding more than five rail car lengths from the mainline switch. After the crew returned to Aiken by car, the brakeman notified the dispatcher that the switch had been realigned.

The NTSB report quotes the brakeman as saying "in my mind, when I left (the siding), everything was properly lined back to the main line — I had no doubts inmy mind when I left there." Yet he also said, "I am not 100 percent sure that I did (reline the main line switch) — I would say I might have made a mistake."

Norfolk Southern train 192, authorized to use the main line, departed Augusta at 2:10 a.m., Jan. 6, for Columbia. About 30 minutes later, the train, operating atnear the maximum authorized speed of 49 miles per hour, approached the switch tothe Graniteville siding. The conductor told the NTSB he heard the emergency brakes activate, followed by the engineer saying "The target (switch banner) is wrong."

Train 192, hitting the misaligned switch, entered an eight degree left-hand curve onto the siding occupied by P22. Owing to the sudden curve, the first car behind the train's two locomotives rolled to the right and derailed. As it toppled, the car uncoupled from the locomotives, but not without also derailing the rear of the second locomotive. The second through 14th cars progressively derailed, coming to rest in a pile of wreckage. Two more cars derailed but did not join the pileup.

Five of the derailed cars contained hazardous material. One carried sodium hydroxide; another was loaded with a residue of an elevated temperature liquid known as NOS (rosin). Worst of all, three derailed cars each contained 90 tons of chlorine. One of those cars, the ninth in train 192, received a 34-inch-long, five-inch-wide gash through which pressurized chlorine escaped.

Chlorine, a powerful oxidant in bleaching and disinfectants, is also a widely used reagent in the chemical industry. As a poisonous gas, chlorine was used as a chemical weapon during World War I. At atmospheric pressure, chlorine changes from liquid to gas at -29 degrees Fahrenheit.

If inhaled, it reacts with moisture in the respiratory tract and lungs to form hydrochloric acid, resulting in inflammation of these tissues. Severe exposure causes pulmonary edema, suffocation, and death. Almost simultaneously with the first car uncoupling, the locomotives of 192 and the parked P22 struck head on. The collision derailed the P22 locomotive, propelling it about 217 feet north along the track. The lead locomotive of train 192 traveled nearly 145 feet after impact.

"Event recorder data indicated that the speed of the train at 2:39 a.m., approximately 467 feet from the final resting point, was 47 mph," the NTSB reportstates. "At 2:39:20, the speed registered 0 mph."

The conductor told the NTSB that the impact threw him to the floor of the locomotive. He said he recalled smelling chemicals. Because the window and doorswere jammed on his left, the conductor followed the engineer out the other side ofthe locomotive.

"All of the train members did survive the initial impact," Turno said. "It was getting out through the chlorine cloud that got them."

Winds were light. Because gaseous chlorine is 2½ times heavier than air, the escaping vapor cloud settled in the low-lying valley along the tracks. Based onemergency responder observations and the locations of those receiving fatalinjuries, the cloud extended at least 2,500 feet to the north, 1,000 feet east, 900 feet south and 1,000 feet west. The sudden release and expansion of the escaping gas caused one-third of the product left in the damaged tank to auto-refrigerate in a liquid state, slowing the release of additional gas.

The engineer and conductor walked about 100 yards before meeting anyoneelse. White or gray smoke was visible, but no fire, the conductor said. He heard the engineer say that they needed to get downwind. A short distance later, both men fell to the ground. The engineer died several hours later. Cause of death is listed aslactic acidosis. The only crew member to die, the engineer was also the only Graniteville fatality who lived long enough to reach a hospital.

The fumes traveled only 200 feet before reaching Avondale Mills. Immediately after the collision, an employee called the Aiken County Sheriff's Office 911 Emergency Call Center. She said she went outside to investigate but could not tell what had happened. Near the end of the 48-second call, the caller became increasingly agitated, saying, "I smell smoke." She then exclaimed, "I gotto get out of here," at which point the call abruptly ended.

Of the nine fatalities, six were employees found in three locations at nearby Avondale Mills."Avondale Mills sits low in a natural valley," Turno said. "The plants have large ventilation systems to cool those machines. Of course, the chlorine cloud wassucked in."

