On April 27, Steve Holm and three other inspectors drove right over a set of broken railroad bolts that later would cause a massive oil train explosion.
Holm rode shotgun as Union Pacific Railroads specially equipped pickup rolled along at 10 mph over its tracks through the Columbia River Gorge National Scenic Area.
He stared out the front windshield at the steel rails, the wood ties beneath and the plates and bolts that held them together.
Had Holm seen anything he suspected was out of alignment he would have stopped, hopped down from the truck and walked for a closer look. But he didnt.
It was a normal inspection, said Holm, a track inspector with the Oregon Department of Transportation. There was nothing outstanding that stood out in my mind about it.
ODOT has concluded that several of the lag bolts fastening the rail lines to the ties had probably been sheared and rusted over for some time. Holm says he just missed them.
Union Pacific said it followed federal laws, meaning in the five weeks that followed Holms track survey, its own inspectors wouldve passed over those bolts at least 10 more times.
On the afternoon of June 3, those bolts failed under the weight of a train hauling 94 cars of crude oil from the Bakken region of North Dakota. The rails spread apart. The train left the tracks. Oil spilled. Flames erupted.
When I got up there and I saw what had happened, I was very surprised, Holm said.
Simple steps could have prevented the fiery derailment. Had inspectors from Union Pacific Railroad or government regulators walked the stretch of track in the weeks or months prior, they might have spotted the broken bolts.
But no one did.
Those unseen, broken bolts in Mosier expose a significant flaw in the current system for railroad inspections. Yet, federal and state regulators, as well as the railroads, all say current rules are adequate. Minimum federal requirements allow railroads considerable leeway for how they inspect their own track, while government checks are few and far between. As Mosier showed, the system can allow potentially dangerous defects to go unaddressed for months.
The fact is, it doesnt pick up all the defects, said Fred Millar, an independent consultant in hazardous materials transport who has been critical of a proposal for the countrys largest oil-by-rail terminal in Vancouver.
Now, should that give you any pause about whether the inspections system, the inspection regime, is itself designed to be really rigorous and really work or not? Millar said.
The Federal Railroad Administration, the countrys rail safety regulator, blamed Union Pacific for the derailment. The agency is considering enforcement action against the railroad.
When it comes down to it, its Union Pacifics failure to maintain its track led to this incident, FRA Administrator Sarah Feinberg told NPR's All Things Considered in June.
Union Pacific is to blame. But it isnt alone.
In its initial report on Mosier, the FRA said broken lag bolts are more effectively caught if inspections are done by walking on the tracks instead of driving. Regulators and safety experts say walking curved sections of track is a good safety measure and sometimes railroad policy.
But the FRA doesnt require it. And Union Pacific didnt do it.
The railroads inspections, done by vehicle as recently as four days before the derailment, identified no such flaws.
Before the derailment, the FRAs own inspectors hadnt laid eyes on the tracks in Mosier or reviewed the railroads inspection records for its tracks through the Columbia River Gorge since early this year. After the derailment, the Oregon Department of Transportation was so concerned its inspector missed the defects that it requested a halt on oil train traffic a request federal officials have indicated theyre not likely to grant.
Union Pacific surpassed the bare minimums for inspection frequencies in the gorge.
We were adhering meeting or exceeding the FRA standards for inspections prior to the derailment, Union Pacific spokesman Justin Jacobs said.
Union Pacific said twice a week it had an inspector look for defects while traveling in a truck that is equipped to operate on railroad tracks. The railroads policy before Mosier included no walking inspections of curves or spot checks for these so-called hi-rail inspections.
Union Pacific also used special equipment four times per year to test for internal flaws and problems with track geometry that visual inspections cannot detect. Some experts have said a proper inspection should have caught a series of broken lag bolts regardless of whether they were walking or driving.
Once every 18 months, Union Pacific used a device called a Gage Restraint Measurement System to measure rail strength. The railroad and other safety experts have said that test likely would have caught the broken bolts that caused the Mosier derailment. The FRA has no requirement for those inspections, which means railroads are under no obligation to run them more frequently in the hopes of catching these defects.
Union Pacific voluntarily increased inspections after the derailment.
Across the Columbia River on the Washington side of the gorge, BNSF Railway inspects its track every day, spokesman Gus Melonas said. Its policy mandates walking inspections of curves a minimum of once per year.
Like Union Pacific, it runs automated inspections of track geometry four times per year. It tests track strength and movement at least once per year.
Walking inspections fluctuate. Tonnage, wear, age of rail, weather (numerous conditions) all dictate frequency, Melonas said in an email. Inspectors are over the track daily and may call for a detailed look on occasion.
The FRA encourages and expects railroads to exceed its requirements to ensure track safety. The federal agencys compliance manual for track and rail infrastructure states that its track safety standards are minimum safety requirements and are not appropriate for track maintenance purposes.
Look, railroads can always and they should go above and beyond our minimum maintenance requirements and our minimum inspections requirements, Feinberg said. But the reality is we have to move dangerous products in this country all the time.
Despite this latest oil train explosion, FRA data show overall derailments are on the decline and have been for years. However, the costliest derailments, with damages exceeding $1 million, are not.
The railroad industry says more than 99 percent of hazardous material shipments reach their destination safely. That slim failure rate has included more than two dozen crude by rail incidents in recent years.
Bad track has caused the majority of them. Experts say the weight and movement of oil trains puts a new burden on the nations rail infrastructure.
Meanwhile, railroads have little oversight from the government when it comes to inspections and track maintenance.
The FRA has fewer than 100 track inspectors for 140,000 miles of track across the country. Ten FRA track inspectors in the Northwest region are responsible for eight states, including Alaska.
In state government, Oregon has three track inspectors. Washington has two. Together the two states have more than 5,000 miles of track.
The FRA guidelines for track infrastructure take up more than 180 pages, but they still leave many decisions to railroads on how they conduct inspections.
For instance, there is no maximum speed at which inspections should be done, leaving it to the sole discretion of the inspector, based on track conditions and inspection requirements. Current rules allow one person to inspect two tracks at once. The FRA has requirements for railroad track inspectors, but the agency itself does not certify them. Thats left to the railroads.
Through their union, railroad track inspectors have complained of having large territories, too little track time and pressure to complete inspections quickly.
They are self-regulated to a degree. The regulations that are in place theyre the bare minimum, said Mike Elliott, a Seattle train engineer and former union safety official. In 2015, Elliott won a court case against BSNF Railway after the railroad fired him for flagging safety issues.
They have a lot of leeway, Elliott said of railroads. And they have favorable laws on their side.