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The school district announced the closure early Monday morning.

Early on in his administrative career, longtime Missouri educator Chris Belcher had what he called the worst experience of his life. “The kid screamed, and I felt awful,” he said. He didn’t want to do it, but he had to. It was the 1980s, and Belcher was told to paddle a student who was enrolled […]

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Parents have the right to drop off or send their children to safe schools. Teachers have the right to educate them in safe classrooms. Their rights are just as important as the rights of gun owners, if not more so. So where is the outcry for the rights of parents and teachers? Here we are […]

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Missouri among several states considering legislation to ban certain books from school libraries.

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The woman was found Sunday night.

The Kinks became rock 'n' roll superstars with Ray Davies as lead vocalist, but he says that was never really his ambition when he started playing music. In an interview with The Sun, Ray says…

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by Dan Schwartz and Topher Sanders, with additional reporting by Gabriel Sandoval and Danelle Morton, graphics by Haisam Hussein

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Just before 5 a.m., Harry Shaffer’s wife called to him from across the living room, where he’d fallen asleep on the couch, exhausted from installing an aboveground pool. Did he hear that sound, that metallic screeching from up the valley? She opened the door of their double-wide trailer and walked outside as Shaffer closed his eyes.

A moment later came a thunderous crack of splintering lumber. Debris shot through the living room. Shaffer opened his eyes again to find a hulking train car steps from where he lay. It had shorn off the roof, exposing the murk of the pre-dawn sky. He jumped up and ran outside and saw the garage next door in flames.

Though it sat at the floor of a valley along a busy stretch of railroad tracks, the quiet town of Hyndman, Pennsylvania, hadn’t seen a major derailment in recent memory. Trains didn’t frighten residents like Shaffer even though 21 of them trundled through the town’s center day and night.

But unbeknownst to them, the corporations that ran those trains had recently adopted a moneymaking strategy to move cargo faster than ever, with fewer workers, on trains that are consistently longer than at any time in history. Driven by the efficiency goals of precision scheduled railroading, companies are forgoing long-held safety precautions, such as assembling trains to distribute weight and risk or taking the proper time to inspect them, ProPublica found. Instead, their rushed workers are stringing together trains that stretch for 2 or even 3 miles, sometimes without regard for the delicate physics of keeping heavy, often combustible tanker cars from jumping off the tracks.

Rail safety grabbed headlines this February after a Norfolk Southern train passed sensors designed to flag mechanical issues and catastrophically derailed in East Palestine, Ohio; Republicans and Democrats alike are now calling for tighter regulations on company operations, especially in light of precision scheduled railroading.

ProPublica’s reporting suggests they should start by looking at federal regulators’ ponderous response to the mounting warnings about the dangers of long freight trains.

Before that morning in Hyndman in August 2017, regulators had already investigated seven long-train accidents in which the length was a culprit, and the nation’s largest rail worker union had sounded alarms about a pattern of problems.

None of this caused the Federal Railroad Administration, the agency in charge of train safety, to intercede — even as more long trains crashed in the years after the Hyndman derailment, sending cars spilling into other communities.

Today, the rail administration says it lacks enough evidence that long trains pose a particular risk. But ProPublica discovered it is a quandary of the agency’s own making: It doesn’t require companies to provide certain basic information after accidents — notably, the length of the train — that would allow it to assess once and for all the extent of the danger.

“It’s one of our biggest frustrations, without question,” said Jared Cassity, the alternate national legislative director for the International Association of Sheet Metal, Air, Rail and Transportation Workers, or SMART. The union representative said the agency can track train length for accidents “and they’ve chosen not to.”

In the absence of data, the industry insists that long trains have actually helped to improve rail safety, pointing to an overall decline in derailments. The Association of American Railroads, the industry lobby, says safety is the priority when building long trains and notes that regulators have never cited length as the direct cause of an accident. The nation’s seven largest rail companies, the so-called Class 1s, echo these points, defending their safety practices and saying that PSR has led to fewer problems.

To make sense of this gap in information, ProPublica reviewed court and regulatory records of thousands of incidents involving trains of all lengths, as well as technical and investigative notes in federal files from nearly two decades of long-train incidents. We conducted more than 200 interviews, including candid conversations with rail personnel who described how companies have sidestepped best practices when building and running long trains. Then we went to Hyndman to learn what happens to a community in the aftermath of a preventable catastrophe, uncovering damage that cannot be repaired, even with millions in rail company checks.

An aerial view of the Hyndman crash (CSX Train Derailment with Hazardous Materials Release via National Transportation Safety Board)

That summer morning, the sky was burning red when Shaffer, a thin, stoic man of 50, surveyed his neighborhood. Mounds of what looked like grain had spilled from the train cars and molten sulfur, like lava, crawled across the grass. He spotted his wife standing on a neighbor’s porch, but before he could process the relief, he saw another neighbor, Kristina Sutphin, screaming from a second-story window. “Help me!” she yelled. “I can’t get out!”

Sutphin, 27, had thought it was an earthquake when her house started shaking, and she’d rolled on top of her 2-year-old daughter, Mia, to protect her. When it stopped, she hit the lights and found drywall dust everywhere. Her house, too, had been struck by a train car, knocking a wall panel studded with nails over the stairs, trapping her and her daughter as the fire outside grew.

Shaffer ran for a ladder, but the train car had demolished one side of his home, including the bedroom where, on any other night, he and his wife would have been sleeping and where his German shepherd, Diamond, had her kennel. He couldn’t see Diamond, and he wouldn’t learn until a few days later that she had been crushed to death.

