Question

Explain the industrial disaster of Lac-Megantic rail disaster including background, reasons of disaster, physical, economic and environmental damages caused by the disaster, legal implications to the parties involved, lessons learned from the safety point of view, significant decisions taken/law passed by company/governments after the disaster. Matter of 13-15 slides is required.

Answer 1

The accident

On the evening of July 5, 2013, at about 10:50 p.m., a Montreal, Maine & Atlantic Railway (MMA) train arrived at Nantes, Quebec, carrying 7.7 million litres of petroleum crude oil in 72 Class 111 tank cars. Originating in New Town, North Dakota, these were bound for Saint John, New Brunswick.

In keeping with the railway's practice, after arriving in Nantes, the locomotive engineer (engineer) parked the train on a descending grade on the main track. A replacement engineer was scheduled to continue the trip east in the morning.

The engineer applied hand brakes on all five locomotives and two other cars, and shut down all but the lead locomotive. Railway rules require hand brakes alone be capable of holding a train, and this must be verified by a test. That night, however, the locomotive air brakes were left on during the test, meaning the train was being held by a combination of hand brakes and air brakes. This gave the false impression that the hand brakes alone would hold the train.

The engineer then contacted the rail traffic controller in Farnham, Quebec, to advise that the train was secure. Next, the engineer contacted the rail traffic controller in Bangor, Maine, who controls movements for the crews east of Lac-Mégantic. During this conversation, the engineer indicated that the lead locomotive had experienced mechanical difficulties throughout the trip, and that excessive black and white smoke was coming from its smoke stack. Because they expected the smoke to settle, it was agreed to leave the train as it was and deal with the situation the next morning.

Shortly after the engineer left, the Nantes Fire Department responded to a 911 call reporting a fire on the train. After shutting off the locomotive's fuel supply, the firefighters moved the electrical breakers inside the cab to the off position, in keeping with railway instructions. They then met with an MMA employee, a track foreman who had been dispatched to the scene but who did not have a locomotive operations background.

Once the fire was extinguished, the firefighters and the track foreman discussed the train's condition with the rail traffic controller in Farnham, and departed soon afterward. With all the locomotives shut down, the air compressor no longer supplied air to the air brake system. As air leaked from the brake system, the main air reservoirs were slowly depleted, gradually reducing the effectiveness of the locomotive air brakes. Just before 1 a.m., the air pressure had dropped to a point at which the combination of locomotive air brakes and hand brakes could no longer hold the train, and it began to roll downhill toward Lac-Mégantic, just over seven miles away.

As it moved down the grade, the train picked up speed, reaching a top speed of 65 mph. It derailed near the centre of the town at about 1:15 a.m.

Rail transportation safety investigations and reports

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Rail transportation safety recommendations

As part of its mandate, the TSB makes recommendations to eliminate or reduce safety deficiencies that pose significant risks to the transportation system and warrant the attention of regulators and industry.

Under the Canadian Transportation Accident Investigation and Safety Board Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies. The Act does not require other stakeholders to respond to the TSB's recommendations, but they usually do.

Using the Assessment rating guide, the Board assesses responses to recommendations according to the extent to which the safety deficiency has been or is being addressed. Once recommendations have been assessed as Fully Satisfactory, they are closed. The TSB continually monitors the progress being made on its recommendations.

Aftermath and emergency response

Almost all of the 63 derailed tank cars were damaged, and many had large breaches. About six million litres of petroleum crude oil was quickly released. The fire began almost immediately, and the ensuing blaze and explosions left 47 people dead. Another 2000 people were forced from their homes, and much of the downtown core was destroyed.

The pileup of tank cars, combined with the large volume of burning petroleum crude oil, made the firefighters' job extremely difficult. Despite the challenges of a large emergency, the response was well coordinated, and the fire departments effectively protected the site and ensured public safety after the derailment.

Key issues in the investigation

This investigation looked at many issues to find out what happened, why it happened, and what needs to be done to prevent it from happening again. This section describes some of these key issues.

Braking force

The Canadian Rail Operating Rules required that unattended equipment be left with a "sufficient" number of hand brakes applied to prevent movement, and that the effectiveness of the hand brakes be tested. MMA's rules called for a minimum of nine hand brakes for a 72-car train. These rules also required that a train's air brake system not be depended upon to prevent an undesired movement.

