TSB identifies systemic problems leading to Lac-Mégantic train accident and calls for additional safety defences to improve rail safety (investigation report R13D0054),

TSB identifies systemic problems leading to Lac-Mégantic train accident and calls for additional safety defences to improve rail safety

Lac-Mégantic, Quebec, 19 August 2014 – The Transportation Safety Board of Canada (TSB) investigation into the Montreal, Maine & Atlantic Railway (MMA) train derailment in Lac-Mégantic, Quebec (investigation report R13D0054), concluded that a multitude of factors led to the accident which left 47 people dead. The TSB is now calling for additional physical defences to prevent runaway trains, and for more thorough audits of safety management systems‎ to ensure railways are effectively managing safety.

On the evening of 5 July 2013, an MMA train was parked on a descending grade on the main track in Nantes, Quebec. The engineer applied hand brakes on all five locomotives, plus two other cars, and shut down all but the lead locomotive. Railway rules require hand brakes alone to be capable of holding a train, and this must be verified by a test. That night, 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, giving a false impression that the hand brakes alone would hold the train. When a fire began in the engine, emergency responders shut off the engine, causing the air holding the independent brakes to leak off, reducing their effectiveness. Without enough force from the hand brakes, the train began rolling 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, and derailing near the centre of town. Almost every derailed car was breached, releasing almost six million litres of crude oil, which ignited into a large fire.

“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.

The TSB found MMA was a company with a weak safety culture that did not have a functioning safety management system to manage risks. The TSB also learned that Transport Canada did not audit MMA often and thoroughly enough to ensure it was effectively managing the risks in its operations. Furthermore, the Board found problems with training, employee monitoring, and maintenance practices at MMA; with industry rules for the securement of unattended trains; and with the tank cars used to carry volatile petroleum crude oil.

“This investigation and its findings are complex, but our goal is simple: we must improve rail safety in Canada,” added Tadros. “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.” She concluded, “This is about governments, railways and shippers doing everything in their power to ensure there is never another Lac-Mégantic.”

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.