A trucker waiting overnight to pick up a load also became a victim.

"He was a young man from Quebec, Canada, who was there to pick up a delivery of blue jeans," Turno said. "He went to sleep that night in the cab of his 18-wheeler and never woke up again."

The closest residence lay only 150 feet away from the crash site. Yet only onefatality was reported in a nearby home.

"One of the biggest challenges we had was the residents living in the area," Turno said. "At 3 a.m. they were all at home. On the other hand, there were three schools in the vicinity which fortunately were not in session."

The coroner's reports for the truck driver, the local resident and the Avondale Mills employee listed the probable cause of death as asphyxia, which occurred within minutes of the exposure.

A local death three months later was widely reported as due to chlorine exposure after the collision. The official autopsy listed the death as natural causes due to pulmonary thromboemboli.

At 2:40 a.m., the GVW VFD was dispatched. Less than a minute later, the first responding unit was on the way. However, some important information did not get passed to responders initially, Turno said. Within two minutes, the dispatcher alerted responders that the smell of chlorine had been noticed.

GVW Fire Chief Phil Napier advised further responding personnel to stand by until further notice. That came too late for some GVW VFD personnel who were overcome en route to the fire station, not the fire, Turno said. As for the fire station, corrosive chlorine gas soon enveloped the building. Two engines, one ambulance and one service vehicle were immediately out of commission.

"The insurance company wrote them off as a complete loss," Turno said. "It was the effect of that concentration of chlorine on any exposed metal." Chlorine also ruined furnishings and equipment. The building itself had to be gutted and rebuilt.

Napier, approaching the accident scene, smelled an intense chemical odor and had trouble breathing, the NTSB report states. This helped other hazmat officials quickly isolate the problem and determine which product was involved, Turno said. The county hazmat team, notified at 2:45 a.m., was on the scene 15 minutes later.

"We contacted the NOAH weather station in Columbia, and asked them toactivate their NOAH radios, something that has been available to us since September 11," Turno said. "About every hour I was in contact with them and they were reissuing their alert based on our report from the command post."

Toxic fumes forced Napier to withdraw within several minutes. A request was made that dispatch initiate the Aiken County Reverse 911 Emergency Notification System, with instructions that residents shelter indoors.

Although the system was put in operation within 10 minutes of the incident, problems arose in spreading word of the emergency, Turno said.

"Our local emergency planning commission and the firefighters' association for the county had decided to put the reverse 911 into effect," Turno said. "We raised the money; bought the system for the county; and put it in place. This was the first time it had been used."

The understanding was that the county would pick up the reoccurring costs, he said. Regrettably, much of the original database was outdated because these costs had never been budgeted.

"We had a lot of people who were either not notified or who had moved," Turno said. "These days, since you can take your phones with you, they lived well outside the boundary."

Beginning at 2:50 a.m., additional resources — ambulances, hazardous materials personnel and equipment, Aiken municipal responders and other mutual aid services — were asked to respond. Only minutes later, dispatch advised responders that people were trapped inside Avondale Mills. Dispatch alerted Aiken Hospital thatpeople overcome by fumes were en route. At 2:57 a.m., GVW VFD asked that approach roads be blocked, effectively establishing a one-mile hot zone around the accident.

"We made the initial decision to evacuate one mile because of the potential of the three chlorine cars," Turno said. "One had released but two were still full. After some discussions at the unified command level, we talked about a three-to-five-mileevacuation."

Napier marshaled his firefighting personnel and equipment at a staging area upwind of the toxic gas release site. That site would later be identified as a forward command site when an overall command site further removed from immediate danger was designated.

Within 34 minutes of first dispatch, all Aiken County fireresources were placed on standby. About the same time, an Avondale Mills employee told firefighters that workers at a nearby steam plant could not be contacted. Concern grew that if the workers had departed without properly shutting down the boiler, it could explode.

Within 53 minutes of the first dispatch, responders established the first of four decontamination stations. A quarter hour later, responders made their first entry into the hot zone. Several firefighting entry teams wearing personal protective equipment used privately owned pickup trucks to reach the accident site. The teams picked up those exposed to the gas vapor and transported them to a decontamination station, then repeated the search and rescue cycle.

