Technical investigation of the Lac-Mégantic rail disaster
The technical investigation of the Lac-Mégantic rail disaster looked into the instigating and mitigating factors regarding the incident, one of the deadliest in Canadian railway history, with 47 deaths. It identified 18 factors related to the cargo, maintenance of the tracks, maintenance and operation of the train, and weak government oversight all combined to produce the disaster. Five recommendations for change resulted from the investigation. Background. "Parent article: Lac-Mégantic rail disaster" The involved tracks and train were operated by the Montreal, Maine and Atlantic Railway (MMA, also MM&A). Over the  decade leading up to this accident, aggressive cost cutting for freight train operations and continued deferred maintenance on the tracks resulted in much of the trackage being in marginal condition. By 2013, speed reductions were required on 23 portions of the line involved in the incident, including a limit at Sherbrooke yard and on a stretch east of Magog. Freight trains operated by MMA were allowed (not "permitted", see parent article) by regulators in Canada (Transport Canada) and the United States (Federal Railroad Administration) to have Single Person Train Operation (SPTO, alternately OPTO) status (1 operator). The permit process, which  requires public input, was not followed. The Canadian regulator and the MMA entered into a negotiation process at the culmination of which, sometime before the second week of July 2012, the government allowed MMA to reduce their manpower to SPTO. The Maine regulator had already allowed SPTO status before the first week of April 2012. In October 2012, eight months before this accident, the lead locomotive (5017) was sent to MMA's repair shop following an engine failure. The engine was repaired with an epoxy-like material that lacked the required strength and durability. This material failed in service, leading  to engine surges and excessive black and white smoke. Eventually, oil began to accumulate in the body of the turbocharger, where it overheated and caught fire on the night of the derailment. Events shortly prior to the derailment. The involved freight train, known as "MMA 2", consisted of five head-end locomotives, led by # 5017; one remote-control "VB" car (used to house the Locotrol equipment necessary for MMA’s single engineer train operation); and one loaded box car used as a buffer car; followed by 72 non-pressure dangerous goods DOT-111 tank cars, each loaded with of petroleum crude  oil (Class 3, UN 1267). It departed the Canadian Pacific Railway (CPR) in Côte Saint-Luc on July 5 earlier in the day and subsequently changed crews at the MMA yard in Farnham. "MMA 2" departed Farnham and stopped at the designated MMA crew change point in Nantes at approximately 23:00. Nantes is located west of Lac-Mégantic. The tracks in this location are at a 1.2% grade (slope). Following the MMA's operating plan, the engineer parked the freight train on the main line. He set the brakes and followed standard procedure by shutting down four of the five  locomotives. The train could not be parked on the adjacent siding because MMA used it routinely to store empty boxcars. The Nantes siding has a derail that could have stopped the train from accidentally departing. According to Transport Canada, it is unusual to leave an unattended train parked on a main line, but there were no regulations in place to prevent that behaviour. The engineer left the lead locomotive, #5017, running to keep air pressure supplied to the train's air brakes and also applied a number of manual hand brakes. The engineer also attempted a brake test but incorrectly  left the locomotive air brakes on during the test; this gave the false impression that the hand brakes alone could hold the train. The engineer then contacted the rail traffic controller in Farnham, Quebec, to advise that the train was secure. Next, the engineer contacted the rail traffic controller in Bangor, Maine to report that the lead locomotive had experienced mechanical difficulties throughout the trip and that excessive black and white smoke was coming from its smoke stack. Expecting the smoke to settle, they agreed to deal with the situation the following morning. Having finished his work, the engineer departed  by taxi for a local hotel for the night. After the engineer had departed, the Nantes Fire Department as well as a police officer from the Sûreté du Québec's Lac-Mégantic detachment responded to a 9-1-1 call from a citizen at 23:50, who reported a fire on the first locomotive; according to Nantes Fire Chief Patrick Lambert, "We shut down the engine before fighting the fire. Our protocol calls for us to shut down an engine because it is the only way to stop the fuel from circulating into the fire." The fire department extinguished the blaze  and notified MMA's rail traffic controller in Farnham. MMA did not grant permission to the engineer to return to the scene, instead summoning a track maintenance foreman unfamiliar with the operation of railway air brakes. By 00:13 two MMA track maintenance employees had arrived from Lac-Mégantic; the Nantes firefighters left the scene as the MMA employees confirmed to the police officer and to the Farnham rail traffic controller that the train was safe. Derailment and explosion. With all the locomotives shut down, the air compressor could no longer supply air to the air brake system. As air naturally  leaked from the brake system, the main air reservoirs were slowly depleted, gradually reducing the effectiveness of the locomotive air brakes. At 00:56, the air pressure had dropped to a point at which the combination of hand brakes and (now-reduced) locomotive air brakes could no longer hold the train, and it began to roll downhill toward Lac-Mégantic, just over seven miles away. The track was not equipped with signals to alert the rail traffic controller to the presence of a runaway train. "MMA 2" entered the town of Lac-Mégantic at up to entering a curve in an  area with a speed limit of Sixty-three of the 72 tank cars as well as the buffer car