Figure 10: Lac-Mégantic derailment

Figure 10: Lac-Mégantic derailment Transportation Safety Board (TSB) findings on the Lac-Mégantic derailment11

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. 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.

11 Available at http://www.tsb.gc.ca/eng/rapportsreports/rail/2013/r13d0054/r13d0054-r-es.pdf

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. 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