4.1 CASE STUDY (rail incident): Lac-Mégantic derailment, 6 July 2013

At 22:50 Eastern Daylight Time (EDT) on July 5, 2013, a Montreal, Maine, and Atlantic Railway (MMA) train (MMA002) arrived at Nantes, Quebec, carrying 7.7 million litres of petroleum crude oil (UN 1267) in 72 Class 111 tank cars and was parked on a descending grade on the main track. The engineer applied hand brakes on all five locomotives and two other cars, shut down all but the lead locomotive and left. The train was now held by the hand brakes and the air brakes on the lead locomotive. Shortly after the engineer left, the Nantes Fire Department responded to a 911 call reporting a fire on the train. The firefighters extinguished the fire and shut the lead locomotive down. Air pressure for the air brakes slowly reduced. Just before 1:00 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 [TSB, 2014a]. The train, having reached a top speed of 105 kph, derailed near the centre of the town at about 1:15 a.m. Fiftynine of the 63 derailed tank cars were breached and released crude oil due to tank damage (see TSB, 2014b Table 3, Photos 16-23). Approximately 6 million litres of petroleum crude oil was quickly released. The fire, which burned for nearly two days, began almost immediately. The ensuing blaze and explosions left 47 people dead. Another 2,000 people were evacuated. Forty buildings and 53 vehicles were destroyed [TSB, 2014b]. One hundred fifteen businesses were destroyed, displaced, or rendered inaccessible [RC, 2013]. The hydrocarbon recovery and clean-up operation began as soon as the fire was extinguished and the site was stabilized, approximately two days after the derailment. About 740,000 litres of crude oil were recovered from the derailed tank cars. Crude oil migrated into the town’s sanitary and storm sewer systems by way of manholes. An estimated 100,000 litres of crude oil ended up in Mégantic Lake and the Chaudière River by way of surface flow, underground infiltration, and sewer systems Approximately 31 hectares of land was contaminated [TSB, 2014b].

Public health response

Actions taken by the Public Health Department (PHD) of the Eastern Townships, in close collaboration with community-based organizations, during the impact phase emergency response (July-August 2013) included: providing direct services needed to protect the citizens and the on-site responders from health hazards (e.g., exposure to chemical, physical, and biological agents); risk assessments for on-site responders and clean-up personnel including firefighters, police, decontamination, team members, railway specialists, and contractors; initiation of epidemiological investigations; and risk communication to the general public and disaster workers [Généreux, 2015]. During the recovery operations phase (September 2013 to present), the PHD implemented a local surveillance system focusing on health issues related to the train derailment to keep track of the potential after-effects of the tragedy and conducted the first survey on population health (2014) [Généreux, 2015]. The second survey (2015) found that 67% of the residents of Lac-Mégantic continue to suffer moderate to severe post-traumatic stress and that one in six reported an increase in alcohol consumption [Généreux, 2016; Vision, 2016; Peritz, 2016]. The third survey (2016) indicated that (1) the population is still suffering from the consequences of the tragedy, particularly individuals who were more exposed and those experiencing difficulties in coping with the loss of a loved one; (2) psychological health is stable and even showing some improvement; and (3) use of medical and psychosocial services is increasing [Sante estrie, 2017].

Environmental monitoring and remediation

The Quebec Ministry of the Environment immediately deployed a mobile laboratory to measure air quality. Elevated concentrations of polycyclic aromatic hydrocarbons (PAH), nitrogen oxide, and total suspended particles (TSP) resulted in the Medical Health Officer ordering the evacuation of 1,000 people downwind of the disaster site [Genereux, 2015]. Municipal water systems that used the Chaudiere River were obliged to find alternate sources [Millette, 2014a]. The initial work focused on preventing the spread of contamination via preferential paths (e.g., sewers) into water courses [Millette, 2014b]. Surface water and sediment sampling stations were set up on Lac-Mégantic and the Chaudière River [Millette, 2014b; Galvez-Cloutier, 2015]. Contaminated soil, primarily in the impact zone

and building foundations, was identified [Millette, 2014b]. Post-emergency remediation included the removal and treatment of 135,000 MT of contaminated soil, cleaning or replacement of storm sewers, treatment of 62 million litres of ground water to remove oil, and removal of sediment from the Chaudière River [Marcotte, 2015]. Contaminated soil was removed from the railway right of way and it was rebuilt in the original location [Millette, 2014b]. Three mobile monitoring stations to continuously monitor particulate matter (PM10) and Volatile Organic Compounds (VOCs) were set up at the perimeter of the site during remediation [Marcotte, 2015].

Safety recommendations

In 2014, the Transportation Safety Board (TSB) issued recommendations that it will monitor for compliance [TSB 2014a] R14-01 (Jan 2014) Enhanced protection standards must be put in place for Class 111 tank cars. R14-02 (Jan 2014) Railway companies should conduct strategic route planning and enhance train operations for all trains carrying dangerous goods. R14-03 (Jan 2014) Emergency response assistance plans (ERAPs) must be created when large volumes of liquid hydrocarbons, like oil, are shipped. R14-04 (Aug 2014) Canadian railways must put in place additional physical defences to prevent runaways. R14-05 (Aug 2014) Transport Canada must take a more hands-on role when it comes to railway safety management systems—making sure not just that they exist, but that they are working and that they are effective.

Legal issues

MMA has filed for bankruptcy protection [CBC, 2013a, CBC, 2013b]. The engineer, the manager of train operations and the railway's traffic controller were tried and found NOT guilty on 47 counts of criminal negligence causing death [Laframboise, 2018]. Six people employed by the rail company at the time of the incident and the two companies involved are facing two charges each under the Railway Safety Act for failing to ensure the train was properly braked before it was left unmanned for the night. A federal Fisheries Act charge for the crude oil that flowed into LacMégantic and the Chaudière River after the accident has also been laid [CBC, 2015a]. A settlement of $446 million Cdn was approved for victims of the disaster [Sharp, 2015]. $113 million has been paid out for wrongful death claims [Canadian Press, 2016]. A class action suit against World Fuel Services and the Canadian Pacific Railway has been allowed to proceed [Canadian Press, 2015]. The Government of Quebec submitted a claim of $400 million against MMA to cover the estimated costs of the clean-up and reconstruction [Woods, 2014]. The Government of Quebec is suing CPR for damages of $409 million [CBC, 2015b].

Causes and contributing factors

The Transportation Safety Board findings of the causes and contributing factors in the Lac-Mégantic derailment are detailed in Section 4.1 and Figure 11 [TSB, 2014b]. Note: TSB has an animation of the accident Lac-Mégantic MMA Train Accident - 6 July 2013 - YouTube [TSB, 2014c]. A technical assessment of lessons learned is given in reference Lacoursiere,2015.