Some patients seeking medical aid on their own were determined to put as much distance between themselves and Graniteville as possible.

"Some went 65 miles away to Columbia," Turno said. "Once we found out about the first one we notified all the hospitals to ask patients where they camefrom."

As in a great many such emergencies, the initial hours were chaos, Turnosaid. Some emergency responders observed hot zone protocol; others did not. "While law enforcement and the hazmat personnel were using the main road,

EMS was going down the back road," Turno said. "Law enforcement and hazmat never knew that EMS was making entries into the hot zone."

Other aspects of hot zone protocol proved challenging to observe as well. "When the departments responded, they brought their own gear," Turno said. "They would go into the hot zone with their own gear and then leave with it. One of the things that we have learned about since is the (corrosive) effect of chlorineon SCBAs (self-contained breathing apparatus)."

The wiser move would have been to let the initial entry team and one or two other departments use their gear in the hot zone, then reuse it as other personnel rotated in and out of the zone, he said.

"We did decontaminate everything," Turno said. "However, when you asked firefighters if they took a specific piece of equipment into the hot zone, no one could remember."

First official entry into the hot zone was made for purposes of reconnaissanceand to set up remote monitors. Responders discovered that chlorine was not theonly chemical released.

"When we sent in our recon team the fog and the light color green of the chlorine made it hard to see," Turno said. "But the cresol rosin that is shipped at an elevated temperature of more than 115 degrees Celsius (239 degrees Fahrenheit) gave off a beautiful orange cloud. That is what the initial response team was concentrating on as they were taking pictures and giving us information. They almost missed the chlorine. However, we got a lot of good information from residents in the area as they dialed 911 telling us they could smell bleach."

Although the fog restricted vision, the weather also had its benefits. "Even though it was in January it was warm," Turno said. "We had light to moderate fog that did help us keep the chlorine low. We had a prevailing wind from the southwest, so we knew the wind direction to expect for the day. It was 59 degrees F with a relative humidity of 95 percent, which helped us to some extent."

Usually, when a freight train is put together, the crew will insert several rail cars with non-hazardous cargo between the engine and the first rail cars loaded with hazardous materials. This was the case at Graniteville, but not as many non-hazardous cars as usual, Turno said.

"One of the reports we were getting was that there were rail cars cut in half," he said. "We thought we really had a mess. It turned out that the gondola cars with tops on them carried spooled steel. We found some of those spools (buried) six feet in the ground."

Photos and video that the entry team brought back to the command post made it clear that more outside help would be needed, Turno said.

"We knew that it was beyond our capabilities, not because of lack of training but because to get at the leaking cars we were going to need cranes," he said. "We decided to set up a hot zone and start evacuating everyone."

The one-mile radius for evacuation might have been reduced if responders hadtaken the topography of the area into consideration, Turno said.

"When you look at a map, you think that it is flat," he said. "This is actually a natural valley and we may have used the terrain to our advantage. We may have closed up some of our evacuation radius because the chlorine was held in the valley by the natural topography of the land."

Operating under a unified command structure, 111 agencies participated in theGraniteville response. Enforcing the evacuation fell to the South Carolina Highway Patrol, South Carolina Transport Police, county sheriff's office and other law enforcement from across the state.

As compared to evacuating the general public, controlling emergency respondersacting outside the unified command system proved more demanding, Turno said.

"If you had a credential that said you were a firefighter, you usually were let in," he said. "This happened largely because the people taking care of the outside perimeter were not from our area. They were from upstate or the coast. All they saw were badges saying someone was law enforcement, firefighter or EMS and they letthem in. We are now considering a statewide credentials system."

At the top of the unified command structure is the emergency operations center.In Aiken County, the center consists of two key people, Turno said.

"One is the overall fire chief for all 23 departments," he said. "The departments agree to give over control to him and he can move equipment and men anywhere in the county by radio, based on what is needed. The person next to him represents law enforcement."

To guard against exhaustion, these two people are replaced every eight to 10 hours, Turno said. Assisting them is a county administrator authorized to sign checks. Also, in support is a chief information technology person and an assistant. Norfolk Southern brought in chemists and other experts to answer any questions.

