Final Report Lists Many Contributing Factors in Lac-Megantic Derailment
The Transportation Safety Board of Canada's report lists 18 contributing factors involved in the July 6, 2013, accident that killed 47 people and destroyed 40 buildings in Lac-Mégantic, Quebec.
The Transportation Safety Board of Canada released investigation report R13D0054, its final report on the July 2013 derailment in Lac-Mégantic, Quebec of a train transporting crude oil, on Aug. 19. The Montreal, Maine & Atlantic Railway train had been parked by its engineer on a section of main track on a descending grade. Firefighters were called to extinguish a fire in the locomotive after the engineer had departed. The firefighters turned off the locomotive, following U.S. railroad policy, which caused air holding the independent brakes to leak off. The train rolled downhill, traveled about 7 miles, and derailed in the center of Lac-Mégantic at 65 mph, with 63 tank cars derailing and nearly all of them being breached during the derailment. Almost 6 million liters of crude oil spilled and ignited.
The engineer was working alone that day and had regularly parked his trains at this point along the grade. The comprehensive report explains how the Montreal, Maine & Atlantic Railway came to implement single-person train operations. "On the whole," it states, "it could not be concluded whether SPTO contributed to the incorrect securement of the train or to the decision to leave the locomotive running at Nantes despite its abnormal condition. However, it is clear that MMA's implementation of SPTO did not address all critical risks, specifically how a single operator might deal with any abnormal conditions, the risks of single-person securement, or the need for joint compliance. Moreover, [Transport Canada] did not develop an oversight plan to ensure that MMA implemented SPTO in accordance with MMA's risk assessment. Despite being aware of significant operational changes at MMA, TC did not provide adequate regulatory oversight to ensure that the associated risks were addressed."
The report says four "crucial indicators" showed that this railroad did not have a functioning safety management system:
- absence of an internal safety auditing process
- weaknesses in the process for ensuring adequate employee training
- weaknesses in the Operational Tests and Inspections Program that limited its effectiveness in identifying areas of non-compliance
- inconsistently used risk assessment processes
In the report, TSB lists 18 contributing factors involved in the accident and calls for additional physical defenses to prevent runaway trains and more thorough audits of safety management systems to ensure railways are effectively managing safety. "Accidents never come down to a single individual, a single action, or a single factor. You have to look at the whole context," said Wendy Tadros, chair of the TSB. "In our investigation, we found 18 factors played a role in this accident. This investigation and its findings are complex, but our goal is simple: We must improve rail safety in Canada. That's why, in addition to our three previous recommendations, we are issuing two new recommendations to ensure unattended trains will always be secured and Canada's railways will have safety management systems that really work to manage safety. This is about governments, railways, and shippers doing everything in their power to ensure there is never another Lac-Mégantic."
The train had traveled through Milwaukee, Chicago, Detroit, Montreal, and Toronto on its way from New Town, N.D., toward its intended destination of St. John, New Brunswick, before it derailed.
Among the contributing factors cited in the report are an insufficient number of hand brakes applied to secure the train, no proper hand brake effectiveness test was conducted, and despite significant indications of mechanical problems with the lead locomotive, the engineer and the Bangor, Maine, rail traffic controller agreed that no immediate remedial action was necessary, and the locomotive was left running to maintain air pressure on the train.
Since the derailment, Montreal, Maine & Atlantic Railway has ceased, by agreement with the Canadian Transportation Agency, handling crude oil of any type from any location and has eliminated single-person train operations, according to the report.