By the time he got to Sutphin, her brother had run across the street and a neighbor had arrived with a ladder. Her brother climbed up and carried Mia down as Sutphin followed behind. Volunteer firefighters, fear on their faces, raced door to door, urging people to evacuate.

Kristina Sutphin and her daughter, Mia (Jamie Kelter Davis for ProPublica)

For longtime residents, it felt like another dark chapter: In 1949, a Christmas tree fire burned through dozens of businesses and homes; a flood in 1984 lapped at door frames and swamped basements; and in 1996, another flood submerged window sills in brown, swirling water.

But this disaster, thought Bobby Walls, Hyndman’s 36-year-old emergency manager, was something else. He’d grown up in Hyndman, starting a family in the green, peaceful valley. Now a flaming geyser towered over the rooftops, and Walls wondered: Was anyone dead? As he ran toward the blaze in his firefighting gear, Walls didn’t know that the tanker car at its center contained propane — enough that if it erupted and set off the six others around it, the explosion could engulf the entire town of some 900 people.

The tanker car still howled about seven hours later as Walls and a number of first responders waited in a cinderblock-walled classroom for word from a train company crew that was monitoring the fire. Then, the door flung open. The room quieted as a CSX worker hustled to the whiteboard and began to write.

The tanker car is rapidly failing.

An explosion is imminent.

We need to evacuate now.

Footage from the Hyndman derailment (Associated Press via YouTube)

For generations, railroad workers considered a 1.4-mile-long train huge.

Then Hunter Harrison came along.

Harrison was a railroading innovator with only a high school education, hired as a car oiler in a Memphis yard in 1963. By the 1980s, he had moved into the top management of Illinois Central, a carrier he viewed as bloated and fatally unprofitable. It was an era when most railroads, including his, had an operating ratio in the 90s, meaning that the company had to spend about 90 cents to make a dollar and was netting less than a dime, or 10%, in profit.

Harrison, a self-described “stern, disciplinarian taskmaster,” was obsessed with efficiency. At a time when other executives feared computers, he used them to track every boxcar and locomotive and learned which ones sat idle. “Railroads,” he once said, according to the biography “Railroader,” “only make money when cars are moving. ... So why would we lay down tracks just to have cars sit idle?”

When he became CEO in 1993, Harrison looked for even the smallest ways to cut costs, from tearing up unused tracks to eliminating document storage and overnight stays for train crews. By 1998, he had managed to drop the operating ratio to 62.3, a significant jump in profitability. But the savings were never enough. He flew around in a corporate jet with a tail number that read OR59, his aspirational operating ratio.

In the years that followed, Harrison made his mark as a senior leader at Canadian National after it acquired Illinois Central; he sold off 35% of its locomotive fleet and focused on moving cars in and out of yards at breakneck speeds. To do this, the employees had to work harder, and so did the trains. “I’m impatient,” he once told Progressive Railroading. “I’m also demanding. But I’m asking people to stretch.” By then, he was CEO.

Longer trains would become integral to the management philosophy he dubbed precision scheduled railroading. The rail industry makes its money by the weight and distance of the freight it hauls. A long train makes in one trip what a short train would make in two or three or four, and with fewer employees. There was no need to design a new breed of super trains; these behemoths could be built from more of the same components: more cars with engines spliced into midsections to help move, and stop, more weight.

By 2013, Harrison was CEO of Canadian Pacific when he wrote in its annual report: “We’re driving longer and longer trains, which means fewer train starts, faster network velocity and better service at lower cost.”

Hunter Harrison in 2015 (Chris Goodney/Bloomberg via Getty Images)

America’s largest railroads took note. They began making their trains longer and their staffing margins smaller; in 2015, companies started laying off what would become a fifth of the workforce at the largest railroads. That year, CSX bragged to its investors about its “train length initiative” and how longer trains helped to reduce staff needs. Harrison left Canadian Pacific to run CSX in 2017; that year, the company reported $249 million in “efficiency savings.” CSX told ProPublica that it “impugns the assertion that its management philosophy promotes dangerous practices.”

Harrison died nine months after taking over CSX, but he’d already secured his legacy. Many of the biggest railroad companies operating in the U.S. had adopted precision scheduled railroading. They were running long trains. The Association of American Railroads told ProPublica the industry has been safely running long trains for more than 80 years. It says they are more fuel efficient and allow companies to run fewer trains, which means fewer chances of collisions at railroad crossings.

In April 2017, the Federal Railroad Administration got a letter from the nation’s largest railroad union, SMART. Workers had been seeing troubling patterns related to these long trains, wrote John Risch, the union’s national legislative director at the time. “While I am fully aware that there are no federal regulations limiting the size of trains, running these monster trains [is] inherently unsafe and FRA has broad authority to investigate the practice and put an end to it.”

By the time Risch sent his note, the agency was well aware that the growing length of trains was creating unique issues. ProPublica’s review of more than 600 investigative reports on train accidents over almost two decades found that the FRA had known of problems for years.

The reports revealed that some long trains were too big to fit into sidings off of main tracks that were often built to accommodate trains no longer than 1.4 miles, and passing trains were crashing into their rear ends. It happened in September 2005 when a 1.5-mile-long BNSF train tried to fit into a siding in Missouri that was 1.4 miles long. The same thing happened the following year in Utah to a 1.5-mile-long Union Pacific train.

