Canadian Railroads > The Full TSB Lac-Megantic Report

http://www.tsb.gc.ca/eng/rapports-reports/rail/2013/r13d0054/r13d0054.asp



Edited 1 time(s). Last edit at 08/19/14 08:45 by RayLGrinder.

Thanks for posting the report. Certainly interesting, and very detailed. Seven hand brakes tied down, for example. the RTC (who had been an engineer in the district) was much more involved with Mr Harding than had been previously reported.

Lots of content about issues with the 5017 lead engine, including the immediately prior trips. Confirmation that the fire department shut down the 5017, and that was discussed with the RTC in the absence of an employee with locomotive experience on the site. Engine was smoking and throwing oil when the cab driver picked up Mr Harding. The oil part was previously revealed, but not the smoking part.

Need to read this in more detail.

Copy of the findings from the TSB report:
3.1 Findings as to causes and contributing factors
1.MMA-002 was parked unattended on the main line, on a descending grade, with the securement of the train reliant on a locomotive that was not in proper operating condition.
2.The 7 hand brakes that were applied to secure the train were insufficient to hold the train without the additional braking force provided by the locomotive’s independent brakes.
3.No proper hand brake effectiveness test was conducted to confirm that there was sufficient retarding force to prevent movement, and no additional physical safety defences were in place to prevent the uncontrolled movement of the train.
4.Despite significant indications of mechanical problems with the lead locomotive, the locomotive engineer and the Bangor, Maine, rail traffic controller agreed that no immediate remedial action was necessary, and the locomotive was left running to maintain air pressure on the train.
5.The failure of the non-standard repair to the lead locomotive’s engine allowed oil to accumulate in the turbocharger and exhaust manifold, resulting in a fire.
6.When the locomotive was shut down as a response to the engine fire, no other locomotive was started, and consequently, no air pressure was provided to the independent brakes. Further, locomotives with an auto-start system were shut down and not available to provide air pressure when the air brake system began to leak.
7.The reset safety control on the lead locomotive was not wired to initiate a penalty brake application when the rear electrical panel breakers were opened.
8.Because air leaked from the train at about 1 pound per square inch per minute, the rate was too slow to activate an automatic brake application.
9.When the retarding brake force provided by the independent brakes was reduced to about 97 400 pounds, bringing the overall retarding brake force for the train to approximately 146 000 pounds, the train started to roll.
10.The high speed of the train as it negotiated the curve near the Megantic West turnout caused the train to derail.
11.About one third of the derailed tank car shells had large breaches, which rapidly released vast quantities of highly volatile petroleum crude oil, which ignited, creating large fireballs and a pool fire.
12.Montreal, Maine & Atlantic Railway did not provide effective training or oversight to ensure that crews understood and complied with rules governing train securement.
13.When making significant operational changes on its network, Montreal, Maine & Atlantic Railway did not thoroughly identify and manage the risks to ensure safe operations.
14.Montreal, Maine & Atlantic Railway’s safety management system was missing key processes, and others were not being effectively used. As a result, Montreal, Maine & Atlantic Railway did not have a fully functioning safety management system to effectively manage risk.
15.Montreal, Maine & Atlantic Railway’s weak safety culture contributed to the continuation of unsafe conditions and unsafe practices, and compromised Montreal, Maine & Atlantic Railway’s ability to effectively manage safety.
16.Despite being aware of significant operational changes at Montreal, Maine & Atlantic Railway, Transport Canada did not provide adequate regulatory oversight to ensure the associated risks were addressed.
17.Transport Canada Quebec Region did not follow up to ensure that recurring safety deficiencies at Montreal, Maine & Atlantic Railway were effectively analyzed and corrected, and consequently, unsafe practices persisted.
18.The limited number and scope of safety management system audits that were conducted by Transport Canada Quebec Region, and the absence of a follow-up procedure to ensure Montreal, Maine & Atlantic Railway’s corrective action plans had been implemented, contributed to the systemic weaknesses in Montreal, Maine & Atlantic Railway’s safety management system remaining unaddressed.

After reading the report it appears only 7 hand brakes were applied even though the number of cars required 9. Ther was mention of handbrakes applied to each engine and I wonder if that is included in the number of 7. They used the term cars when stating 7 were applied. With the train being on a 1.3% grade perhaps more than nine handbrakes would have been needed to secure the train.

So the root cause was pretty much what I've said since this happened. Insufficient number of hand brakes and they were not properly tested (independent brake was not released with the automatic). All the other "contributing factors" wouldn't have mattered if not for the insufficient number of hand brakes. What a shame.