"The command post area actually consisted of four vehicles," Turno said. "The sheriff had one, the fire department had one, hazmat had one and the state agency that runs our environmental programs had one. The emissions from those four vehicles gave me and a few others headaches. We forgot about spreading themout or watching the emissions from those vehicles."

Implementing the unified command structure presented its own problems in the opening hours of the emergency, he said.

"We probably had too many people at the command briefings to start with," he said. "We narrowed that down to a few select people who then, in turn, conducted briefings with other people. By Friday things calmed down to where everything was pretty much under control and we had our action plan truly in place. "Radio communications became critical to unified command. In the first six hoursthere were 500 EMS transmissions, 370 fire transmissions and 450 sheriff transmissions.

"We brought in a mobile command post and basically did all the transmissionsfrom there," Turno said. "We had four dispatchers — one for the sheriff, one forfire, one for EMS and one is a supervisor who can take over from another console."

Normally, the sheriff, EMS and fire departments have different radios that are not interoperable except through dispatch. A large state owned repeater — a combination radio receiver and transmitter used to boost weak signals — was activated. Responders were then furnished with radios operating at 800 megahertz that could "talk" to each other.

More than 200 calls to 911 dispatch were logged in the first 3½ hours. Officials set up a 211 line for the public to use as an information-only extension of 911. Almost 3,000 211 calls would be logged during the course of the emergency. "Those were the calls asking everything from 'What can I do about Fluffy the cat?' to 'How can I get my medicine?'" Turno said.

A university campus near the hospital became the location for mass decontamination. Ambulance crews who had recently completed hazmat training were dressed in Level B suits and dispatched to retrieve people from either residences or local mills. Six ambulance companies, both private and volunteer, were pressed into service.

Using a car dealership as its forward command post, the county hazmat team proceeded to make 300 entries into the hot zone over the next four days. "We did everything from evacuate people to recon, assist the Coast Guard and EPA with monitoring and even feeding animals," Turno said. "We used more than 500 pounds of dog and cat food in the first few days."

Making use of every possible resource, the hazmat team contacted a nearby U.S. Department of Energy facility, the Savannah River Natural Laboratory, and asked them to develop a plume model for air quality assessments based on the information available.

"This is a nuclear facility where they used to make a lot of the plutonium andtritium for our nuclear arsenal," Turno said. "We have software programs like Cameo and Aloha that we use for plume models, but their software is much more sophisticated."

According to Savannah River, the chlorine plume from the Graniteville wreck extended as far as Interstate 20 five miles north. Calls from that area reporting the odor of chlorine confirmed the accuracy of the model, he said.

"We went back and asked them to model the plume as if the entire contents were released at one time," Turno said. "We took that model and went back to the incident. We took pictures. We looked at all the foliage and where the victims were. It matched 100 percent. From now on we will ask for plume models in two different ways — one based on the largest container of the incident if we have a sudden release and the other is dependent on a leak rate in a given amount or a given set of time."

Evacuation routes indicated on maps at the emergency operations center were updated daily based on the latest plume models.

"One thing we were glad about was we had the information technologists right there in the same room with us," Turno said. "They ran the computers and printed the maps for us."

The emergency in Graniteville marked the first time that the Department of Homeland Security's Prepositioned Equipment Program "pod" system has beenused, he said. PEP is comprised of highly specialized equipment, as well as off-the-shelf items, stored in 11 caches or pods dispersed nationwide and transportable by land or air within one to 12 hours. Through formal request, the federal government transfers custody of these assets to local officials.

"It was extremely difficult to get the equipment," Turno said. "We put in the request on Thursday and it did not arrive until Monday. Due to this incident and the time it took, the Department of Homeland Security reexamined the way that they deploy the PEP pods."

Once equipment and other supplies arrive, keeping track of it becomes a chore. A logistics officer is an immediate necessity in any major emergency response,Turno said.

"We still can't find 500 sets of warmup suits that were donated by a localindustry for all the firefighters, law enforcement and emergency medical folks thatwent in and out of the hot zone," he said. "We don't know where they ended up but we know they were delivered."

With so many entries into the hot zone, the hazmat team soon ran out of Level B suits and boots.