An October 2017 derailment in Atlanta (John Spink/Atlanta Journal-Constitution via AP)

The hulking trains could generate forces powerful enough to break the heavy-duty materials their cars were made of. In March 2008, the rear end of a 1.5-mile-long BNSF train ran forward as the front of the train decelerated, sandwiching the train and cracking an old repair on a tanker car. The train broke in two in Minnesota, dumping 20,000 gallons of ethylene glycol, commonly used in antifreeze, into a tributary of the Mississippi River.

And long trains that were assembled with too much weight in the rear and too little up front were hurtling out of control and jumping off of tracks. It happened in Virginia in 2006, in Wisconsin in 2015 and in Iowa in May 2017. Short trains can derail in the same way, but experts say longer trains can cause more damage when they fling dozens of cars and their contents through neighborhoods.

The companies involved in these accidents did not comment on them specifically, but Union Pacific and Norfolk Southern, in separate statements, said they spend more than $1 billion annually maintaining and improving infrastructure for safety and work closely with regulators. See what they said about their broader safety practices here. BNSF did not reply to a request for comment.

On July 31, 2017, CSX assembled Train Q38831 in a rail yard in Chicago, destined for a city outside of Hyndman. It had five locomotives at the front and 136 cars trailing behind, about half hauling hazardous material: propane, isobutane, ethyl alcohol, phosphoric acid and molten sulfur heated to 235 degrees Fahrenheit. It was a bomb train, as some workers refer to them, given its combustible cargo. When it left the yard and traveled east, the train grew. In Lordstown, Ohio, workers added 28 cars. In New Castle, Pennsylvania, they added 14. Now the train was 2 miles long.

Engineer Donald Sager, who boarded the train on the night of Aug. 1 in Connellsville, Pennsylvania, about 50 miles west of Hyndman, was uncomfortable with it. It was, he later told federal investigators, “big and heavy and ugly.” It had 38 empty cars near the front with almost all the train’s tonnage behind them, so the empty cars would be lurching around as all that weight bore down on them. He said the train would be bucking.

Sager took the train with his conductor, James Beitzel, from the Connellsville yard at 8:28 p.m. under a clouded sky and began climbing the backside of the mountain outside Hyndman. The climb was steep and the train needed a push from an extra locomotive, which coupled onto the rear. The locomotive broke off when the bulk of the train crested the mountain, passing a sign that read: “Summit of Alleghenies, Altitude 2258.”

The long, winding descent into Hyndman is one of the steepest in all of CSX territory, and the train weighed 18,252 tons, heavier than 200 fueled and loaded Boeing 737s. An engineer on a train like that has to closely watch the speed. It’s best to operate the brakes proactively, but as the train started down the mountain, Sager’s instruments were telling him the air brakes were beginning to fail. He stopped the train at 11:36 p.m. and radioed dispatchers.

“Got a problem with the train.”

Beitzel climbed down from the engine with his light and began walking in the gravel along the tracks. He had to manually set the brakes on 30% of the cars to be sure the train didn’t start moving on its own. Per company rules, he applied them on 58 cars near the front, cranking around and around a big steel wheel at the end of each car. Then Beitzel walked nearly 2 miles to the rear, where he found the problem at Car 159. A brake line had cracked and air was hissing out. That type of malfunction typically affects the brakes on all of the cars, like a chain reaction.

About two and a half hours later, when he finally got back, his shift had ended and Sager was briefing a new crew. Mechanics replaced the brake line while Ron Main, the new engineer, and Michael Bobb, the new conductor, waited. It was around 2 a.m. The train wouldn’t budge with the hand brakes on, so Bobb climbed down and walked back, knocking off brakes as he went. He released 25 and left the remaining set because the descent was steep, a practice at odds with accepted rail safety then and now, investigators and railroad workers say. Then finally, at 4:17 a.m., the train began rolling down the valley into Hyndman.

Bobb’s approach created a dangerous problem, investigators would later conclude. The 33 cars with hand brakes left on were toward the head of the train, and 13 of those were empty. There were also 25 other empty cars near the front. This meant the lightest section of the train was doing the bulk of the braking. It also meant that the heaviest section of the train — literally the rest of it — was bearing down on them. Such forces can pop empties or lightly loaded cars off the tracks, as had already happened in at least three long-train derailments investigated by the FRA.

The other part of the problem was in the hand brakes themselves. They play the same role as emergency brakes in an automobile; conductors usually put them on when they need to park a train. Applied and functioning properly, they immobilize a train car’s wheels. But driving a train with the hand brakes set can damage it, and that’s what happened to the Hyndman train. Its speed fluctuated as its locked steel wheels ground along the tracks, beginning to deform and lose purchase.

It’d be easy to blame Bobb or Main for what was about to happen. But they were only following CSX policy when they set the hand brakes on this huge, heavy train and sent it rolling down the long, steep hill. A safe and proper move would have been to break the train into two at the top of the hill and drive each section down separately, said Grady Cothen, a former FRA attorney who has written a widely cited white paper on the challenges of operating longer trains. But it would have taken more time, and the train was already delayed. CSX at the time was the only one of the seven largest train companies to allow the use of hand brakes to control the speed of a train down a hill.

It would also be easy to blame the crew in New Castle that had added eight empty and six loaded cars to the head of the train, making it longer and less stable. Or the crew before it in Lordstown that added 28 cars, all empty, to the head of the train. But these crews, too, were following a CSX policy, which dictated they could ignore a more sensible policy — don’t put so many loaded cars behind empties — if they were pressed for time. It was a risky edict considering crews are always pressed for time in the age of precision scheduled railroading.

