A worn and fractured rail along train tracks through Ellicott City caused the coal train derailment that killed two women in 2012, the National Transportation Safety Board said Thursday.
In its final report on the accident, the NTSB said it found evidence that the section of CSX Transportation rail showed signs of "gradual deterioration of the rail-head surface" from passing trains.
The finding makes official preliminary conclusions about a rail break contributing to the accident that were released in a docket of investigatory documents last month.
The break in the rail was several hundred feet from where 19-year-old college students Rose Louese Mayr and Elizabeth Conway Nass, both graduates of Mount Hebron High School, were seated on an overpass that carries the railroad above Main Street.
Mayr and Nass were trespassing at the time of the incident, as the bridge is part of the railroad's right-of-way. The NTSB said their presence next to the tracks "placed them in harm's way" but "did not contribute to the derailment in any way."
The two women's parents have said they are considering litigation against CSX unless the railroad offers a public apology for the incident and a financial settlement.
Ronald Goldman, the parents' attorney, said Thursday that the families were "deeply disappointed" with the NTSB report, in part because it "fails to go further" in making recommendations that would force real change in the railroad industry.
"We have had investigation after investigation of defective track that leads to derailments, but nobody's doing the hard work that I think needs to be done to determine how they can prevent track from becoming defective in the first place," Goldman said. "They should do investigations and studies to determine if rails should be life-limited. We haven't done that hard work. They do it in aviation, but not in rail."
In a statement, CSX largely stuck to comments it has made before: that its sympathies remain with the families, that it values and is committed to safety, and that it follows all federal regulations and its own internal policies.
"We are evaluating the conclusions and look forward to applying lessons learned through the investigation to further enhance our ability to prevent such incidents in the future," the company said of the NTSB investigation.
The NTSB report found that CSX had been conducting routine inspections of local tracks, including ultrasonic testing more frequently than is required by federal regulations, in part because of a "history of rail defects" in the area and an "increase in tonnage due to a rise in coal traffic over the previous years."
The report also found stress on the tracks was "relatively high" at the time of the failure.
"The high stresses likely resulted from a worn rail head that was approaching levels for scheduled replacement combined with poor ballast conditions and high axle loads," the NTSB found. "These conditions produce defects that can grow relatively quickly and can fail at a relatively small size."
The last ultrasonic test for internal rail flaws in the area occurred Aug. 3, 2012, 17 days before the accident, the NTSB investigation found, but "no defective rails were marked near the derailment area." Defects were noted along other sections of the more than 15 miles of track studied.
The derailment sent 21 train cars off the tracks, seven of which landed in a nearby parking lot. Damage was estimated at $1.9 million. Mayr and Nass were asphyxiated after being buried in coal from an overturned car on the overpass.
According to the NTSB report, the pair had climbed over "a short wooden fence" sometime before midnight on the cool summer night to enter the restricted area. In line with local speculation at the time, the report also notes that Mayr and Nass were "seen consuming alcoholic beverages prior to the accident."
At the time of their autopsies by the medical examiner, the report said, the two women had ethanol in the vitreous fluid of their eyes equivalent to blood- alcohol levels of 0.05 percent and 0.03 percent. The report did not ascribe the levels to the women individually. At those levels, the women would have been able to drive were they of legal age to drink.
Goldman said it was "offensive" to mention alcohol in the report at all, calling it a "deflection of responsibility away from CSX" that would cause the families more distress.
"It had nothing to do whatsoever with this accident. They were not under the influence of alcohol in any legal sense of the word. They were sitting quietly," he said. "Many, many, many people routinely go to that area because it's beautiful, it's scenic, it's part of the town, part of the culture."
Eric Weiss, an NTSB spokesman, said the report was a "thorough, factual" accounting of the derailment, which he called a "tragedy." The agency noted in the report that CSX installed chain-link fencing along its right-of-way in the area after the derailment, where no fencing had existed before.
The accident drew a large emergency response and shut down the community for days amid a large-scale cleanup, including environmental assessments of coal contamination in the nearby Patapsco River.
The NTSB found the accident mirrored two others involving Norfolk Southern Railway trains derailing because of wear leading to broken rails, one in Pennsylvania in 2006 and another in Ohio in July 2012, just a month before the Ellicott City derailment.
In September 2012, as a result of the three accidents, the Federal Railroad Administration formed a "Rail Safety Advisory Committee" to study the effects of wear on tracks. That group released recommendations, reached with industry consensus, in April.
Last week, the FRA distributed new guidelines based on the findings, which the NTSB called "a substantial effort to significantly reduce broken rail accidents due to rolling contact fatigue, and provide improvements for better management of the industry risk management programs."
The guidelines make various recommendations to railroads, including that they form new "rail failure prevention programs" that tighten reviews of tracks, establish better protocols for addressing rail wear, improve record keeping and create guidelines for "rail service life monitoring."
The NTSB cited those recommendations in lieu of creating new ones based solely on the Ellicott City incident. CSX said that it participated in the study group and that the recommendations are part of its "commitment to continuous improvement in safety."
The NTSB said it will also hold a public forum next year to educate the public about the dangers of entering a railroad right-of-way. It noted that 476 pedestrians died in 2013 as a result of railway trespass, according to Operation Lifesaver, a railroad-funded safety awareness organization.
Goldman, the parents' attorney, called the forum a good step, but said the recommendations and the NTSB's overall investigation fall short.
"The NTSB is doing the same thing over and over. They're looking at the defective track and saying, 'Well that's what caused it, and we're making recommendations how to better inspect and detect once the defect has occurred.' We are saying, 'Not good enough,' " Goldman said. "This accident needs to have a deeper investigation."
Goldman said it "doesn't take a rocket scientist" to know that metal rails under stress should be phased out after a certain amount of time, not repaired or replaced as they fail.
Ed Dobranetski, a former chief NTSB rail accident investigator in the region, said he also was disappointed with his former agency's report, which he said should have included more detail about fractures discovered along the CSX rail line, accident-related markings found on the wheels of the train and how both related to the derailment. He also wanted more information on the circumstances surrounding Nass' and Mayr's deaths, such as a look at the frequency of trespassing in the area and CSX's efforts to stop it.
Both Goldman and Dobranetski said the case would have benefited from a full public hearing where NTSB investigators would have to answer questions on their findings, but no such hearing was scheduled.
Defending the agency, Weiss cited the hundreds of pages published in the case docket, which are full of technical details not found in the final report.
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