TEUTOPOLIS, Ill. (WCIA) — Just weeks before the second anniversary of a deadly HAZMAT disaster in Teutopolis, the National Transportation Safety Board released on Tuesday its final report on the disaster.

The 27-page report, provided to WCIA by the Effingham County Coroner’s Office, details the events of Sept. 29-30, 2023, and provides information about the scene of the disaster, the people and vehicles involved, and the investigation. It also includes lessons learned from the disaster and recommendations on how to prevent the factors and circumstances from happening in the future.

The NTSB confirmed what it had determined in an initial report released a month after the disaster: that the cause was the passing of a semi-truck carrying anhydrous ammonia by a minivan in a no-passing zone on U.S. Route 40. With another vehicle approaching in the opposite direction, the truck’s driver steered to the right to give the minivan space to avoid a head-on collision and the truck went off the road.

Contributing to the severity of the crash was the impact of the truck’s tanker trailer with a small utility trailer parked at the scene of the crash. The impact caused the anhydrous ammonia to leak out and create a toxic plume of gas. Five people died, 13 were hurt and hundreds living in Teutopolis were evacuated. More than 30 agencies responded to the disaster as it unfolded over the course of 24 hours.

Driver of minivan had ‘lack of experience’

The NTSB said in its final report that the driver of the minivan was a 17-year-old girl from Ohio. She had completed that state’s graduated driver licensing program and had a probationary license at the time of the crash. She was relatively new to driving — her license had been issued less than a year earlier.

“Her lack of experience was the primary reason for attempting the unsafe and illegal passing maneuver,” officials wrote.

The NTSB added that Ohio driving records showed no violations, suspensions or withdrawals in the teen’s name. At the time of the crash — 8:40 p.m. on Sept. 29 — she was in compliance with Ohio driving laws concerning curfew and passengers; the teen’s mother and brother were in the van with her. Phone records showed no cell phone use at the time of the crash.

In an interview with the Illinois State Police five days after the crash, the teen admitted to having a history of inaccurately judging distances and the available time to pass other vehicles safely. As she passed the truck on Route 40, the teen said she accelerated to 90 miles per hour, in part because she realized the oncoming vehicle was driving faster than she estimated.

The teen said she started the passing maneuver in a passing zone, but video footage from the truck shows it crossed into the no-passing zone before the minivan could pass. The NTSB said that regardless of where the passing maneuver starts, it is illegal to pass in a no-passing zone.

Driver of semi-truck ‘had to get out of the way’ for minivan

The 24-year-old driver of the semi-truck had a valid commercial driver’s license, with no violations, suspensions or withdrawals in his name, and had completed hazardous materials training. He was employed by Prairieland Transport in Brownstown and, prior to the crash, he had completed four road trips in three months, transporting hazardous materials each time.

The NTSB said that the day of the crash, the driver left Brownstown around 6:22 a.m., traveled to Lima, Ohio, and picked up a load of 7,500 gallons of anhydrous ammonia. He had been on duty for about 14.5 hours when the crash occurred just 35 miles away from Brownstown.

The driver reported to the NTSB that as he was approaching Teutopolis, he saw in his side mirror that the minivan behind him started a passing maneuver. He assumed the driver would abort once she saw the oncoming headlights.

“The driver stated that he determined the minivan could not successfully complete the passing maneuver, at which point he decided ‘that I had to get out of the way and that’s when I took the ditch,'” the NTSB said. “He reported feeling the tires hit the gravel and the grass.”

The teen reported that she was unaware that the truck she had passed had gone off the road and only learned about the crash from the news.

Crash scene included metal culvert, utility trailer critical in HAZMAT leak

The NTSB found that at the time of the crash, the weather was dry and clear. At the scene of the crash, Route 40 was a rural, unlit, undivided highway with one lane of travel in each direction. Each lane was 12 feet wide with shoulders three feet wide — one foot paved and two feet of crushed gravel — with no rumble strips. Beyond the gravel shoulder was a ditch about two feet deep.