"We called up a company in Ohio that made the boots for us," Turno said."Volunteers came in from a sister plant and worked overtime to make them. Then we had to get local people with privately owned airplanes to donate their planes and fuel to bring the boots in."

That plan proved unworkable because the large number of boots needed dangerously overloaded the planes. The only alternative was to truck the boots to South Carolina. To deliver the cargo in less than 18 hours without violating Department of Transportation regulations, four drivers were assigned to each truck.

"We could not have them commercially flown to us because of the post 9/11 rules regarding paperwork on air cargos," Turno said. "We couldn't get the paperwork in order fast enough to satisfy the FAA and still get the boots soon enough."

Further problems with emergency shipments were eliminated when Federal Express offered to handle the job no matter how big the cargo, he said. Providing shelter for more than 100 responders posed another obstacle. Every local hotel room was quickly taken. The visiting responders also needed to be fed.

"We had a lot of people who wanted to feed us on that first Monday, but by Tuesday there wasn't anyone," Turno said. "We were lucky enough to find someone to coordinate this with the volunteers so that breakfast showed up on Monday, lunch on Tuesday, etc. The Red Cross and Salvation Army also came with provisions."

The Charleston (South Carolina) Police Department brought its emergency "chuck wagon" used to serve food during hurricane evacuations.

"They are the ones that ended up feeding us, and I can tell you it was some of the best food you could ask for," Turno said. "We had lamb one night, then steak and shrimp. We did not lack for good meals, at least at the command post. We did have to remember to deliver food out to all our barricades. They fed more than 400 meals a day, three times a day, and transported it to all our security points."

As with any major industrial accident, Graniteville garnered tremendous media attention. News outlets from across the nation sent reporters to cover the evacuation and clean up. Local officials established a media station to disseminate information. "Some of the biggest tractor-trailer rigs I've ever seen were there for the media," Turno said. "Some stayed a day, and some stayed the entire two weeks." Residents displaced by the emergency wanted information too. Officials conducted a series of five town meetings to discuss what had happened, what was going to happen and anything else citizens wanted to know, Turno said.

About 11 p.m. on Jan. 6, responders inserted a temporary polymer patch inthe opening of the punctured tank car. By the afternoon on Jan. 8, firefighters and hazmat responders thought their jobs were winding down. However, one suspected casualty remained missing. At 7 p.m., responders began unloading sodium hydroxide from tank car number eight. At 8:50 p.m., the temporary polymer patch on the punctured chlorine tank failed, releasing vapor. The unloading of the sodium hydroxide car had to be temporarily discontinued.

On Jan. 9, the final fatality was found. However, Norfolk Southern asked theresponders to stay on the scene, Turno said.

 "South Carolina has legislation called the Firefighter Mobility Act," he said. "It requires every firefighter in the state to be in the mobility database. That database lists your name, where you live, what certificates you hold — firefighter I, II, hazmat technician — and whether you specialize in high-angle or confined-space rescue. At that time, we activated the mobility data base, and every 12 hours we rotated our hazmat crews."

At 8:37 a.m. Jan. 9, responders inserted a second polymer patch in the opening of the punctured chlorine car. Vapor was then drawn from the car to create a vacuum and reduce the amount of chlorine gas escaping. A sodium hydroxide solution neutralized the chlorine vapor as it was removed from the tank.

"They used another chemical that they mixed with the chlorine that was leftover, turning it into weak bleach," Turno said. "By the time they were finished, the chlorine was actually turned into something like salt."

Unloading the sodium hydroxide car resumed and was completed by 3:30 p.m. On Jan. 10, the punctured chlorine tank car was rotated so the puncture was at the highest elevation on the car. This rotation disturbed the liquid chlorine in the tank and delayed efforts to unload other tank cars. Several hours later, responders began draining chlorine from the derailed sixth car in the train.

On Jan. 11, responders rejected a plan to use a lead patch on the punctured tank in favor of a steel patch. The next day, the steel patch was in place and unloading started. Because the puncture tank had extensive damage, the remaining chlorine could not be removed as easily as with the intact tank cars. The chlorine had to be vaporized and transferred as a gas. Then it was passed through a sodium hydroxide solution in a separate tank, converting the chlorine to a relatively safe solution.

