When and where did it happen? On July 5,

When and where did it happen?

On July 5, 2013, at approximately 10:50p.m., a train carrying
approximately 7.7 million litres of crude oil arrived in Nantes, Quebec. It
wasn’t until around 1:15a.m. on July 6th that sixty-three tank cars,
and two box cars derailed in Lac-Mégantic unleashing a large fire and multiple
explosions (Figure 1) 3.

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Who was involved?

The train was
owned and operated by Montreal, Maine & Atlantic Railway. The train was
being solely operated by locomotive engineer Tom Harding who was stationed in
the lead locomotive. Rail traffic controller Richard Labrie who was stationed
in Bangor, Maine, and operations manager Jean Demaître were also involved in
the incident 2. Transport Canada was also a player in the severity of this
incident 3.

Executive summary

A
Montreal, Maine & Atlantic Railway train consisting of 72 tank cars, 1 box
car, and a locomotive entered Nantes, Quebec at 10:50p.m., July 5, 2013. By
1:15a.m. central Lac-Mégantic was engulfed in flames and littered with debris
and environmental contaminants. This disaster lead to the death of 47 residents
and forced 2000 others out of their homes 3.

Why did it happen?

There were a series of key issues that were addressed when investigating
this incident as there was negligence on behalf of multiple individuals that induced
such a horrific crash. These issues are as follows:

1.     Just eight months prior to the crash, the train’s
locomotive had been sent for repair following an engine failure. Used to repair
this was an epoxy-like material that had previously failed in service and
lacked in strength and durability. This material caused overheating of the
turbocharger and lead to it igniting the morning of the incident 3.

2.     Upon stopping the train in Nantes, Quebec, locomotive
engineer Tom Harding performed a ritual hand brake effectiveness test whilst
the locomotive air brakes were still applied. This meant that his test was void
as it did not indicate that the hand brake force applied was insufficient. “The
Canadian Rail Operating Rules required that unattended equipment be left with a
“sufficient” number of hand brakes applied to prevent movement, and that the
effectiveness of the hand brakes be tested” 3.

3.     The class of the tank cars on this train were all built
to lesser standards. Class 111 cars, of which these all were, are built without
a jacket, a full head shield, and thermal protection. Nearly all the cars that
derailed suffered the consequences of these low building standards, most having
puncture wounds and releasing crude oil, fueling the fire (Figure 2) 3.

4.     Montreal, Maine and Atlantic Railway was known for their
poor outlook on safety. They lacked proactivity in their safety culture. There
was little parallel between their policies, and how operation functioned on a day to day basis. They
lacked employee training, testing, and supervision 3.

5.     Transport Canada’s regional office in Quebec lacked
diligence when dealing with Montreal, Maine and Atlantic Railway’s lack of safe
work practices. During inspection, Transport Canada frequently found recurring
discrepancies with the effectiveness of safety standards of the company but
neglected to follow up on these issues 3.

6.     The shipping documents were inaccurate regarding the
level of volatility of the cargo 3.

7.     Prior to the collision, a conversation occurred between
locomotive engineer Thomas Harding and rail traffic controller Richard Labrie
where Harding indicated that the lead locomotive was experiencing mechanical
difficulties. They both agreed that these issues would be dealt with on the
morning of July 6th 4.

What was the result?

The results were catastrophic to the town of Lac-Mégantic, there were 47
casualties, and approximately 2000 people had evacuated. Further to that, 6
million of the 6.7 million litres of crude oil were lost and contaminated
nearly 31 hectares of land (Figure 3). It is estimated that 100,000 of the
litres released made its way to the Mégantic Lake and the Chaudière River 3.
The cost of cleanup for this disaster was estimated at $200 million as of July
2014 1. Tom Harding, Richard Labrie, and Jean Demaître of Montreal, Maine and
Atlantic Railway were all facing charges of criminal negligence, however all
three were later acquitted 2.

How do we keep this from happening again?

Being that there were numerous contributing factors that caused this
disaster to occur as well as intensified the severity of the incident, there are
many changes that were implemented, they are as follows:

1.     Transport Canada must be more involved in the implementation
and effectiveness of railway company’s safety management systems 3.

2.     “All
older Class 111 tank cars must not transport flammable liquids” 3.

3.     When shipping large amounts of volatile cargo, emergency
response assistance plans must be in effect 3.

4.     Progress is to be made by railway companies to ensure
safe transportation of dangerous goods 3.

5.     When
single-person operations are in effect railways need to be aware of all risks
and ensure safety measures are in place to avoid incidents 3.

6.     The Transportation Safety Board called for changes in the
testing and description of goods regarding shipping documents 3.

7.     Supplementary physical defenses must be implemented to
prevent runaway trains 3.