That August morning, the train hit a speed of 29 miles an hour as it reached the bottom of the hill, passing the house where Shaffer slept on his living room couch. Main and Bobb felt a lunge in the cab. The train’s emergency brakes kicked in and it screeched to a stop.

“Hey, Alex,” Main called to the dispatcher. “We just went into emergency. ... I’m not sure what’s going on back there, but the conductor’s getting ready to get on the ground.” (Main, Bobb and Sager could not be reached, and Beitzel declined to comment. Their remarks are from transcripts in the federal investigation of the accident.)

Bobb climbed down from the cab and began walking toward the problem. Suddenly, there was an explosion and a fireball rose into the night about a half-mile back from the engines. Main, up in his locomotive, hadn’t noticed. He didn’t learn about it until a man drove up to his window and yelled the news into the cab.

Federal investigators would later learn that Car 35 — empty, hand brakes set — had jumped the tracks on a curve, and two cars ahead of it and 30 behind it had followed.

Early on the morning of Aug. 2, 2017, CSX Train Q38831 was traveling east toward Hyndman, Pennsylvania.

The train was 2 miles long and weighed over 18,000 tons.

It was loaded with innocuous cargo like paper and corn syrup as well as hazardous materials such as propane and molten sulfur.

Ninety percent of the train’s weight was behind the leading 42 cars.

Because of a previous brake failure, 33 cars had their hand brakes on as the train rolled downhill toward Hyndman.

With its wheels locked and over 16,000 tons of weight trailing it on a downhill, the 35th car was the first to derail west of Hyndman.

Thirty-two more cars derailed as the train entered Hyndman on a 1.7% downslope while rounding a curve.

The derailment caused massive destruction, and three of the loaded cars released hazardous material.

After the derailment, the National Transportation Safety Board recommended in a letter that CSX prohibit using hand brakes on empty cars to control a train’s speed down a hill. It also recommended that large blocks of empty cars be placed near the end, not the front. “We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations.”

But CSX responded more than two years later and only after ProPublica began asking recently why it had ignored the NTSB. In its response letter, CSX says the agency was wrong; the train’s makeup did not contribute to the crash. However it still reformed the policy, requiring, among other things, placing more weight near front of the train and prohibiting trains from “having more than a third of its weight in the trailing fourth of the train.” It also adopted the NTSB’s other recommendation on hand brakes, prohibiting their use on empty cars in “mountain grade territory,” a company spokesperson told ProPublica. It said the derailment was caused by “hand brakes on empty rail cars to control train speed on steep grade ... not PSR.”

By that afternoon, emergency manager Walls and the other first responders had evacuated everyone who would agree to leave Hyndman. The tanker burned for two days and yet did not explode. Though it came close: The pressure inside the car caused the steel wall of its inner hull to stretch as thin as a credit card. They’d come 1 millimeter, Walls said, from disaster.

Bobby Walls (Jamie Kelter Davis for ProPublica)

The U.S. House Transportation and Infrastructure Committee took note of the derailment and asked the Government Accountability Office to study the safety and impacts of long trains. The committee’s two ranking members hadn’t even signed the letter before CSX derailed another long train in Georgia, just two months after Hyndman.

It was 2.4 miles long, and like the Hyndman train, a bulk of its tonnage had been loaded in the rear. When the engineer began to brake, the back of the train slid forward and shoved a car ahead of it off the tracks on a curve, and 13 other cars followed. One car crashed into a home and the person inside was rushed to a hospital. The man survived. CSX did not comment on this accident but did tell ProPublica the company is committed to operating safely and is constantly evaluating its rules, specifically on train handling. See what else it said about its safety practices here.

The 2017 derailment in Atlanta that sent a person to the hospital (John Spink/Atlanta Journal-Constitution via AP)

It was only after all of this happened that the FRA, in March 2018, replied to the union officials who had expressed concerns that previous spring. In a letter, the agency said it “began looking at the length of trains as a potential contributing cause of FRA reportable accidents/incidents” in 2016. The agency still did not have “the sufficient data or evidence to justify an Emergency Order limiting the length of trains.”

In May 2019, the GAO completed its study, coming to a similar conclusion: long trains may be dangerous, but more information was needed. Its effort was partly stymied, the GAO said, because most rail companies refused to hand over enough of their private train-length data to allow investigators to make findings. The FRA also told ProPublica it has asked companies for this data but never gotten it.

On Thursday, the FRA told ProPublica it is starting the process of requiring companies to disclose the train length for every reportable accident, a move prompted by the Infrastructure Investment and Jobs Act. But there is no guarantee the regulators will succeed. The FRA said it first needs to publish a notice of the new data-collection effort and ultimately the Office of Management and Budget would need to approve the measure.

Had the FRA issued an emergency order as the union requested in 2017, a rare and extreme step, the railroads would have likely gotten a judge to block it, said Cothen, author of the white paper on longer trains. He acknowledged that most of the long trains in the country arrive at their destinations without incident, but he feels the railroads are operating with an unreasonable degree of risk. He believes the FRA has the evidence it needs to start crafting a rule to limit train lengths, a process that would include input from the industry. “My issue to this point,” Cothen said, “has been that effective action has not been taken.” The FRA says it disagrees.

Across the country, worried state lawmakers have tried to cap the lengths of trains that roll through their communities. Since 2019, in Arkansas, Iowa, Kansas, Georgia, Nebraska, Washington, Arizona and other states, lawmakers have proposed maximum lengths of 1.4 to about 1.6 miles. But every proposal has died before becoming law. Opponents, which include Class 1 railroad companies, claim that the efforts are driven by unions to create jobs and that the proposals would violate interstate commerce laws.