I haven't had time to read it thoroughly yet but one thing that jumped out at me was this:

1.23.5 Research into single-person train operations

In the United States, the FRA conducted a series of cognitive task analyses pertaining to railway operating crews.88 With respect to the role of the conductor, they found the following:
· Conductors and LEs not only work together to monitor the operating environment outside the locomotive cab, they also work together to plan activities, to solve problems, and to plan and implement risk mitigation strategies.
· Operating in mountain grade territory can significantly alter the complexity of a conductor’s duties, introducing additional cognitive demands.
· When the conductor must handle unexpected situations, “these unanticipated situations impose cognitive as well as physical demands on the conductor.“89
· New technologies, such as positive train control (PTC), will not account for all of the cognitive support that the conductor provides.

tomstp Wrote:
-------------------------------------------------------
> After reading the report it appears only 7 hand
> brakes were applied even though the number of cars
> required 9. Ther was mention of handbrakes
> applied to each engine and I wonder if that is
> included in the number of 7. They used the term
> cars when stating 7 were applied. With the train
> being on a 1.3% grade perhaps more than nine
> handbrakes would have been needed to secure the
> train.

It was 7 including the locomotives, which is permitted by MM&A rules. The "minimum number" is only a guideline. "Sufficient number" is the prevailing standard and required by rule. Seven brakes was insufficient and the effectiveness was not properly tested. End of story.

Assuming the tonnage of the train was in the 8000-10,000 range, it would have required at least 27 to 33 handbrakes, and that is assuming the handbrakes are all working properly. That's why its imperative that when a train is left unattended , a securement check must be made to determine if the handbrakes that were set will hold the train. Had a securement check been done;none of this would have happened.

Correct. The MM&A had lots of safety training, testing and oversight issues which are going to come back and haunt a lot of people, but ultimately, if the engineer follows the rule book for properly securing and testing the train, the accident doesn't happen. Sorry, but someone with THAT amount of time on job working in that region darn well should have known better.

The barrel of reports, instructions, radio tapes are proving to be very interesting. It seems like there was a lot of discussion prior to the runaway, and several "probably should have" situations.

I haven't read the entire document, but is there any mention of World Fuels (the broker) and Irving Energy (the consignee) in the selection and leasing of these tank cars?

Give it a few hours and the Globe & Mail / Star should have any number of experts chiming in.

The tank cars and the oil in them was covered pretty extensively from an informational standpoint, as was track structure.

Regarding "number of breaks applied", when a train is left alone like this, and a new crew comes to take over, do they just keep walking back until they release all set handbrakes or is there a record somewhere that the crew notes about number of brakes applied?

This report shows how a series of small mistakes can lead up to a large tragedy.

On CP, at least, handbrake information and such is documented on a "crew to crew" form which is left on the locomotive for the relieving crew.

Darren Boes
Lethbridge, AB
Southern Alberta Railfan

nicknack Wrote:
-------------------------------------------------------
> Regarding "number of breaks applied", when a train
> is left alone like this, and a new crew comes to
> take over, do they just keep walking back until
> they release all set handbrakes or is there a
> record somewhere that the crew notes about number
> of brakes applied?

Not where I work. You walk back kicking brakes until you don't find any, then you check three behind that.

Seems like a time wasting way of doing things to me..

Why is it a waste of time? It puts the responsibility for properly releasing the brakes on the crew that is on the train. It doesn't rely on the accuracy or memory of the crew who left it earlier, which may have even been more than one crew. You won't ever see me dragging cars around with hand brakes set because I follow this to the letter. Not a waste of time at all. It's guys who think this is a "waste of time" who get stopped at the detector 8 miles out of the terminal.



Edited 1 time(s). Last edit at 08/19/14 11:35 by trainjunkie.

I see your point, but having the crew that applied the brakes leave behind some documentation just seems obvious to me. I would agree that it would be wise to check ONE more than what the paperwork said, but beyond that, there should be no need.

trainjunkie Wrote:
-------------------------------------------------------
> So the root cause was pretty much what I've said
> since this happened. Insufficient number of hand
> brakes and they were not properly tested
> (independent brake was not released with the
> automatic). All the other "contributing factors"
> wouldn't have mattered if not for the insufficient
> number of hand brakes. What a shame.

Actually, the report found the opposite. The quote in the Globe:

"However, TSB chair Wendy Tadros said the chain of causes and contributing factors “goes far beyond the actions of any single person.” She said the agency found 18 different factors that played a role in the disaster. “Take any one of them out of the equation,” she said, “and this accident may not have happened.” "

The attitude that "all you need is good hand brakes" is part of the railways' safety culture problem. The report talks about inadequate "safety management systems" which is a pretty standard approach across many industries to industrial and public safety. It also finds fault in the lack of "additional barriers" to prevent parked trains from moving. In other words, there should have been multiple parallel measures providing defense in depth.