Also at the scene of the crash was the driveway to a home and a 12-inch diameter metal culvert beneath the driveway that connected the roadside ditches on either side of the driveway. In addition, there was a utility trailer parked near the home, 27 feet away from the highway and 105 feet west of the culvert.

As the truck ran off the road, the NTSB said it started to overturn. The front of the truck-tractor struck the culvert underneath the driveway, and the combined vehicle jackknifed, exposing the front of the tanker trailer containing the anhydrous ammonia. The tanker struck the utility trailer’s hitch, puncturing the tanker in the area of a weld seam and tearing a 7-by-4-inch hole in the tanker.

Condition of tanker not a factor in ammonia leak

The NTSB reported that the tanker was manufactured in 1978 by the Mississippi Tank Company, and post-crash inspections found no preexisting deficiencies that would have caused or contributed to the crash. It met the manufacturing standards that existed in 1978 — it even met current manufacturing standards — and the tanker was properly marked and placarded to indicate its cargo.

“Technicians from Mississippi Tank Company inspected the cargo tank and performed a wet fluorescent magnetic particle test on the head and all welds for signs of stress cracking,” officials wrote. “This test revealed two areas of stress cracking, but they were not near the area of puncture. The investigation could not determine whether these were pre-crash conditions.”

Leaking anhydrous ammonia created plume ‘immediately dangerous to life or health’

Through the hole torn in the tanker, approximately 4,000 gallons of liquefied anhydrous ammonia leaked out of the tanker, encountered moisture in the air and evaporated, and created a plume dangerous to anyone exposed to it.

“The gas reacts with moisture in the linings of body passages and cavities, including eyes, throat, lungs and skin. When concentrated, anhydrous ammonia is corrosive to tissue,” the NTSB said. “Anhydrous ammonia is immediately dangerous to life or health at a concentration of 300 parts per million of higher.”

A total of 18 people experienced these effects the night of Sept. 29, 2023. Five people were fatally injured — a father and his two children who lived at the home where the crash happened — and two people driving on Route 40 — a pastor from Missouri and a truck driver from Ohio. They all suffered chemical burns to their skin, eyes and mouth and “hemorrhaging in the respiratory system”.

Nine people driving through the crash zone suffered injuries described as “serious,” including the driver of the truck that crashed, Terrie Tudor, who was traveling with the pastor, and a quartet of students from the University of Missouri.

Four more people suffered minor injuries — two people in nearby vehicles, one person who lived nearby and a firefighter who was splashed on his leg by anhydrous ammonia.

Hundreds of others had to leave their homes in Teutopolis as the toxic plume started moving in the town’s direction. Even first responders had to relocate their staging area and command post multiple times as the emergency response continued into the late night of Sept. 29 and throughout much of the day on Sept. 30.

NTSB notes flaws in HAZMAT response

The first 911 calls were made at 8:43 p.m. — just three minutes after the crash. The NTSB said that when the Teutopolis Fire Protection District arrived nine minutes later, its assistant chief could smell a pungent odor. He immediately recognized the odor as ammonia, ordered all firefighters to retreat and called for mutual aid from other agencies.

Route 40 was ordered to be closed at 8:55 p.m. and five minutes later, HAZMAT-trained firefighters from Teutopolis and Montrose began entering the “hot zone” to locate and evacuate victims. At about 11:17 p.m., a mutual aid HAZMAT unit led by Charleston’s fire chief applied a patch to the tanker that slowed, but did not completely stop, the leak.

The NTSB said Charleston’s chief consulted the Emergency Response Guidebook while en route to Teutopolis to help assess the necessary evacuation zones and isolation distances. The ERG recommends that first responders wear Level A personal protection equipment during incidents involving anhydrous ammonia. Level A PPE includes self-contained breathing apparatuses and totally encapsulated chemical- and vapor-protective suits.

“While Level A PPE was available for the HAZMAT team members…the team remained in their turnout gear with SCBA,” officials wrote. “The HAZMAT team members used the same gear in the subsequent entries to the hot zone; they never donned Level A PPE.”