Georgia state Sen. Rick Williams, a Republican, attempted to work around this angst by offering a simple resolution last year that would have urged the FRA to limit train length. Even that died. “It’s frustrating,” he said, “when you see something that happens, like in East Palestine, Ohio, and you know it very easily could happen here and we could suffer the same consequences.”

Democratic Arizona state Rep. Consuelo Hernandez’s bill to limit train length was approved by two committees this session with bipartisan support. But Republicans refuse to put the bill on the floor for a general vote, and so it has stalled. ProPublica spoke with her the day after a 1.9-mile-long BNSF train derailed there. “The train companies are so powerful,” Hernandez said. “What it comes down to is public safety versus corporations.”

Many states have passed laws that would punish railroads for blocking road crossings, but that power, state courts rule every time, rests solely with the federal government.

At any moment, Congress could intervene and limit the length of trains. If it did, independent experts say, there’d be more trains, moving faster with fewer breakdowns and derailments, and customer service would improve. But the rail companies, which move 40% of the country’s cargo, have a lot of leverage. For more than a century, the industry has convinced lawmakers that the success of America is tied to the success of the rails; it’s a view that persists today, sustained by the $10 million the Association of American Railroads spends some years lobbying Congress.

So long trains have continued jumping the tracks.

In June 2019, one month after the inconclusive GAO study, a 2.2-mile-long Union Pacific train derailed in Nevada. It was so long and the terrain so mountainous that at times sections of the train climbed uphill while other sections climbed downhill, which made driving it a nightmare. Ultimately the engineer couldn’t manage it, and the train lifted a car up and dropped it on the ground. Twenty-seven cars followed.

In July, a 2.5-mile-long Union Pacific train derailed for the same reasons elsewhere in Nevada.

In August, a 1.6-mile-long Union Pacific train going 48 miles an hour derailed in Texas. The company ran computer simulations after the crash and concluded it never should have been operating the long train at that speed at that spot on the tracks.

In September, Union Pacific crashed yet another long train. It was 1.5 miles long and broke in two in Illinois. Half of the train rolled out of control away from the other half. It then slowed, stopped and began rolling back. The two halves collided and exploded. The fire spread underground through a storm drain and ignited a holding pond at a chemical plant. More than 1,000 residents and at least 1,000 schoolchildren were evacuated.

And then in October, in separate instances, Norfolk Southern derailed two long trains, both in Georgia. One was 2 miles long. The engineer had struggled to control it, and his use of the brakes caused the rear of the train to run into the front and lift a car off the tracks. The other train was 1.6 miles long. Its autopilot had the brakes applied in the front and the engine in the middle giving it gas, and as it reached the bottom of a hill the opposing forces popped 32 cars off the tracks. They ruptured a pipeline, which released nearly 2.3 million gallons of natural gas.

The following summer, in June 2020, a 2.3-mile-long Union Pacific train derailed in Idaho because it was too big, the FRA determined. It was constructed unevenly with 34 empty cars coupled near the front and loaded, heavy cars behind them. The heavy cars pushed the light cars off the tracks. The FRA also determined the engineer lacked the training necessary to operate a train of that length.

In July 2020, a 2-mile-long BNSF train derailed in Arizona for similar reasons: a long block of heavy cars coupled behind a set of empty cars squeezed them off the tracks.

The companies involved in these accidents did not comment on them specifically. See what they said about their safety practices here. BNSF did not comment at all.

First image: A 1.5-mile-long train that broke in two in Illinois. Second Image: A 2.2-mile-long train that derailed in Nevada. (First image: Derik Holtmann/Belleville News-Democrat via AP. Second image: Nevada Department of Public Safety via AP.)

Finally, in September 2020, the FRA launched a study examining the brake systems in long trains. The agency did not say why it took three years after the Hyndman derailment and the warnings from the union to begin examining the issue. It plans to complete the study this year. Also, late last year, it completed a small survey of rail workers, labor unions and railroad managers. Managers claimed long trains pose no new dangers, but government employees and labor unions said they are concerned.

The National Academies of Sciences, doing a separate assessment of trains longer than 1.4 miles at the request of Congress, must report its findings by June 2024.

Three days after the evacuation of Hyndman, Walls and his family returned home. They’d been gone only 72 hours, but it felt like a reunion with neighbors they hadn’t seen in years. He mowed his grass. It felt good doing something so pedestrian.

But Shaffer and his wife never returned to their doublewide trailer. It wasn’t safe, Shaffer recalls being told by CSX. “Pretty much had to fight with them to get my guns and stuff out of there,” he said. The company paid out a settlement the couple used to buy a big house with a big porch 7 miles out of town, far away from the railroad tracks. But even years later, the derailment haunts him, whether he is waiting uneasily in his truck at a railroad crossing or watching the news. When the East Palestine disaster appears on his TV, he has to get up and walk away. “It’s definitely still with me,” he said.

Sutphin and Mia bounced from her aunt’s house out of town to a hotel with her stepdad then to a house on Myrtle Beach, an upscale vacation town on the coast of South Carolina, and stayed there for a year. Every time an airplane flew over the house, Sutphin shook and ran to the window, afraid that something was about to crash into them. Mia rarely slept through the night. Sutphin financed their long vacation with a $50,000 check from CSX. The railroad also bought her a brand new Hyundai Santa Fe valued at $32,000.

