The National Transportation Safety Board said Tuesday that burning off chemicals after a Norfolk Southern train derailed in Ohio last year was unnecessary.

Officials intentionally released and burned off toxic vinyl chloride from five derailed cars, sending smoke and chemicals into the air despite the potential health effects.

NTSB officials said Tuesday that the train operator and its contractors failed to tell incident commanders that the maker and shipper of the vinyl chloride had said venting and burning the chemicals wasn't needed. In fact, they said Norfolk Southern and its contractors continued to assert that it was necessary, even though they had evidence that should have lead them to conclude otherwise.

The findings came as NTSB officials returned to East Palestine Tuesday to share findings of their investigation into the calamitous 2023 train derailment and offer recommendations to prevent similar disasters from happening in the future.

In February 2023, a Norfolk Southern train derailed in a tiny Ohio town near the Pennsylvania border. Residents initially watched the fires from the crash and were later evacuated as officials feared a potential hazardous chemical explosion, and they executed the vent and burn.

NTSB officials have said an overheated bearing on one of the railcars likely caused the crash, but questions remained about whether that could have been prevented and whether officials made the right choice to burn off the vinyl chloride. The NTSB recommended Tuesday that Norfolk Southern revise its incident report about the derailment to reflect that the vent and burn of vinyl chloride was not necessary.

The agency listed 47 findings from its investigation, covering everything from rail car bearings and DOT-111 rail car failures to melted placards and outlined recommendations ranging from creating a nationwide database to track overheated wheel bearings, to increasing training for Ohio volunteer firefighters. The recommendations are not binding, but U.S. lawmakers could act to enforce them.

What caused the bearing to fail?

It was impossible to tell what caused the bearing failure in East Palestine because the fire destroyed the components, according to the NTSB. When asked what causes bearings to fail, NTSB Investigator Joey Rhine said when there's a bearing defect, it causes friction, which leads to heat.

"It's like putting an iron skillet on a stove," Rhine said.

But the bearing that failed was attached to a car that sat in a flooded area for an extended time and water intrusion can also cause bearing failures, Homendy said.

Timken, the manufacturer of the bearing, recommends replacing bearings that sit in floods. There was no evidence this bearing was replaced and, Homendy pointed out, there was no way for Norfolk Southern to know because railroads generally don't own the cars they transport.

Most bearings on freight trains in the U.S. are re-conditioned, according to Rhine, meaning they have only about half the life of new bearings. The NTSB has investigated two other train derailments since East Palestine that also involved a bearing failure, he said. Each bearing that failed was reconditioned and in the same axle position as East Palestine, he said.

When investigators tried to find data to see if this was a larger pattern, they discovered that there isn't a single database. The Association of American Railroads (AAR) maintains a database, but it's broken down by car, not train. The NTSB recommended the AAR create a single database to illuminate patterns in wheel bearing failures across the industry. Bearing failures are the primary cause of U.S. train derailments, the NTSB said.

NTSB recommends tank cars with built-in protections

The fire that began at the East Palestine derailment likely happened when a DOT-111 type of train car was punctured, the NTSB said, "spilling fire" onto an 1,100-foot section of track. NTSB member Michael Graham said the breach of those DOT-111s in East Palestine "led to the large, raging fire" that overwhelmed firefighters and ultimately led to the vent and burn.

DOT-111 cars are susceptible to breaching and are due to be phased out for carrying flammable material after May 2029. The NTSB recommended mandating an accelerated phase-out. Flammable and hazardous materials should instead be carried in tank cars with more built-in protections, the board said.

But the scheduled phase-out of the DOT-111 in 2029 will not take this rail car off of America's rail lines. Veteran NTSB Inspector Paul Stancil said that two of the three DOT-111 cars that were part of the East Palestine derailment would still be allowed to carry the same material after 2029.

The NTSB has been raising safety concerns about the DOT-111 rail car since 1991, Homendy said. It recommended changes to the car's construction at least twice. A train with the cars derailed in 2013 in Lac-Mégantic, Quebec, unleashing a flood of oil and 47 people died, Stancil said.

"An entire town was literally decimated," Homendy said, noting that 25,300 DOT-111 rail cars are still in service today. "People are dying."

Homendy pointed out that shippers own the rail cars and it's up to them to get rid of them. She also noted that railroads are required to carry hazardous materials.

