TSB report outlines ‘multitude of factors’ behind Lac-Megantic train derailment

A multitude of factors led to July 6 derailment of a runaway train in Lac Megantic, Que., carrying 72 carloads of Bakken crude oil bound for Irving Oil Ltd.’s refinery in Saint John, NB, according to an investigation report released Aug. 19 by the Transportation Safety Board of Canada (TSB) (OGJ Online, July 8, 2013).

The incident, which involved a train operated by Montreal, Maine & Atlantic Railway (MMA), a division of Rail World Inc., resulted in fires and explosions that destroyed much of the town and left 47 people dead.

TSB now is calling for additional physical defenses to prevent runaway trains, and for more thorough audits of safety management systems‎ to ensure railways are effectively managing safety.

“Accidents never come down to a single individual, a single action, or a single factor. You have to look at the whole context,” said TSB Chair Wendy Tadros. “In our investigation, we found 18 factors played a role in this accident.”

TSB found that MMA was “a company with a weak safety culture that did not have a functioning safety management system to manage risks.”

The board said it also learned that, “Transport Canada did not audit MMA often and thoroughly enough to ensure it was effectively managing the risks in its operations.”

The board also found issues with training, employee monitoring, and maintenance practices at MMA; with industry rules for the securement of unattended trains; and with the tank cars used to carry volatile petroleum crude oil, it said.

“This investigation and its findings are complex, but our goal is simple: we must improve rail safety in Canada,” Tadros said. “That’s why,” she said, “in addition to our three previous recommendations, we are issuing two new recommendations to ensure unattended trains will always be secured, and Canada’s railways will have safety management systems that really work to manage safety.”

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