Sutphin and Mia play on a swing set in Sutphin’s grandmother’s yard in Hyndman. (Jamie Kelter Davis for ProPublica)

After it nearly razed the town, CSX handed out a lot of money. It bought residents clothing, medicine, food, gas and hotel rooms. It reimbursed businesses for lost revenue. It paid volunteer firefighters every day about $1,000. It gave residents so-called inconvenience fee payments of about $300 a day. It gave one family $10,000 for veterinarian bills and damage to its property. It gave the fire department $190,000. A church pastor said residents welcomed the payments, but he also said they felt like “hush money,” and that’s the effect the money appears to have had on some residents. When ProPublica asked about the derailment, many said that the railroad did “all right by” them. Cleaning up and rebuilding the town and the tracks, according to the FRA, cost $9.6 million. CSX defended the money it spent around town, saying it did not ask the residents to release their legal rights in exchange for the payments. “Such actions,” a spokesperson told ProPublica, “are part of CSX’s industry-leading standard of care when incidents like the derailment in Hyndman occur.”

Walls remembers a CSX official walking up to him while he was standing on the front steps of the charter school on the morning of the derailment, a gray column of smoke from the tanker car still billowing into the sky. “I know we came in and messed your town up,” the official said, “but we’ll make it right before we leave.” Walls appreciates the money CSX spent on the town and its people. But that was the railroad’s responsibility. What would make things right, he said, is “making sure that the trains coming through here are safe.”

Hyndman (Jamie Kelter Davis for ProPublica)

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Correction

April 3, 2023: This story originally misstated the brand of Kristina Sutphin’s car. It is a Hyundai Santa Fe, not a Honda.

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by Emily Hopkins and Jeremy Kohler

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week. This story was co-published with Minnesota Public Radio and KARE-TV.

Amy Morris started working at Hilltop Health Care Center in Watkins, Minnesota, in June 2021 with a clean nursing license that belied her looming troubles.

Morris, a licensed practical nurse, had been fired from a nearby nursing home seven months earlier for stealing narcotics from elderly residents. The state of Minnesota’s health department investigated and found that the accusation was substantiated, and then notified the Board of Nursing, the state agency responsible for licensing and monitoring nurses.

But even though state law requires the board to immediately suspend a nurse who presents an imminent risk of harm, it allowed Morris to keep practicing.

In September 2021, supervisors at Hilltop discovered that pain pills were disappearing during Morris’ shifts and called the sheriff. Only then did Hilltop learn of allegations of narcotic theft that had been made nearly a year earlier at the other nursing home.

“I thought, ‘How is she practicing now?’” Meeker County Sheriff Brian Cruze recalled.

In an excerpt from an October 2021 Minnesota Department of Health report, a manager for Hilltop Health Care Center said the facility didn’t know about a previous incident in which nurse Amy Morris was found to be involved in drug “diversion,” or theft. (Screenshot by ProPublica)

The answer, ProPublica found, is that the nursing board’s investigations frequently drag on for months or even years. As a result, nurses are sometimes allowed to keep practicing despite allegations of serious misconduct.

It wasn’t supposed to be this way. In the face of intense criticism eight years ago, the nursing board announced changes to improve its performance. But that progress was short-lived, ProPublica found.

Since 2018, the average time taken to resolve a complaint has more than doubled to 11 months, while hundreds of complaints have been left open for more than a year; state law generally requires complaints to be resolved in a year. Some nurses, like Morris, have gone on to jeopardize the health of more patients as the board failed to act on earlier complaints.

Some of the board’s problems stem from vexingly bureaucratic issues, ProPublica found. For example, the board had started meeting every month to resolve cases more quickly. But, for the past few years, it has gone back to meeting every other month.

Some complaints get caught in a general email inbox, where they sometimes sit for weeks or months before being forwarded to staff for investigation, according to current and former staffers.

And the board, which oversees licensing and discipline for more than 150,000 nurses, has been perennially shorthanded. By state law, the board is supposed to have 12 nurses and four members of the public. But at times, it has operated with barely enough members to make up a quorum. In March, Gov. Tim Walz made five appointments to the board, leaving one vacancy.

Other problems stem from the board’s professional staff, who investigate complaints and prepare the materials the board uses to make disciplinary decisions. Several former employees told ProPublica that the lag time in resolving discipline cases could be attributed to a dysfunctional office environment and a wave of resignations, many of them since the board’s August 2021 selection of veteran staffer Kimberly Miller as executive director.

David Jiang, who resigned from the board in August because he moved out of the state, told Walz in a letter that the board’s problems “arise because of a general lack of confidence from the staff, lack of communications to the board, and, most importantly, a general lack of oversight by the Board.”

Walz’s office did not respond to ProPublica’s requests for comment about Jiang’s concerns.

David Jiang resigned from the Minnesota Board of Nursing in August, telling Gov. Tim Walz in a letter that mismanagement by Executive Director Kimberly Miller had contributed to dysfunction at the agency. (Highlights added by ProPublica)

William Hager, a former legal analyst for the board, vented his frustrations about Miller’s leadership in an email to another employee in February 2022. “I am very concerned the Director seems to have been unaware of this ‘backlog,’” Hager, who left the board a few months later, said in the email. Miller “has chosen to not learn how to work” the case management system “or engage with software and staff to oversee our work.”

Miller, who worked for the board for more than two decades before becoming executive director, acknowledged the case backlog in an interview but said she was working to “right the boat,” including by hiring a consultant to improve board performance. Although the number of pending complaints is higher now than it was after a critical 2015 state audit, the backlog has been reduced by about a quarter since peaking last summer, according to state data.

