Guidance for the Environmental Public Health Management of Crude Oil Incidents
Section 4. CASE STUDIES
Figure 10: Lac-Mégantic derailment Transportation Safety Board (TSB) findings on the Lac-Mégantic derailment 11 The TSB report listed 18 findings regarding the causes and contributing factors to the LacMégantic derailment (see Figure 11) [TSB, 2014a; TSB, 2914b]. 1. (The train) MMA-002 was parked unattended on the main line, on a descending grade, with the securement of the train reliant on a locomotive that was not in proper operating condition.
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Available at http://www.tsb.gc.ca/eng/rapportsreports/rail/2013/r13d0054/r13d0054-r-es.pdf
Version 1.0 – August 2018
2. The seven hand brakes that were applied to secure the train were insufficient to hold the train without the additional braking force provided by the locomotive’s independent brakes. 3. No proper hand brake effectiveness test was conducted to confirm that there was sufficient retarding force to prevent movement, and no additional physical safety defences were in place to prevent the uncontrolled movement of the train. 4. Despite significant indications of mechanical problems with the lead locomotive, the locomotive engineer and the Bangor, ME, rail traffic controller agreed that no immediate remedial action was necessary. The locomotive was left running to maintain air pressure on the train. 51
