Canada’s transportation safety agency believes that “taking out of the equation” any one of 18 factors that played a role in the Lac-Megantic crude train derailment 14 months ago and the “accident might not have happened,” Chief Operating Officer Jean Laporte said in issuing the final investigative report Aug. 19.
The Transportation Safety Board, TSB, Chair Wendy Tadros said the chain of causes and contributing factors “goes far beyond the actions of any single person.”
However, she said the “booming (crude-by-rail) industry where oil trains were shipping more and more oil across Canada and across the U.S. border ran largely unchecked.”
But the 190-page report by the TSB made no attempt to pin blame on the composition of the Bakken crude which filled the 72 tankers cars involved in the Quebec derailment, claiming 47 lives when the crude exploded and caught fire.
However, the TSB did note that neither Western Petroleum Co., which leased the cars, nor the consignee, Irving Oil of Saint John, New Brunswick, attempted to determine the flashpoint of the crude.
It said the standard operating procedure used by Strobel Starostka Transfer, which operated the rail loading facility at New Town, North Dakota, was to collect and sample on a monthly basis composite samples representing the product being shipped from New Town.
The tests primarily determined the sulfur content, API gravity, boiling point and the presence of light-end gases, the TSB said.
Asked whether crude on the MM&A train was “more hazardous” than what was listed on the shipping documents, the TSB’s investigator-in-charge Don Ross replied: “It certainly was.”
Critical of Transport Canada
While concluding that no single factor was responsible for the accident, the TSB was strongly critical of Transport Canada for its failure to conduct frequent audits of the train operator, Montreal, Maine & Atlantic Railway, which in turn the regulator accused of having a “weak safety culture that did not have a functioning safety management system to manage risks.”
The TSB said Transport Canada did not audit MM&A often and thoroughly enough “to ensure it was effectively managing the risks in its operations.”
The report identified problems at MM&A as gaps in training, employee monitoring and maintenance practices, which Laporte linked to a company he said was “operating close to the margins (by) cutting corners” on maintenance and training.
He said those deficiencies were “unfortunately a reason why this accident could happen elsewhere in Canada,” noting that since 1996 there have been 120 runaway trains across Canada, without the same tragic consequences as Lac-Megantic.
In January, the TSB made three recommendations, by calling for: enhanced protection standards for all Class 111 tank cars used to transport flammable liquids; route planning and analysis by the railway companies carrying dangerous goods; and, emergency response plans for the transportation of large volumes of liquid hydrocarbons.
Tadros said the TSB’s final report recommends measures to “ensure unattended trains will always be secured and Canada’s railways will have safety management systems that really do work to manage safety.”
“This is about governments, railways and shippers doing everything in their power to ensure there is never another Lac-Megantic,” she said.
Tadros said the decision to charge the engineer on the MM&A train and two other MM&A employees with 47 counts each of criminal negligence causing death was strictly a matter for the police and the Canadian government’s justice department.
Transport Canada responds
Transport Minister Lisa Raitt was not prepared to concede that she and her department had failed to provide leadership.
“As we have said all along and as the criminal charges show, not all the rules were followed,” she told reporters.
But Raitt insisted that the government has implemented “every recommendation” it has received from the TSB and will thoroughly review the final report before developing its next set of “concrete actions.”
She said that an extra C$100 million was allocated to Transport Canada in 2009 and that money is being used to hire more auditors in response to the rapid increase in crude shipments by rail from zero in 2007 to 234,000 tanker cars in 2012 and 408,000 in 2013.
Moving forward
The Canadian Association of Petroleum Producers predicted in June that the amount of crude transported by rail in North America will climb from 230,000 barrels per day in 2013 to 700,000 bpd in 2016, which prompted Tadros to insist the pressure is on to ensure that “these flammable liquids” must move safely through communities.
Separately, a Canadian advocacy group is calling for federal and provincial inquiries into the Lac-Megantic train, citing eight failures by government transportation and safety authorities it says contributed to the accident.
The Canadian Center for Policy Alternatives, CCPA, said Aug. 18 that only an independent probe can uncover those lapses, expressing its doubt that the TSB would expose the failures.
CCPA executive director Bruce Campbell told CBC News he doubted the report would “go hard on senior officials at Transport Canada.”
The CCPA report coincided with a disclosure in the Globe and Mail that the federal investigation into Lac-Megantic has concentrated on a repair conducted in October 2012 on the MM&A lead locomotive.
Sources told the newspaper that material used in the 2012 repairs was inadequate and eventually failed, a claim that was partly endorsed by Ross.
The TSB said only seven of 17 handbrakes on the MM&A train (which consisted of five locomotives) were applied when the engineer left the train unattended on the mainline west of Lac-Megantic and retired for the night.
That proved to be insufficient when a subsequent fire occurred on the lead locomotive. That was quickly extinguished, but the brakes failed an hour later, sending the train rolling downhill for 7 miles to Lac-Megantic, reaching a top speed of 65 miles an hour.
