Lac-Megantic: More safety audits needed to prevent another disaster - TSB

First responders fight burning trains after a train derailment and explosion in Lac-Megantic,...

First responders fight burning trains after a train derailment and explosion in Lac-Megantic, Quebec early July 6, 2013 in this file picture provided by the Transportation Safety Board of Canada. (REUTERS/Transportation Safety Board of Canada/Files)

Brian Daly, QMI Agency

, Last Updated: 4:24 PM ET

MONTREAL, Que. — The train blast in Lac-Megantic, Que., that killed 47 people last year could happen again unless Transport Canada improves monitoring and forces railways to do more to prevent runaway trains, the country's transportation watchdog says.

In its report, the Transportation Safety Board of Canada (TSB) singles out the Montreal, Maine and Atlantic Railway (MMA) for a "weak safety culture" and says Transport Canada didn't audit the firm often or thoroughly enough.

MMA's 72-car crude-oil train derailed and exploded near Quebec's border with Maine on July 6, 2013, killing 47 people in Canada's deadliest railway blast.

The train had been left unattended on a slope in Nantes, Que., about 12 km away when it began rolling towards Lac-Megantic.

The train engineer and two colleagues are awaiting a criminal trial.

During a news conference not far from the blast site, the TSB called for better "physical defences" to prevent runaway trains, and better safety management systems for Canada's railways.

"Can this kind of event happen again elsewhere? Unfortunately, presently, there are risks that it could happen again," chief operating officer Jean Laporte said. "That's why today we are drafting additional recommendations where we are asking for additional physical defence measures to secure the trains so that they remain immobilized."

TSB chair Wendy Tadros suggested the use of wheel chocks, which are locking mechanisms that fit over the tracks on either side of a train's wheel. She said the ultimate solution, however, is an overall culture change in railway safety.

"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."

Watch the Transportation Safety Board recreation video below:

The watchdog says it first brought up the idea of runaway train defence systems in 1996. There have since been more than 120 runaway trains in Canada, the TSB said.

"Equipment runaways are low-probability events, but as this accident demonstrates, they can have extreme consequences, particularly if they involve dangerous goods," the report reads. "As demonstrated in Lac-Megantic, the cost to human life and our communities can be incalculable."

The TSB reserved its harshest criticism for MMA, the now-defunct Illinois outfit that faces $50 million in wrongful-death lawsuits.

Tadros said MMA was "running its operations at the margins" and cut corners on engine maintenance while "relying on employees to follow the rules."

She said the railway didn't have a safety management system (SMS) while transporting large amounts of crude oil.

Tadros urged Transport Canada to get more involved in keeping a closer eye on railways.

"We're saying it's not enough to determine if they (the railways) have an SMS," she said. "You have to go in and audit in sufficient depth to determine whether that SMS is really working, whether that company is really managing safety."

MMA's aging lead locomotive also played a role in the crash, the TSB said.

A badly repaired engine block caused a leak that caught fire on the night of the crash, the report says.

When responders shut off the engine to put out the fire, the air holding the independent brakes leaked out and there wasn't enough force to hold the train in place.

TSB's 18 factors that contributed to Lac-Megantic explosion:

Derailment:

- Excessive train speed

Locomotive:

- Uncorrected mechanical problems

- Failure of a non-standard engine repair

- Locomotive engine fire

- Safety device not wired to initiate braking

Tanker cars:

- Breached cars and highly volatile crude oil

Parking of the train:

- Insufficient handbrakes

- Improper hand brake test

- Air leaked out of the independent air brakes

Transport Canada:

- Inadequate monitoring of operational changes

- Limited follow-up on safety gaps

- Ineffective monitoring of safety management system (SMS)

Montreal, Maine & Atlantic Railway:

- Train left unattended on hill

- No additional safety defences

- Ineffective training and oversight on train securement

- Weak safety culture

- Safety management system not fully implemented

- Not effectively managing risks

Two new recommendations:

- Transport Canada should play more active role in making sure rail industry's safety management systems exist and are effective.

- Canadian railways should develop additional measures to prevent trains from running away.

TSB's earlier recommendations:

- More stringent standards for all DOT-111 tank cars

- Strategic planning of rail routes and improved safety for all trains carrying dangerous goods

- Emergency response plans along all routes used to transport large amounts of crude oil

Lac Megantic: Transportation Safety Board report

 


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