derailed, with many of the tank cars rupturing badly. About six million litres of petroleum crude oil was quickly released; the fire began almost immediately, generating a ball of fire three times the height of the downtown buildings. Heat from the fires was felt as far as away. People jumped from the third floor of buildings in the central business district to escape the fire. As the blazing oil flowed over the ground, it entered the town's storm sewer and  emerged as huge fires towering from other storm sewer drains, manholes, and even chimneys and basements of buildings in the area. Investigation. The Transportation Safety Board of Canada (TSB), which is prevented statutorily from issuing judgements or finding blame, started an investigation into the accident under reference R13D0054, deploying a team of 20 experts to the site to gather evidence and interview officials and witnesses. While the investigation was underway, the Transportation Safety Board asked Transport Canada review the Canadian Rail Operating Rules and special instructions by railways that cover securing equipment. They also advised that trains carrying dangerous goods  should not be left unattended on a main track. On July 8, Transport Canada investigated a second MMA train reported by police as unattended since July 5 on the Vachon Station siding near Frontenac. That train had been parked on a slope with only five handbrakes set, and did not comply with federal regulations. At least nine brakes should have been used to secure the train on level track, with additional handbrakes applied when on an incline. A local resident had posted online video of an unattended locomotive with a cabin door ajar and an engine left running. On July  19, Transportation Safety Board of Canada chief investigator Donald Ross said "Not enough brakes were applied to the train that derailed. A sufficient number of brakes needed to be applied and the quality of brakes needs to be examined." TSB investigators looked into the air brake system which is normally charged to 90 PSI (621 kPa) and, when the engineer reduces the air pressure to 65 pounds per square inch (448 kPa), applies the brakes. Investigators tried to determine how the air brakes were released by examining the theory that a relatively small change in air pressure could have produced  a "pressure wave" to trigger a quick release of the brakes. However, Wally Kirkpatrick, manager of rules and operations at RTC Rail Solutions, said the air brakes could have leaked off over time once the engine was shut down. Because crude oil generally does not readily ignite, TSB investigators looked into the composition of the train's cargo. Theories under investigation were: The TSB concluded that the severity of the fire was due largely to the large amount of oil rapidly released and the oil's inherent physical properties; there was no evidence of contamination with fracking additives or hydrogen  sulphide gas. On July 19, 2013, the TSB issued an urgent safety advisory requesting that Transport Canada consider reviewing all railway operating procedures to ensure that trains carrying dangerous goods are not left unattended on the main track. Also on July 19, the TSB issued another urgent safety advisory requesting that Transport Canada review Rule 112 of the Canadian Rail Operating Rules (CROR) and all related railway special instructions to ensure that equipment and trains left unattended are properly secured in order to prevent unintended movements. The TSB noted that most railway special instructions specify the minimum number of hand  brakes needed in general operating conditions but not always for specific conditions. It is often left up to the operating employee to determine the number of hand brakes to apply. The employee must take into consideration the slope or grade of the track and the approximate tonnage of the equipment to be secured at a specific location. The TSB also noted that the effectiveness of the hand brake system varied from car to car depending on the design, condition and maintenance, and also from one operator to another due to differences in physical capability and personal technique. The TSB also  stated that it is inadequate for railway operators to depend on the push–pull test to verify whether the hand brakes can hold the cars. On August 1, the TSB said it has taken samples of the oil for analysis. Both Canadian and US investigators have found the Bakken crude was not identified correctly in shipping documents, and the incorrect classification led to its volatility being underestimated. The following month, the TSB identified a defective piston in the head engine as the cause of the original fire in Nantes. Transport Canada issued notices of non-compliance after inspection of six  track segments found fair to substandard rail conditions which legally must be fixed, including a concentration of defective ties on a section near a propane storage facility. On September 12, following a failed inspection, Transport Canada shut down one segment of the MMA line until hazards could be fixed. Subsequent inspections led to an October 11 embargo on the line between Lennoxville and Lac-Mégantic. On August 19, 2014, the TSB issued its report documenting findings and recommendations. Findings. In its August 2014 report, the TSB identified 18 distinct causes and contributing factors, many of them influencing one another: Single  person train operation was initially investigated as a 19th factor in the derailment, but the investigation was not able to conclude whether having another crew member would have prevented the accident. It was thus was omitted from the final report. A second operator could have provided a second opinion about the thick smoke from the defective engine or verified the number of brakes to be set to hold the train on an incline. The TSB report also contains 16 findings as to risk even though these safety risks did not lead directly to the accident. Some of the risks that  the TSB recommends to be addressed are: Recommendations. In its August 2014 report, the TSB documented the following recommendations: