Worn, fractured rail caused Ellicott City train derailment, NTSB determines

July 31--A worn and fractured rail along train tracks in historic Ellicott City caused the massive coal train derailment that killed two local women in 2012, the National Transportation Safety Board said Thursday.

The NTSB said it found evidence that the section of CSX Transportation rail showed signs of "rolling contact fatigue," or a "gradual deterioration of the rail-head surface" over time.

The finding comes nearly two years after the accident, and 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 while their presence next to the tracks "placed them in harm's way," it "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 offers a financial settlement.

Ronald Goldman, the parents' attorney with Baum Hedlund Aristei & Goldman, said Thursday 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.

The company thanked NTSB for investigating the incident. "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.

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 prior to the accident on Aug. 20, 2012, occurred Aug. 3, 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. Mayr and Nass were asphyxiated after being buried in coal from an overturned car on the overpass.

The accident drew a large emergency response and shut down the small community for days amid a massive clean-up, 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 rail tracks. That group released recommendations, reached with industry concensus, in April.

Last week, the FRA distributed new guidelines 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 pointed to those recommendations in lieu of creating new ones based solely on the Ellicott City incident. CSX said it actively 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.

To deter trespassing on the Ellicott City railroad bridge, CSX installed a chain-link fence along its right-of-way after the accident.

Goldman, the parents' attorney, called the NTSB's forum a good step, but 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.

He also said so-called "hopper cars" -- or uncovered train cars like those that allowed coal to spill freely in Ellicott City -- should be phased out, and that technology should be advanced so that when one car derails, 20 others don't go with it.

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