By the morning hours of Jan. 13, the two unbreached chlorine tanks cars had been unloaded, placed on railroad flat cars and moved from the site. By midnight on Jan. 18, the unloading of the punctured tank car was complete. The following day the tank car was cleaned and purged on site, then loaded on a flat car to be moved to Augusta.

Turno and his team would be involved in nearly 10 days of around-the-clock response operations.

Within two days of the Graniteville wreck, a Burlington Northern Santa FeRailway Company (BNSF) freight train unexpectedly diverted onto an industrial track in Bieber, California. According to the NTSB report, the BNSF train struck two loaded grain cars, derailing seven locomotives and 14 cars. Two railroad employees were injured.

Two similar incidents occurred in August 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 line of cars. The engineer was severely injured. In Heber, California, a Union Pacific (UP) freight train, operatingat 30 mph, unexpectedly diverted into a siding where it also struck a standing line of cars. The three crew members survived even though the collision destroyed the control compartment of the lead locomotive.

The next month, in a case weirdly similar to Graniteville, a southbound UP freight train unexpectedly diverted onto a passing siding in Shepherd, Texas, where it struck a northbound local train. The northbound train had been parked on the siding 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. To avoid violating federal hours-of-service regulations, the crew secured the train and, without relining the switch, departed.

A short time later, a three-person relief crew arrived. The relief engineer was aboard the locomotive when the southbound train unexpectedly diverted onto thesiding, striking the parked train head on. The impact killed the relief engineer and injured four other crew members aboard the two trains.

Regarding the Graniteville wreck, the NTSB found that neither fatigue, training, qualifications or excessive speed played a role. Likewise, drugs or alcohol were not a factor. The crew of train P22 simply failed to reline a main line switch after using it, leading to the unexpected diversion of train 192 onto a siding where it struck P22 and derailed.

The crew members of P22 rushed to complete their work and secure the train before reaching their hours-of-service limits, the NTSB ruled. The crew had achieved their main objective of switching cars and were focused on securing their equipment and going off duty. The switch was not visible to the crew as they worked, leaving them without a visual reminder to reline the switch. Had the conductor held a comprehensive job briefing at the Avondale Mills siding, as required, the accident may not have happened.

Even after the wrecked trains were removed, many signs of the accident remained in Graniteville. While most of the homes survived, the chlorine cloud left its mark in other ways. One local church had to be completely rewired after the fumes seeped into its structure.

"They had a lot of brass in it that was corroded, especially the stained glass that had to be replaced," Turno said. "The plumbing in the church was well over 100 years old."

Chlorine, mixed with other chemicals, is used as a disinfectant to keep swimming pools clean. Chlorine released at the strength apparent in Graniteville is a full-scale biocide that kills germs, microorganisms and algae.

"One lady came up to us afterward and said, 'What did you do to our house?'" Turno said. "We asked her what she meant. She said 'Well, our pool out back was filthy and nasty. We haven't used it in years. Now it looks like it has just installed.'"

South Carolina Electric and Gas lost many of its power substations throughout the area because of the chlorine. As for Avondale Mills, corrosion from chlorine contamination damaged or destroyed equipment throughout the facility. One of the most heavily affected areas was a building that housed data administration. The chlorine concentration wiped out the computers in use.

Avondale Mills closed or sold all 20 of its textile plants throughout the southeast U.S. in 2006, citing international trade pressure and the extensive damage to the Graniteville facility. The company had roots in Graniteville going back to the mid-1800s. Of the 4,000 jobs lost when Avondale Mills closed nationwide, half were in Graniteville.

Avondale Mills subsequently sued Norfolk Southern for $420 million, charging that damage at the Graniteville site was so extensive as to exceed the value of the business. After four weeks of trial in 2008, the parties reached a confidential settlement.

As if the death toll and property damage were not reminder enough, the crossing arms, bells and lights operated continuously in the hot zone for nearly two weeks after the wreck, Turno said.

"Emergency responders were not allowed to dismantle or even touch this equipment until the NTSB had ruled out the possibility of terrorism.

Editor's note: This after-action review appeared in "Disasters Man-Made" by David White and Anton Riecher that was published in 2011.