Rail Safety Advisory Letter 07/14
Adequacy of short line railway training
Place du Centre
200 Promenade du Portage
15 August 2014
Mr. Luc Bourdon (ASR)
Director General, Rail Safety
14th Floor, Enterprise Building
427 Laurier Avenue
Dear Mr. Bourdon:
Adequacy of short line railway training
On 06 July 2013, shortly before 0100 Eastern Daylight Time, eastward Montreal, Maine & Atlantic Railway freight train MMA-002, which was parked unattended for the night at Nantes, Quebec, started to roll. The train travelled approximately 7.2 miles, reaching a speed of 65 mph. At around 0115, when MMA-002 approached the centre of the town of Lac-Mégantic, Quebec, 63 tank cars carrying petroleum crude oil (UN 1267) and 2 box cars derailed. About 6 million litres of petroleum crude oil spilled. There were fires and explosions, which destroyed 40 buildings, 53 vehicles and the railway tracks at the west end of Megantic Yard. Forty-seven people were fatally injured. There was environmental contamination of the downtown area and of the adjacent river and lake. (TSB Occurrence No. R13D0054)
After applying hand brakes to secure the train on the grade at Nantes, the locomotive engineer (LE) conducted an improper hand brake effectiveness test, as the independent brakes had been left applied. As a result, the insufficient retarding force being provided by the hand brakes was not identified. It was determined that other LEs at MMA had also been performing this test at this location in a similar manner. Further investigation determined that MMA operating crews were not being regularly trained and tested on the application of the hand brake effectiveness test, bringing into question the adequacy of MMA’s testing and training procedures.
In addition to the rules regarding securement of equipment (i.e., CROR 112 and MMA’s special instructions on hand brakes), the investigation revealed that some MMA operating crew members lacked the knowledge and training required to safely perform their tasks. These gaps in knowledge and training included the use of the Quick Release Valve and the Auto-Start System of some locomotives.
The TSB identified a number of deficiencies in MMA’s training, requalification, and in-field monitoring of employees. For example, there were instances where:
- employees’ qualifications were extended beyond the regulated 3-year deadline,
- qualification tests were taken home for completion, and
- tests did not properly assess an employee’s knowledge of the rules.
In addition, the small number of candidates concurrently participating in the requalification programs limited the opportunity for meaningful classroom discussion, which is a challenge for every short line railway.
The safety issues related to MMA operating crew training may not be limited to this one short line. Since 2005, the TSB has conducted 6 investigations into runaway train events that occurred on short line railways. Human error through rules misinterpretation or misapplication was identified to be a cause or contributing factor in 5 of these investigations. A review of TSB data from 2004 to 2013 indicated that federally regulated short line railways experienced runaways at a rate of 2.36 per million main track train-miles, which is 4 times greater than the rate of similar occurrences in Class 1 railways.
In addition to the 6 runaway investigations, there have been 10 other TSB investigations involving short line railways in the past 20 years. Of the 16 TSB investigations involving short line railways, deficiencies in rules compliance or misinterpretation or deficiencies in training have been identified as a causal or contributing factor in 10 cases (62%).
In a rules-based industry, employees frequently are the strength or weakness of a company’s safety system, which in turn is dependent upon the quality and effectiveness of its training program. However, employees working for short line railways may not always be receiving the training and requalification required to ensure safe operations. Given the important role that training plays in promoting safe train operations, Transport Canada may wish to review the processes and procedures in place to ensure that short line railway employees receive the necessary training to perform their duties in a safe manner.
Investigation Operations Rail/Pipeline
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