Release of Railway Investigation Report R13D0054
Wendy A. Tadros
Chair, Transportation Safety Board of Canada
Lac-Mégantic, Quebec, 19 Augsut 2014
Check against delivery.
On the early morning of July 6, 2013, a Montreal Maine and Atlantic train carrying 7.7 million litres of petroleum crude oil derailed not far from here, just past the Frontenac Street crossing.
Some of what happened that night has already been reported, but today we are here to put those facts in context. We will explain how the train ran away, causing such devastation. And then we will reveal the underlying issues, explaining how this situation could develop. And how the chain of causes and contributing factors goes far beyond the actions of any single person.
We are also here today to make two recommendations to improve the safety of Canada's railways:
- First, that Transport Canada make sure additional physical defences are in place so trains will always be secure.
- And second, that Transport Canada make sure railways are really working to manage safety. Not just that they have systems on paper, but that these are effective.
These recommendations complement the 3 made by the TSB last January, and together they will move Canada's railways toward a safer future.
Because the goal is simple: We must do whatever we can to make sure the events of that night—the events that devastated a town and left 47 people dead—never happen again.
We will now play you a short animation. It will lay the groundwork for much of what we will discuss today. Run-time is about 3 minutes.
So, those are the basic facts: a crude oil train parked on a main track on a descending grade, with the lead locomotive running and 7 hand brakes set. A fire begins in an engine that had been causing problems for days. Emergency responders shut off the engine, but then the air holding the locomotive brakes leaks off. Without enough force from the hand brakes, the train begins its tragic descent downhill.
When you first look at an accident, there's a tendency to focus only on those basic facts. But our investigations must also look at the context. And in Lac-Mégantic, that context was about more than hand brakes or what the engineer did or didn't do that night. In all, we found 18 factors that played a role. Take any one of them out of the equation, and this accident may not have happened.
The context starts with MMA: A short-line railway running its operations at the margins. Choosing to lower the track speeds rather than invest more in infrastructure. Cutting corners on engine maintenance and training—and then relying on employees to follow the rules.
Complex systems, though, require more than that. Because experience has taught us that even the most motivated and well-trained employees make mistakes. And that is why the best safety systems identify risks … and put defences in place in advance. In fact, this is the very basis of SMS: safety management systems.
But MMA did not have a functioning SMS. It did not effectively manage risk—either in day-to-day operations, or when operations changed. Not when reducing crew numbers from two to one, nor when transporting increasing amounts of crude oil. This was a company with a weak safety culture, a company where people did what was needed to get the job done, rather than always follow the rules. A company where unsafe conditions and unsafe practices were allowed to continue.
Which begs a question: Who, then, was in a position to check on this company … to make sure safety standards were being met? Who was the guardian of public safety?
That's the role of government. To provide checks and balances. Oversight. And yet this booming industry—where unit trains were shipping more and more oil across Canada, and across the border—ran largely un-checked. Yes, Transport Canada knew about some of the problems at MMA, but the follow-up wasn't always there. Instead, the focus was on making sure railway companies had an SMS … not how they were using it and whether it was effective.
In the weeks and months following this accident, the TSB communicated critical safety messages about unattended trains and the classification of petroleum crude oil. And then, last January we went further, making 3 recommendations: for enhanced standards for Class 111 tank cars. For railways to conduct route planning and analysis. And for Emergency Response Assistance Plans whenever liquid hydrocarbons are transported by rail.
And this accident has prompted strong action. Transport Canada and the railway industry responded faster, and went farther, than I have ever seen them go before. But more still needs to be done. That is why today we are making 2 new recommendations.
The first is about going back to basics on train securement. Transport Canada must require railways to put in place additional physical defences to prevent runaway trains. This could mean things like wheel chocks, or modern braking technology. Because right now, Transport Canada is relying on the rules, and they still allow a train carrying dangerous goods to be left unattended on a descending grade.
Our second recommendation goes back to what I just said about the role of government, and the need for better oversight. The TSB isn't the only organization to point this out, either. A report last year from Canada's Auditor General said the same thing.
Here's what we mean: It's not enough for a company to have a safety management system on paper. That SMS also has to work, to do what it is designed to do. And the best way to ensure this happens is for Transport Canada to audit railways' SMS—to audit them in sufficient depth and with sufficient frequency to be sure their safety systems are effective, and that corrective action is being taken when risks are found.
The events of that night — “what happened” — are now well understood. And we now know why the situation developed, and how it grew worse over time: A weak safety culture at MMA. Poor training of employees. Tank cars that didn't offer enough protection. And then Transport Canada didn't audit railways often enough, and thoroughly enough, to know how those companies were really managing—or not managing—risks.
For the people of Lac-Mégantic, today's report won't do anything to bring back their loved ones, or to rebuild their town. We know that. But we can point the way toward a better future. A safer future. One where the trains that travel through our cities … and through our towns … are no longer feared.
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