“I think that we are on a good course at this point, and we’re making the changes that we need to, and learning to work as a team, and working out our system that I think is going to be really wonderful at some point,” Miller said in an interview. She did not respond to questions about criticism of her job performance.

Miller blamed the backlog on the transition to remote work during the height of the pandemic and on a new case management system that she said board members found difficult to use. She said some cases simply take longer than others. When a nurse won’t agree to discipline as part of a settlement, she said, the board must file the case in the state’s administrative court, where Miller said scheduling a hearing can take “at least a year.”

But a spokesperson for the administrative court said that the court was not the source of delays, and nurse discipline cases are concluded on average in four months from the time they are filed.

The state’s own data, in part, counters Miller’s assertions of progress. The board closed more complaints in fiscal years 2020 and 2021, respectively, than it did in 2022, when vaccines were widely available and many industries were returning to in-person work.

It was not clear why the board did not move quickly to suspend Morris after the substantiated report of pill theft. Miller declined to discuss individual discipline cases, citing confidentiality rules.

ProPublica contacted 10 current and seven former members of the board. None responded to requests for comment.

The nursing board finally issued a temporary suspension of Morris’ license in November 2021 — a month after prosecutors filed charges in the Hilltop case. She is facing felony theft charges for both incidents and has failed to show up in court. She has not entered a plea because she has not appeared to face the charges, and authorities have issued warrants for her arrest.

She did not return messages left on her cellphone and sent by email.

Administrators for both facilities declined to comment. Records show that one Hilltop manager was frustrated by a lack of warning about Morris. The manager complained to a state inspector that there was “nothing flagged on the background study or license verification,” according to the facility’s inspection report.

“This is not a facility system problem but a state system problem,” the manager said.

Investigations Drag On

When Christy Iverson started working for the board last year on investigations of nurse misconduct, she was surprised by the backlog of cases. Some she took on were around five years old. It was embarrassing, she said, to put her name on cases that had been on hold for so long.

Then, about four months into her tenure, she said, she was instructed to help the licensing staff with an influx of applications ahead of an anticipated nursing strike at several hospitals in the Twin Cities and Duluth areas. Iverson, who had spent over a decade working in leadership positions at an area hospital, said she largely spent her days folding letters and sorting paperwork. So she quit.

The problems she observed weren’t new. A Minneapolis Star Tribune investigation in 2013 had sparked the state audit that found serious delays at the board and led to improvements for a time.

With auditors scrutinizing it in 2014, the board began to dispose of complaints more quickly. The average age of closed cases was reduced from six months to four. But delays then climbed, eventually reaching the current average of 11 months, according to state data.

And despite a state mandate to resolve complaints within a year, the percentage of cases that go beyond that mark has soared from less than 5% in 2016 to 30% now, the state data shows.

Miller said the board is mindful of the backlog and puts a priority on “all of our more egregious cases.”

Minnesota’s Nursing Board Resolved Complaints Faster After a 2015 State Audit, But Progress Has Reversed Note: Years are the board’s fiscal year, which runs from July to June, and the chart shows complaints according to the fiscal year in which they were closed. The 2023 value is the average as of March 2023. (Source: Minnesota Board of Nursing)

An internal email provided to ProPublica described how complaints can sit for weeks or even months simply because they weren’t forwarded in a timely manner. Those delays, the employee wrote, were “unprofessional” and “inefficient.”

For example, a complaint about a nurse stealing medication sat in the main inbox for more than two months before it was forwarded to the discipline staff, according to that internal email. It was the fourth complaint the board had received about that nurse. The employee’s email describing these delays was sent to several other employees and the board’s executive director in December. Miller did not answer ProPublica’s questions about the employee’s allegations.

Some delays begin in the earliest stages of processing a complaint, according to former employees and lawyers who represent nurses in front of the board. Eric Ray, a former discipline program assistant from January 2020 until fall of 2021, said in an interview that the board didn’t always meet statutory requirements to notify nurses of a complaint within 60 days of receiving it. Ray said he saw complaints “sitting for months or a year” before the board sent a notice to the nurse.

Miller said the board “did take seriously the 60-day issue” and recently made changes to the management software so that it would remind caseworkers that a letter needed to be sent out.

The notification delays can also hurt a nurse’s ability to mount a defense, according to lawyers who defend nurses in front of the board. As complaints age, they become more difficult to investigate, evidence becomes harder to locate, nurses move on to other jobs and witnesses forget key details.

“This is your professional career on the line,” said attorney Marit Sivertson. “It makes it incredibly difficult for someone to be able to fairly defend themselves.”

The state law that requires the board to resolve complaints within a year also gives the board sweeping discretion to take longer if it determines the case can’t be resolved in that time. Still, Sivertson said that does not explain why so many cases take more than a year to resolve. She and eight other lawyers have met several times to raise these issues with Miller and assistant attorney general Hans Anderson, legal counsel to the board. In October, they presented their concerns at a board meeting. They said they are still waiting for a response.

Del Shea Perry is also still waiting. It’s been nearly five years since the death of her son, Hardel Sherrell, in the Beltrami County Jail in northern Minnesota. The incident sparked public outrage and led to reforms and consequences for some of the officials connected to his care. Sherrell died on the floor of his cell after guards and medical staff refused his pleas for help. A pathologist hired by Perry as part of a wrongful death lawsuit later ruled that he died of Guillain-Barré syndrome, a treatable neurological disorder.

