Lac-Mégantic report blames lax oversight, weak safety culture

By KIM MACKRAEL AND GRANT ROBERTSON   The Globe and Mail   Aug. 19 2014

http://www.theglobeandmail.com/news/national/tsb-releases-final-report-on-lac-megantic-rail-disaster/article20106828/

A railway with a “weak safety culture” and a federal regulator that was asleep at the switch combined to bring about the worst accident in modern Canadian history, says a report by the Transportation Safety Board.

The agency’s investigation into the rail disaster in Lac-Mégantic, Que., last summer – which killed 47 people when a train loaded with crude oil derailed and exploded in the centre of town – places considerable blame on the railway, Montreal Maine & Atlantic, for failing to operate safely.

But the findings also take aim at Transport Canada for failing to recognize the railway had safety problems, and for not ensuring MM&A was following the government’s own safety rules.

In its criticism of the federal government, the watchdog agency investigating the crash referred to Transport Canada as “a regulator that did not audit” the safety procedures it required the railway to follow. Transport Canada didn’t do enough inspections and “they didn’t assess the risks properly,” including looking into a company that the government knew had a problematic safety record

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The Transportation Safety Board report comes more than a year after a runaway train jumped the tracks and unleashed a flood of burning oil on the small Quebec town, killing 47 people and destroying dozens of buildings. The July 6, 2013, rail accident was the worst in modern Canadian history and Lac-Mégantic is still struggling to rebuild more than a year after it occurred.

The investigation found that too few hand brakes were set by the train’s operator when the it was parked at the top of a slope in Nantes, Que., on the night of July 5. The engineer applied only seven hand brakes and did not follow rules requiring him to test the hand brakes’ effectiveness, the TSB said.

 

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.”

In making a series of recommendations on how to prevent another disaster, the agency raised serious concerns about Transport Canada’s oversight of risk in the rail industry, particularly after railways began hauling massive quantities of crude oil by rail. “This booming industry where oil trains were shipping more and more oil across Canada and across the border ran largely unchecked,” Ms. Tadros said.

Among the recommendations issued by the TSB, the agency said Transport Canada should require additional physical defences to prevent trains from running away when they are left unattended. It also called for more frequent and detailed audits of railways’ safety management systems to make sure they are effective and that any problems are corrected.

Such steps for securing trains could include introducing wheel chocks for parked trains or installing more modern braking technology that is better at holding trains in place than current equipment, the TSB said.

Ms. Tadros said Transport Canada also should also have done more to ensure MM&A had a functioning safety management system.

After the release of the report Tuesday, Transport Minister Lisa Raitt declined to commit to accepting the latest TSB recommendations, saying only that she has asked the department to assess “concrete” ways to respond to them.

“When we have that, then we can move forward with responding to the recommendations, but it’s clear we want to have concrete action,” Ms. Raitt said. She said Transport Canada has already implemented all of the TSB’s interim recommendations and said “we’ll continue at that pace.” A government news release said the response would come within 90 days.

The minister, who took over her portfolio nine days after the Lac-Mégantic crash last year, faced a series of questions Tuesday over Transport Canada’s actions leading up to the crash and the TSB findings. In response, she largely pointed a finger at the railway and said government is expanding audit powers and safety measures in an effort to crack down and enforce rail regulations.

“Clearly the rules were not followed,” Ms. Raitt said at a 40-minute news conference on Parliament Hill. She spoke roughly 90 minutes after the 191-page report’s release, and said she had not yet read it.

“We need to remember that, in terms of safety, the government puts the rules in place. The companies are expected to follow the rules. The company did not follow the rules. And that’s a very important fact here as well, too,” Ms. Raitt added.

Ms. Raitt outlined what government has already done since the crash last year, including new safety standards for certain tanker cars, requiring railways to slow down trains and develop emergency response plans for trains carrying crude oil or other dangerous goods. “Safety and security of Canadians is our utmost priority,” Ms. Raitt said.

While the TSB report places considerable blame on the absence of proper procedures at MM&A and its “weak safety culture,” the TSB also criticizes the government for contributing to a climate that allowed the accident to happen, saying Transport Canada’s oversight of its own safety rules is lacking. “They have to be audited with sufficient depth and with sufficient frequency,” the agency said.

“This report is a searing indictment of Transport Canada’s failure to protect the public from a company that they knew was cutting corners on safety despite the fact it that was carrying increasing amounts of hazardous cargo,” Keith Stewart, climate and energy campaign coordinator for Greenpeace Canada, said in a statement. “This lax approach to safety has allowed the unsafe transport of oil by rail to continue to grow even after the Lac Mégantic disaster.”

Tuesday’s report was among the TSB’s most complex and demanding rail investigations and took more than a year to complete.

There are notable absences in the report. It focuses mostly on train handling, and mentions little of dealing with highly explosive oil, despite acknowledgements by the government this year that the oil involved in the crash was extremely volatile.

Its findings will attract widespread attention, both in Canada and the United States, because of the scale of the accident and the broader questions it has raised about moving crude oil by rail. The oil that exploded in Lac-Mégantic was from the Bakken formation in North Dakota and was more prone to exploding than traditional crude. The TSB said earlier this year that the train’s cargo was as volatile as gasoline but had been improperly classified as a less explosive flammable liquid.

The accident exposed glaring gaps in Canada’s regulatory system, which had imposed no new safety rules for crude-oil trains in the years before the crash, despite a rapid increase in crude-by-rail traffic. Transport Canada also appeared to be caught flat-footed by the risks of moving volatile light oil. Before the accident in Lac-Mégantic, it did not impose new regulations to prevent the potentially explosive crude from being moved in puncture-prone DOT-111 tank cars.

During the year since the accident, Transport Canada has announced new rules for railways to undertake risk assessments for routes with a high volume of dangerous goods. However, some safety experts argue the regulator should have acted sooner. “Everything that’s happened has been sort of ex post facto,” said Mark Winfield, who researches safety regulations at York University in Toronto. “It’s all been after Lac-Mégantic. It’s been the right moves, but why did 47 people have to die in order for this to happen?”

The Globe and Mail reported earlier this week that part of the TSB’s investigation focused on a repair that was completed nine months before the fatal accident. A source told The Globe that the material used in the repair wasn’t strong enough and eventually failed, sparking a series of other problems that ultimately led to a buildup of oil in the engine.

A fire broke out in that engine about an hour after the train’s engineer left it idling on the main track in Nantes and retired for the night. Firefighters extinguished the blaze and turned off the engine, which eventually caused the air brakes to stop working. Forced to rely on an insufficient number of hand brakes, the train rolled downhill toward Lac-Mégantic, reaching a speed of more than 100 kilometres an hour before it derailed.

MM&A and three of its employees, including engineer Tom Harding, were charged with criminal negligence in connection with the crash earlier this year. Train operations manager Jean Demaitre and railway traffic controller Richard Labrie were also charged. Civil suits have also been filed in Canada and the U.S. and some experts have called for a separate inquiry.

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