Even more crucial is the requirement to test the effectiveness of the hand brakes. That night, the engineer carried out the hand brake effectiveness test with the locomotive air brakes still applied. As a result, the test did not identify that an insufficient amount of hand brake force had been applied to secure the train.

The TSB concluded that, without the extra force provided by the air brakes, a minimum of 17 and possibly as many as 26 hand brakes would have been needed to secure the train, depending on the amount of force with which they had.

Fire in the locomotive

In October 2012, eight months before this accident, the lead locomotive was sent to MMA's repair shop following an engine failure. Given the significant time and cost of a standard repair, and the pressure to return the locomotive to service, the engine was repaired with an epoxy-like material that lacked the required strength and durability. This material failed in service, leading to engine surges and excessive black and white smoke. Eventually, oil began to accumulate in the body of the turbocharger, where it overheated and caught fire on the night of the accident.

Hand brakes 101

In addition to air brake systems, all locomotives and rail cars are equipped with at least one hand brake. This is a mechanical device that applies brake shoes to the wheels to prevent them from moving.

The effectiveness of hand brakes depends on several factors, including their age, their maintained condition, their application in conjunction with air brakes, and the force exerted by the person applying the hand brake, which can vary widely.

Air brakes 101

Trains have two types of air brakes: automatic brakes and independent brakes.

Automatic air brakes are used to slow or stop the entire train, and are controlled by means of a brake pipe connected to each car and locomotive. Decreases in pressure within this pipe cause air to flow into each car's control valve, which injects stored air into the brake cylinder, applying the brake shoes to the wheels.

By contrast, independent air brakes are available only on locomotives. They are activated by the direct injection of air into their brake cylinders, which then apply the brake shoes to the wheels.

Both independent brakes and automatic brakes are supplied with air from a compressor on each locomotive. When a locomotive is shut off, the compressor no longer supplies the system with air.

When air leaks from the various components, the pressure in the brake cylinders gradually drops, and the amount of force being applied to the locomotive wheels by the independent brakes is reduced. Eventually, if the system is not recharged with air, the brakes will become ineffective and provide no braking force.

When the air brake control valves sense a drop in pressure in the brake pipe, they are designed to activate the brakes on each car. In this accident, however, the rate of leakage was slow and steady—approximately 1 pound per square inch per minute—and so the automatic brakes did not apply.

Class 111 tank cars: Damage and construction

All 72 tanks cars were Class 111, manufactured between 1980 and 2012. Although they met requirements in effect at the time, they were built to an older standard, and they lacked enhancements such as a jacket, a full head shield, and thermal protection.

Almost every car that derailed was breached, some in multiple areas, including shells, heads, top and bottom fittings, and pressure relief devices. The exact location and extent of the damage varied depending on the orientation and speed of the cars during the derailment.

When the tank cars were breached, the petroleum crude oil was released, fuelling the fire. The damage to the tank cars could have been reduced by enhanced safety features. This is why the TSB called for tougher standards for tank cars carrying flammable liquids.

Single-person crews

The TSB looked very carefully at single-person train operations, and at whether having just one crew member played a role in the accident. After looking at the circumstances that night, the investigation was not able to conclude that having another crew member would have prevented the accident.

However, there are some clear lessons for the system. If railways in Canada intend to implement single-person train operations, then they need to examine all the risks and make sure measures are in place to mitigate those risks. Transport Canada, for its part, should consider a process to approve and monitor the railways' plans so as to assure safety.

Transport Canada

For several years, Transport Canada's regional office in Quebec had identified MMA as a company with an elevated level of risk that required more frequent inspections. Although MMA normally took corrective action once problems were identified, it was not uncommon for the same problems to reappear during subsequent inspections. These problems included issues with train securement, training, and track conditions. Transport Canada's regional office in Quebec, however, did not always follow up to ensure that these recurring problems were effectively analyzed and that the underlying conditions were fixed.

In addition, although MMA had developed a safety management system in 2002, Transport Canada's regional office in Quebec did not audit it until 2010—even though this is Transport Canada's responsibility, and despite clear indications (via inspections) that the company's safety management system was not effective. Transport Canada Headquarters in Ottawa, meanwhile, did not effectively monitor the Region's activities. As a result, it was not aware of any weaknesses in oversight of regional railways in Quebec, and it did not intervene.