Del Shea Perry, mother of Hardel Sherrell, who died in jail in 2018, founded Be Their Voices, an organization that advocates for incarcerated people and their families. (Caroline Yang, special to ProPublica)

State legislators passed a law named after Sherrell that aims to improve access to health care for jail inmates. Todd Leonard, the jail doctor who monitored Sherell’s condition via telephone, had his medical license indefinitely suspended in early 2022. And this month, Beltrami County and Leonard’s company agreed to settle Perry’s lawsuit by paying Sherrell’s family $2.6 million.

But there have been no consequences for Michelle Skroch, a nurse who worked for Leonard and was directly in charge of Sherrell’s care in the last two days of his life. According to a state administrative judge who ruled in the doctor’s licensing case, Skroch failed to provide care to Sherrell or even check his vital signs as he lay nearly lifeless on the floor of his cell wearing adult diapers soaked in his own urine.

An emergency room doctor had released Sherrell to the jail with instructions to bring him back if his symptoms worsened. Instead, Skroch instructed jail staff not to assist him because she said there was nothing medically wrong with him, according to the judge’s report.

The judge wrote that it could appear from Skroch’s notes that she had “provided some type of care or assessment” of Sherrell. “She, in fact, did not,” the judge wrote.

Video later showed she had only briefly peered into his cell twice and had missed that he was in distress: Sherrell was unconscious on the floor with a white substance coming out of his mouth.

In response to Perry’s lawsuit, Skroch testified that she was able to sufficiently assess Sherrell’s condition without touching him and that she believed his condition was improving. She also noted that emergency room doctors had diagnosed him with weakness and “malingering,” a medical term for faking illness.

In ruling that the medical board had cause to discipline Leonard, the judge also called for the nursing board to investigate Skroch’s “dereliction of duty and shocking indifference.” Noting that the doctor was both Skroch’s supervisor and her romantic partner, the judge wrote it appeared “she was unconcerned about being held accountable by the attending physician.”

Five years later, Skroch still has an unblemished license and her online professional profile identifies her as the nursing director of Leonard’s medical firm. She declined to comment.

Another nurse who provided care to Sherrell at the jail filed an official complaint about Skroch with the nursing board. But she said that after an interview with a board representative about a year after the death, she has not heard an update. The board is required to provide updates every 120 days on the status of a case.

“I have no idea what the board is doing, and it sure as hell shouldn’t take 4 years to investigate,” Perry wrote in a text message.

“A Clear Message”

When a nurse is accused of misconduct, the board can seek discipline ranging from a reprimand, which is essentially a public slap on the wrist, to a license revocation, which means the nurse can no longer work in the field. Typically, the board allows a nurse to continue working while it tries to reach an agreement or takes the complaint to the state’s administrative court.

(Matt Huynh, special to ProPublica)

But in cases when the nurse poses an immediate risk to patients, the board can use its power to issue a temporary suspension and remove the nurse from practice while it investigates.

The board rarely used that power until the state legislature changed the law in 2014. Under the revised rules, the board wasn’t just authorized to use the emergency suspension — it was required to do so in cases where there was “imminent risk of serious harm.”

As a result, the board ramped up its use of temporary suspensions, issuing 55 of them from 2014 to 2017, more than twice as many as it had in the preceding four years, according to data reported to a national database of actions taken against medical professionals.

In 2018, this increase was touted by Daphne Ponds, then a board employee. Speaking at a national seminar on nurse regulation, Ponds, who helped investigate complaints against nurses, told her peers that the Star Tribune’s stories had “made us look bad, made us look ineffective.”

She added, “The legislature had really sent the board a clear message that you have this tool of temporary suspension — you need to use it.”

But about that time, the board had reverted to its pre-audit practices. In 2018, it issued only three temporary suspensions, according to a national discipline database. And it issued only 11 over the next three years.

Miller said the board is now inclined to protect the public by pursuing a voluntary agreement to stop practicing with nurses who’ve been the subject of a complaint. She said this is because there are “more hoops” to jump through to issue a temporary suspension, while the voluntary agreements can be drafted and signed by the nurse in days.

Asked how she reconciles this with a state law requiring a temporary suspension when there is an imminent risk of serious harm, Miller said Minnesota’s attorney general had signed off on the strategy.

Hager, the former legal analyst for the board, said that while a stipulation to cease practicing may work in some cases, it doesn’t work in all of them, especially when nurses don’t want to cooperate. In one case reviewed by ProPublica, a nurse kept her license for more than a year because she refused to sign a stipulation. The board suspended her only after she was convicted of financial exploitation.

Sometimes, the delays hurt patients. In early 2018, the board received complaints about a nurse named La Vang that accused him of stealing narcotics from patients — including one allegation that was validated by the state health department.

But the board didn’t issue a temporary suspension, and Vang got a new job later that year. He stole pain medicines from another patient, LaVonne Borsheim, according to a lawsuit that Borsheim and her husband brought against Vang and the home care company that employed him.

In that lawsuit, Borsheim described pain so severe that she didn’t want to go on living. (Attempts to reach Vang for comment were unsuccessful.)

By the time the nursing board got Vang to sign an agreement to cease practicing in August 2018, the police had already arrested him on charges that he had stolen Borsheim’s drugs. Vang pleaded guilty in federal court to obtaining controlled substances by fraud. At his sentencing, Vang’s attorney said he was in treatment for drug addiction and was embarrassed that he had violated Borsheim's trust. He was sentenced to 18 months in prison.

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