This tragedy here is how it is only just dawning on the railways and their regulators that transportation of hazardous goods needs a more sophisticated approach to safety than hauling grain or coal. That approach has long been in place in airline technology, nuclear operations, etc. It's time for railways to enter this higher plane of practice.

The 1979 report into the accident at the Three Mile Island can be found at http://www.threemileisland.org/downloads/188.pdf . It's scary how similar the root causes of that accident parallel the root causes of the Lac Megantic event. Thirty five years later!

- Paul



Edited 1 time(s). Last edit at 08/19/14 11:47 by crs1026.

junctiontower Wrote:
-------------------------------------------------------
> I see your point, but having the crew that applied
> the brakes leave behind some documentation just
> seems obvious to me. I would agree that it would
> be wise to check ONE more than what the paperwork
> said, but beyond that, there should be no need.

Because the rule states that a "sufficient number" of hand brakes must be applied. Not a "sufficient number of consecutive or adjacent" brakes. Some guys will apply brakes on one side only, skipping the ones on the opposite side. This is especially true of certain types of trains that are difficult to safely cross through. Think auto racks, or open top hoppers with no crossover walkway on the ends and high brakes. Walking six extra car lengths total to check three brakes doesn't take but a few minutes. Cheap insurance if you ask me.

crs1026 Wrote:
-------------------------------------------------------
> Actually, the report found the opposite. The quote
> in the Globe:

Read the report. Under 3.1 Findings as to causes and contributing factors, these are the first three items:

1. MMA-002 was parked unattended on the main line, on a descending grade, with the securement of the train reliant on a locomotive that was not in proper operating condition.

2. The 7 hand brakes that were applied to secure the train were insufficient to hold the train without the additional braking force provided by the locomotive’s independent brakes.

3. No proper hand brake effectiveness test was conducted to confirm that there was sufficient retarding force to prevent movement, and no additional physical safety defences were in place to prevent the uncontrolled movement of the train.

I don't care what the Globe states. Had a sufficient number of hand brakes been applied and tested, this would never have happened. Everything else was a contributing factor, not the root cause.

crs1026 Wrote:
-------------------------------------------------------
> trainjunkie Wrote:
> --------------------------------------------------
> -----
> > So the root cause was pretty much what I've
> said
> > since this happened. Insufficient number of
> hand
> > brakes and they were not properly tested
> > (independent brake was not released with the
> > automatic). All the other "contributing
> factors"
> > wouldn't have mattered if not for the
> insufficient
> > number of hand brakes. What a shame.
>
> Actually, the report found the opposite. The quote
> in the Globe:
>
> "However, TSB chair Wendy Tadros said the chain of
> causes and contributing factors “goes far beyond
> the actions of any single person.” She said the
> agency found 18 different factors that played a
> role in the disaster. “Take any one of them out
> of the equation,” she said, “and this accident
> may not have happened.” "
>
> The attitude that "all you need is good hand
> brakes" is part of the railways' safety culture
> problem. The report talks about inadequate "safety
> management systems" which is a pretty standard
> approach across many industries to industrial and
> public safety. It also finds fault in the lack of
> "additional barriers" to prevent parked trains
> from moving. In other words, there should have
> been multiple parallel measures providing defense
> in depth.
>
> This tragedy here is how it is only just dawning
> on the railways and their regulators that
> transportation of hazardous goods needs a more
> sophisticated approach to safety than hauling
> grain or coal. That approach has long been in
> place in airline technology, nuclear operations,
> etc. It's time for railways to enter this higher
> plane of practice.
>
> The 1979 report into the accident at the Three
> Mile Island can be found at
> http://www.threemileisland.org/downloads/188.pdf .
> It's scary how similar the root causes of that
> accident parallel the root causes of the Lac
> Megantic event. Thirty five years later!
>
> - Paul

Government agencies LIKE to talk like that because it gives them Carte Blanche to spend the next twenty years studying the issue and issuing enough decrees, rulings and recommendations to fill a library and otherwise justify their own existence when simply following the railroad rule book would have prevented the whole incident. Does that mean that there are not things to learn or change? No, but lets be reasonable and attack the things that can and are likely be changed, not get all wadded up with things that are NOT likely to change. Part of the problem with making these tragedies "everybody's fault" is that ultimately it makes it "nobody's fault". If you are going to expand the scope to 18 different problems, you might as well blame God for not making the earth flat while you are at it.