Dangerous goods: Inadequate testing, monitoring, and transport

The petroleum crude oil in the tank cars was more volatile than described on the shipping documents. If petroleum crude oil is not tested systematically and frequently, there is a risk of it being improperly classified. The movement of these improperly classified goods increases the risk to people, property, and the environment. That is why the TSB issued a safety advisory letter calling for changes.

Rail transportation safety concerns and advisories

Safety culture at MMA

An organization with a strong safety culture is generally proactive when it comes to addressing safety issues. MMA was generally reactive. There were also significant gaps between the company's operating instructions and how work was done day to day. This and other signs in MMA's operations were indicative of a weak safety culture—one that contributed to the continuation of unsafe conditions and unsafe practices, and significantly compromised the company's ability to manage risk.

When the investigation looked carefully at MMA's operations, it found that employee training, testing, and supervision were not sufficient, particularly when it came to the operation of hand brakes and the securement of trains. Although MMA had some safety processes in place and had developed a safety management system in 2002, the company did not begin to implement this safety management system until 2010—and by 2013, it was still not functioning effectively.

Safety concerns
Safety concerns provide a marker to the industry and the regulator that the Board has identified a safety deficiency for which it does not yet have sufficient information to make a recommendation. As more data and analysis becomes available, and if the safety deficiency is found to be systemic and not redressed, the safety concern may lead to a recommendation. Safety concerns are usually communicated in final investigation reports.

Safety information letters
The TSB sends safety information letters to regulatory and/or industry stakeholders to advise them of potentially unsafe acts or conditions identified during an investigation that pose low risks and do not require immediate remedial action. The letters aim to promote safety or clarify issues that a stakeholder is already examining, and are sent before the investigation has been completed. Those that do not contain privileged or proprietary information are posted here.

Safety advisory letters
Safety advisory letters are concerned with safety deficiencies that pose low to medium risks, and are used to inform regulatory or industry stakeholders of unsafe conditions. A safety advisory letter suggests remedial action to reduce risks to safety.

Safety action following the accident

In the weeks and months after the accident, the TSB communicated critical safety information on the securement of unattended trains, the classification of petroleum crude oil, rail conditions at Lac-Mégantic, and the employee training programs of short line railways.

MMA, meanwhile, eliminated single-person train operations, stopped moving unit trains of petroleum crude oil, and increased operating-rules testing and enforcement.

For its part, Transport Canada introduced numerous initiatives, including an emergency directive prohibiting trains transporting dangerous goods from operating with single-person crews. Sections of the Canadian Rail Operating Rules were also rewritten, and new tank car standards have been proposed.

Considerable action was also undertaken in the United States. The National Transportation Safety Board issued recommendations aimed at route planning for hazardous materials trains, petroleum products response plans for worst-case spills, and the classification of hazardous materials. The U.S. Department of Transportation also issued an emergency order strengthening train securement rules, and a notice of proposed rulemaking targeting, among other items, improved tank car standards.

Changes to Rail Transportation

The final report into the disaster by the federal Transportation Safety Board (TSB) noted many problems with the way the MMA rail company maintained its infrastructure and trained its employees. The TSB, however, also said regulatory agencies didn’t do enough to force the company to comply with federal rules (see also Transportation Regulation).

The governmental transport agencies of Canada and the United States responded to the disaster by announcing a series of security measures that would apply on both sides of the border. Among the changes, the governments set safety standards for new rail cars, and implemented timelines for older tank cars to be retrofitted to better resist exploding in the case of a derailment. The authorities also imposed speed limits in rural and urban areas and required trains to have an electronic braking system.

Legal Consequences

Civil Proceedings

The Montreal, Maine & Atlantic Railway company (MMA), which operated in both the United States and Canada, didn’t have enough assets or insurance to pay damages to victims and other creditors of the disaster. Shortly after the derailment, the company was forced into bankruptcy in both countries. Victims of the derailment launched a class-action lawsuit against many of the companies connected to the disaster, from the owners of the crude oil that was loaded into the tankers in the US, down to the companies that owned the tracks on which the train travelled, including MMA.

The MMA bankruptcy process was tied to the class-action lawsuit. All the companies accused in the class action were allowed to pay money into a settlement fund for victims in exchange for the right to be permanently removed from the class action. About 25 companies took part in the offer and gave a total of $450 million for victims and creditors. Only Canadian Pacific Railway (CP) refused to pay into the settlement fund, claiming it bore no responsibility for the disaster. While CP was dropped from the class-action lawsuit, those proceedings were merged with another lawsuit against CP from the Quebec government. Canadian Pacific Railway is the only company left accused, and those proceedings are still before the courts. (See also Civil Procedure.)

