The August 2012 derailment of a coal train in the heart of historic Ellicott City likely began at a small break in the rail line several hundred feet from where two 19-year-old women were seated next to the tracks.
The presence of the break, made public in investigative documents released by the National Transportation Safety Board on Monday, further supports a conclusion many community members have been grappling with for nearly two years — that Elizabeth Conway Nass and Rose Louese Mayr, both 19, were simply in the wrong place at the wrong time.
The derailment, which asphyxiated the two friends under a pile of coal, sparked a massive emergency response along the banks of the Patapsco River and the community's Main Street, and spurred an investigation — still continuing — that involved teams of responders carefully culling evidence from a coal-strewn path of destruction.
Among that evidence, according to the newly released documents, were markings indicating there was a break in a rail several hundred feet before the Main Street bridge where Nass and Mayr were seated, close to where trains curve into the town.
James A. Southworth, the NTSB's lead investigator in the incident, wrote in his "factual report" — the most extensive document released to date — that his team had "formed a consensus" that the break was the "point of derailment."
The report also found that the frequency of CSX inspections of the tracks in the area complied with federal regulations, and that an inspection of the rails just one day before the derailment recorded no defects.
The NTSB has yet to release its final report on the incident, which will include direct conclusions on the cause of the derailment and recommendations for what can be done to prevent similar incidents in the future. Eric Weiss, an NTSB spokesman, said the final report could be released in the next several weeks. He declined to comment on the documents posted online.
"We don't comment on factual reports," he said. "We let the voluminous amount of information speak for itself."
Rob Doolittle, a CSX spokesman, said in an email that CSX is committed to safety and routinely reviews and enhances its safety protocols, but withheld comment on the released NTSB documents because the investigation is continuing.
"The derailment was a tragedy, and CSX's sympathies remain with the families and friends of the two young ladies who perished," Doolittle said.
Mark Mayr, Rose Mayr's father, said Monday that he and her mother, Sharon, have discussed the newly released documents with Nass' parents, Eric and Sue, but that none of them had any comment. "We need a little more time to read and understand the documents," he said in an email.
Both Nass and Mayr were 2010 graduates of Mount Hebron High School from Ellicott City and at the time of the derailment were attending James Madison University and the University of Delaware, respectively. They were found still seated on the bridge about 20 feet above Main Street, "engulfed in the spillage of coal" from train cars that had tipped, according to Southworth's report.
A total of 21 cars derailed, many ending up in a parking lot between the river and a railroad retaining wall. The incident shut down busy Frederick Road and renewed concerns about railroad safety in the area.
Nass and Mayr were trespassing on the CSX right of way, and their presence on the bridge raised questions about the accessibility of the tracks in the historic downtown and efforts on the part of CSX to prevent people from entering the area.
According to the Federal Railroad Administration, "human factors" were the leading cause of railroad accidents in 2013, with track problems closely following. Of all railroad-related deaths, about 96 percent were related to trespassing or highway crossings.
Kevin Thompson, an FRA spokesman, said his agency would not comment on the NTSB documents.
The documents run hundreds of pages and capture a range of information, from highly technical recountings of railroad equipment reviews in the months leading up to the accident to a transcript of investigators' interview of Cory Painter, the train engineer.
At one point in the interview, Painter was asked if he saw "people out that night" before the derailment.
"No, I didn't — we didn't see anybody the whole way down. I mean, it was late at night. We didn't see anybody along the tracks," he responded. "Didn't see, obviously, the two girls anywhere in that area."
Ed Dobranetski, a former NTSB investigator who has led reviews of other derailments in the state, said in an email Monday that from a preliminary review of Southworth's report, it "appears that a broken rail with rail defect inspection problems will be the most likely cause of the accident."
He said he doesn't know why the NTSB's final report on the incident has taken so long — they are usually released within 18 months of an incident — but would expect it to include more information on "the events and circumstances" surrounding Nass and Mayr's presence on the tracks.
Southworth's report did not provide such analysis.