In addition, during an operation in the hot zone on Sept. 30, the NTSB said the firefighters involved had the required certification to be HAZMAT technicians, but none of them had specific training to deal with anhydrous ammonia.

The NTSB also found a flaw in decontamination efforts.

“Two decontamination stations were located on the western side of the crash site. Patients who were moved to the west side triage area were decontaminated properly,” officials said. “However, while first responders attempted to decontaminate patients moved to the east side triage area, they lacked decontamination stations there.”

As a result, victims from the east side triage area were transported to the hospital in clothing still saturated with anhydrous ammonia, the NTSB said. This risked the spread of the hazardous material in transport vehicles and emergency departments.

Finally, the NTSB noted that none of the first responders contacted the shipper of the anhydrous ammonia in Ohio. The shipper’s identity and emergency phone number were listed on papers in the cab of the crashed truck, but they were left there by the driver when he self-extricated and were not retrieved by first responders.

Under federal regulations, the shipper was required to provide emergency response and incident mitigation information.

The remaining anhydrous ammonia inside the crashed tanker was offloaded into an empty tanker sent by Prairieland Transport between 3:30 and 5:30 p.m. on Sept. 30. Residents were finally able to return to their homes at 7:30 p.m. and first responders wrapped up operations the following day.

NTSB makes conclusions, ‘lessons learned’ from Teutopolis disaster

The NTSB found that the passing zone at the crash site followed federal guidelines and IDOT policy while the no-passing zone was appropriately marked. Both the truck’s driver and the teenage minivan driver were properly licensed, with no evidence of impairment or fatigue in the truck driver and no violations of the teen’s probationary license. Neither driver was using a phone at the time of the crash.

The mechanical condition of the tanker trailer was not a factor in the crash.

“The circumstances leading to the breach — a small object made of hardened steel impacting the cargo tank at a weld seam — are extremely unusual,” the NTSB said. “A cargo tank with a capacity to withstand such impact forces would require a substantial increase in material thickness. The only other packaging containers with such extreme design characteristics are intended for the transportation of radioactive materials.”

The emergency response was timely and demonstrated effective interagency coordination, the NTSB added. Officials also noted that, in the aftermath of the disaster, a dozen local emergency response agencies made improvements to first responder planning and response to HAZMAT incidents, including improvements to decontamination procedures.

Another improvement in response to the crash was the Illinois Department of Transportation’s plans for construction on Route 40. Engineers added to the plans wider paved shoulders and rumble strips at the site of the crash.

The NTSB also said there are two lessons to be learned from this crash, both stemming from two major factors. One of them is risky behaviors among teen drivers, a longtime issue for the NTSB.

“This crash demonstrates the ongoing challenges associated with teen driver inexperience, particularly in complex traffic situations requiring quick judgment. Even drivers who have completed comprehensive graduated driver licensing programs may lack the experience necessary to accurately assess distances and timing during high-risk maneuvers such
as passing, especially in dark conditions,” officials wrote. “Educational institutions, driving schools, and parents should continue to emphasize the importance of conservative decision-making and the recognition that inexperience can lead to poor judgment, regardless of formal training completion.”

The other major factor and lesson: transportation of anhydrous ammonia and responses to disasters involving this hazardous material. The NTSB cited the disparity between its HAZMAT classification and its effects, along with fact that some first responders in Teutopolis showed a “lack of proper planning” and “insufficient understanding of and adherence to” appropriate PPE requirement.

“This crash also serves as a reminder that anhydrous ammonia, while classified as a Division 2.2 non-flammable, nonpoisonous gas, poses significant risks to public health when released,” the NTSB added. “Emergency responders should prepare and use appropriate PPE and decontamination procedures when responding to incidents involving anhydrous ammonia, and they should verify the appropriate mitigation and protection procedures with the shipper of the hazardous material. The toxic and corrosive nature of this substance requires Level A PPE for safe entry into affected areas, and proper staging of decontamination stations is essential to prevent contamination of transport vehicles and medical facilities.”

The NTSB’s full report can be found by clicking here.