Section 4. CASE STUDIES
5. The failure of the non-standard repair to the lead locomotive’s engine allowed oil to accumulate in the turbocharger and exhaust manifold, resulting in a fire. 6. When the locomotive was shut down as a response to the engine fire, no other locomotive was started, and consequently, no air pressure was provided to the independent brakes. Furthermore, locomotives with an auto-start system were shut down and not available to provide air pressure when the air brake system began to leak. 7. The reset safety control on the lead locomotive was not wired to initiate a penalty brake application when the rear electrical panel breakers were opened. 8. Because air leaked from the train at about one pound per square inch per minute, the rate was too slow to activate an automatic brake application. 9. When the retarding brake force provided by the independent brakes was reduced to about 97,400 pounds, bringing the overall retarding break force for the train to approximately 146,000 pounds, the train started to roll. 10. The high speed of the train as it negotiated the curve near the Mégantic West turnout caused the train to derail. 11. About one third of the derailed tank car shells had large breaches, which rapidly released vast quantities of highly volatile petroleum crude oil that ignited, creating large fireballs and a pool fire. 12. Montreal, Maine, and Atlantic Railway did not provide effective training or oversight to ensure that crews understood and complied with rules governing train securement. 13. When making significant operational changes on its network, Montreal, Maine, and Atlantic Railway did not thoroughly identify and manage the risks to ensure safe operations. 52
Guidance for the Environmental Public Health Management of Crude Oil Incidents
14. Montreal, Maine, and Atlantic Railway’s safety management system was missing key processes, and others were not being effectively used. As a result, Montreal, Maine, and Atlantic Railway did not have a fully functioning safety management system to effectively manage risk. 15. Montreal, Maine, and Atlantic Railway’s weak safety culture contributed to the continuation of unsafe conditions and unsafe practices, and compromised Montreal, Maine, and Atlantic Railway’s ability to effectively manage safety. 16. Despite being aware of significant operational changes at Montreal, Maine, and Atlantic Railway, Transport Canada did not provide adequate regulatory oversight to ensure the associated risks were addressed. 17. Transport Canada, Quebec Region did not follow up to ensure that recurring safety deficiencies at Montreal, Maine, and Atlantic Railway were effectively analyzed and corrected. Consequently, unsafe practices persisted. 18. The limited number and scope of safety management system audits that were conducted by Transport Canada, Quebec Region and the absence of a follow-up procedure to ensure Montreal, Maine, and Atlantic Railway’s corrective action plans had been implemented, contributed to the systemic weaknesses in Montreal, Maine, and Atlantic Railway’s safety management system remaining unaddressed. Changes in Canadian regulations governing the transportation of crude oil resulting from the Lac-Mégantic derailment Since the Lac-Mégantic derailment on 7 July 2013, Transport Canada (TC) and the U.S. DOT have enacted numerous regulation changes that apply to the transportation of crude oil. These regulations required a minimum two crew for all trains transporting dangerous goods, detailed the securement of trains, required Version 1.0 – August 2018