At least five different chemicals were carried in the train cars that derailed in East Palestine, according to a letter from the U.S. Environmental Protection Agency to Norfolk Southern. The chemicals included vinyl chloride, butyl acrylate, ethylhexyl acrylate, ethylene glycol monobutyl ether and isobutylene.

Vinyl chloride, which is a chemical used to make PVC pipe, is considered a carcinogen. Exposure to vinyl chloride is associated with an increased risk of a rare form of liver cancer as well as brain and lung cancers.

Burning it, which was part of the controlled release, creates the toxic gas phosgene and hydrogen chloride. The gas was used as a weapon during World War I.

In the days following the train derailment in East Palestine, Ohio, a group of investigators fell ill while looking into the chemical exposure of residents.

NTSB member Thomas Chapman said he and other members continue to be "mystified" that the American railroad industry, unlike the airline and other transportation industries, continues to largely regulate itself.

NTSB says Norfolk Southern failed to disclose key information

NTSB member Michael Graham said when the decision was made to vent rail cars and burn off toxins, what no one knew, including the incident commander, was that there was disagreement over whether the vent and burn should happen.

The temperatures in the tanks were dropping, not rising, which means the immediate risk was not as great, investigators said. It's not clear why, but Norfolk Southern contractors continued to urge a vent and burn, Stancil said. Norfolk Southern, he said, didn't reveal the declining temperature readings to NTSB until two months afterward.

The NTSB investigation showed that local officials made decisions based on incomplete information provided by Norfolk Southern contractors. Those contractors failed to disclose that technical experts for the company that made the chemicals disagreed with their recommendation, saying no vent and burn was required.

Ohio Gov. DeWine sent out a statement before the toxic burnoff reflecting what Norfolk Southern contractors were telling officials about the dangers at the time. Officials believed at the time that there was danger a chemical reaction would turn tanker cars into exploding bombs, sending deadly shrapnel and hazardous fumes across the areas. People in Ohio and Pennsylvania evacuated the area, many fearing for their lives and safety.

NTSB calls for increased firefighter training, updating placards on tankers

Quickly finding out what hazardous chemicals are on derailed trains in the U.S. is a chronic, recurring problem that's stretches over decades, NTSB members and agency investigators said. In East Palestine, dispatchers called the Norfolk Southern dispatch center in Atlanta to find out what the train was carrying within minutes of the derailment. Norfolk Southern said it would call back, but there's no evidence it ever did, according to NTSB investigator Troy Lloyd. Meanwhile, placards on the rail cars were melted or missing.

One simple change NTSB recommended is updating the standard for placards displayed on tankers showing what hazardous materials they are carrying. The NTSB said the placards now must only be able to withstand weather for 30 days. There are no mandates about the placards standing up to derailments or fires. The NTSB showed missing and damaged placards caused by the East Palestine derailment.

Stancil added that the railroads shouldn't wait for first responders to reach out to them after a derailment. He said the railroads' first call should be to the 911 dispatch center in the area where a train derails, so first responders know what the train is carrying.

Additionally, none of the local volunteer firefighters had hazardous materials training. Two weeks before the East Palestine train derailment, the state of Ohio published a report that said, in part, that the 36 hours of training mandated for volunteer firefighters in the state was an outdated model.

Instead of setting up a command post a 1/2 mile away, as recommended in such cases, firefighters initially set up inside the "danger zone," 400 or 500 feet from burning rail cars without knowing what was in them.

“It's really fortunate that one of the volunteer firefighters from that department was also a chemistry teacher” who evaluated some of the dangers, Homenday said. It wasn't ideal, she said, but it was the "best immediate guidance" first responders had as they rushed to East Palestine from 48 area departments.

The NTSB recommended increasing training for Ohio volunteer firefighters, who often face the same hazardous situations as professionally-trained career firefighters.

NTSB officials pointed across the state line to Pennsylvania, which mandates and funds additional training for volunteers. Time and money is an issue with volunteers, Lloyd said. Hazardous material training can also cost $2,000 per firefighter, plus another $25,000 per firefighter for necessary hazardous response gear. Some states, he said, are now offering incentives to volunteer firefighters, including tax breaks.

Contributing: Max Filby, Columbus Dispatch