Criminal Trial

In 2014, train engineer Thomas Harding and two other former MMA employees, traffic controller Richard Labrie and manager of train operations Jean Demaître, were arrested. They were each charged with one count of criminal negligence causing the death of 47 people.

Their trial began in October 2017 in Sherbrooke, Quebec, about 100 km west of Lac-Mégantic. The Crown prosecutors argued that all three men, in their own way, contributed to the death of 47 people.

Harding was accused of not applying enough handbrakes on the train before he left for the night, in addition to parking the convoy dangerously on a slope, 10 km away from the town of Lac-Mégantic. Labrie was alleged to have failed to properly inquire about the security of the train after it caught fire. Demaître was accused of failing to take the proper measures to ensure the train was secure.

Lawyers for the three defendants argued that MMA did not properly train its employees and lacked a culture of safety. Harding admitted to improperly securing the train, but his lawyer said that this was standard practice at the company, and that if there had been no fire and the firefighters had not turned off the train’s engine, the convoy would not have moved on its own. The defendants’ lawyers argued the disaster occurred because of a perfect storm of unforeseeable events. After a trial that lasted longer than one month, and following nine days of deliberations, the jury came back and declared all three men not guilty.

TSB Recommendations

In January 2014, the TSB made three recommendations aimed at addressing systemic safety issues that posed a significant risk. Three months later, it followed up to assess the action that had been taken by government and industry. In August 2014, the TSB made two additional recommendations.

R14-05 (August 2014)
Transport Canada must take a more hands-on role when it comes to railways' safety management systems—making sure not just that they exist, but that they are working and that they are effective.

R14-04 (August 2014)
Canadian railways must put in place additional physical defences to prevent runaways.

R14-03 (January 2014)
Emergency response assistance plans must be created when large volumes of liquid hydrocarbons, like oil, are shipped.

R14-02 (January 2014)
Railway companies should conduct strategic route-planning and enhance train operations for all trains carrying dangerous goods.

R14-01 (January 2014)
Enhanced protection standards must be put in place for Class 111 tank cars.

1. Railways must make progress on the development and implementation of new rules to improve their operating practices for the safe transportation of dangerous goods.
2. Although progress has been made, more work is required. All older Class 111 tank cars must not transport flammable liquids, and a more robust tank car standard with enhanced protection must be set for North America

Findings

Although these did not lead directly to the accident, they are related to unsafe acts, unsafe conditions, or safety issues with the potential to degrade rail safety. Some of the risks that need to be addressed are:

• the continuing risk of leaving trains unattended
• the risk of implementing single-person train operations
• the risk of not systematically testing petroleum crude oil
• the risk of not planning and analyzing routes on which dangerous goods are carried
• the risk of not having emergency response assistance plans in place
• the risk of Transport Canada not ensuring that safety management systems work effectively

Impact of the Rail Disaster on Residents

The effects of the Lac-Mégantic rail disaster left emotional scars among the people who lived there. Many in the community lost family, friends, neighbours and co-workers.

A study by the Estrie health authority published in January 2017 found that roughly half of residents continued to suffer from post-traumatic stress more than three years after the tragedy. People who lived closest to the blast had the highest rates of post-traumatic stress. Residents said a big step toward healing the psychological scars of the tragedy would be the construction of a rail by-pass. Since 2013, many residents had been calling for the train tracks to be re-routed away from the downtown core. The federal and provincial governments reached a deal to finance the project, which was announced in May 2018, with construction scheduled to begin in 2019.

Lac-Mégantic’s reconstruction of its buildings and other infrastructure is ongoing.

In 2019, Lac-Mégantic residents criticized media company Netflix for using footage of the rail disaster for entertainment in two of its productions, the horror film Bird Box and the sci-fi TV series Travelers. The production company behind Travelers apologized and said it would try to remove the footage. Netflix, however, said that it would not replace the images in Bird Box.

Conclusion

The tragedy in Lac-Mégantic was not caused by one single person, action or organization. Many factors played a role, and addressing the safety issues will take a concerted effort from regulators, railways, shippers, tank car manufacturers, and refiners in Canada and the United States. Although this investigation is complete, the TSB will continue to monitor the five recommendations, and to report publicly on any progress—or lack of progress—until all of the safety deficiencies have been corrected.