The Transportation Safety Board of Canada (TSB) said 18 factors contributed to the derailment and explosion of an unattended freight train loaded with crude oil in Lac-Megantic, Quebec, in July 2013, and made five recommendations to prevent future accidents.
In a 191-page report released Tuesday, the TSB said the railway line (now defunct) involved in the accident -- the Montreal, Maine & Atlantic Railway (MMA) -- had a weak safety culture and did not have a system in place to manage safety risks (see Shale Daily, July 9, 2013). The agency also found that Transport Canada, the regulatory body in charge of transportation, had not audited MMA often or thoroughly enough to see the safety problems with the railway.
The TSB also said it found problems with MMA's training and monitoring of its employees, as well as its maintenance practices. The railway also did not follow industry procedures for securing unattended trains or for tank cars containing crude oil.
"Accidents never come down to a single individual, a single action or a single factor," said TSB Chairman Wendy Tadros. "You have to look at the whole context. In our investigation, we found 18 factors played a role in this accident. This investigation and its findings are complex, but our goal is simple: we must improve rail safety in Canada."
According to the TSB, the MMA train involved in the accident originated in New Town, ND, and its final destination was Saint John, New Brunswick. At about 10:50 p.m. on July 5, 2013, the train arrived at Nantes, Quebec, with a payload of 7.7 million liters (2.03 million gallons) of crude oil in 72 DOT-111 (Department of Transportation) tank cars.
The engineer applied hand brakes to all five locomotives and two other cars on the train, then shut down all but the lead locomotive.
"Railway rules require hand brakes alone be capable of holding a train, and this must be verified by a test," the TSB said. "That night, however, the locomotive air brakes were left on during the test, meaning the train was being held by a combination of hand brakes and air brakes. This gave the false impression that the hand brakes alone would hold the train."
The TSB said the engineer contacted, in separate conversations, rail traffic controllers in Farnham, Quebec, and Bangor, Maine. During the latter conversation, the engineer said the lead locomotive had experienced mechanical problems during the trip, and had been emitting excessive black and white smoke from its stack. The engineer and the Bangor controller agreed to leave the train at Nantes and to deal with the situation the next morning.
Shortly after the engineer left, the TSB said, the Nantes Fire Department responded to a 911 call reporting a fire on the train. Firefighters followed railway procedure and shut off the locomotive's fuel supply and moved the electrical breakers inside the cab to the off position. The firefighters then met with an MMA track foreman who had been dispatched to the scene, but who did not have a locomotive operations background.
After the fire was extinguished, the Nantes firefighters and the MMA track foreman discussed the train's condition with the rail traffic controller in Farnham, the TSB said. Everyone left the scene soon afterward.
"With all the locomotives shut down, the air compressor no longer supplied air to the air brake system," the TSB said. "As air leaked from the brake system, the main air reservoirs were slowly depleted, gradually reducing the effectiveness of the locomotive air brakes. Just before 1 a.m., the air pressure had dropped to a point at which the combination of locomotive air brakes and hand brakes could no longer hold the train, and it began to roll downhill toward Lac-Megantic, just over seven miles away."
The TSB said that as the runaway train moved downhill, it picked up speed. The train had reached a top speed of 65 mph when in derailed in the center of Lac-Megantic.
The investigation found that in October 2012, eight months before the accident, the lead locomotive had been sent to MMA's repair shop following an engine failure. Sixty-three of the 72 tank cars derailed, spilling approximately 6 million (1.59 million gallons) of crude oil.
"Given the significant time and cost of a standard repair, and the pressure to return the locomotive to service, the engine was repaired with an epoxy-like material that lacked the required strength and durability," the TSB said. "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 accident."
Investigators found a safety culture at MMA that was "generally reactive," and not proactive in preventing accidents, and that there were "significant gaps" between its operating instructions and how work actually transpired day-to-day.
"When the investigation looked carefully at MMA's operations, it found that employee training, testing, and supervision were not sufficient, particularly when it came to the operation of hand brakes and the securement of trains," the TSB said. "Although MMA had some safety processes in place and had developed a safety management system in 2002, the company did not begin to implement this safety management system until 2010 -- and by 2013, it was still not functioning effectively."
The TSB added that Transport Canada's regional office in Quebec had identified MMA as a company with a higher risk for accidents, requiring more frequent inspections. MMA corrected problems found during inspections, but the problems sometimes reappeared during later inspections. The problems included securing trains, training employees and track conditions.
"Transport Canada's regional office in Quebec...did not always follow up to ensure that these recurring problems were effectively analyzed and that the underlying conditions were fixed," the TSB said, adding that the regional office had not audited MMA until 2010 "despite clear indications [via inspections] that the company's safety management system was not effective.
"Transport Canada headquarters in Ottawa, meanwhile, did not effectively monitor the region's activities. As a result, it was not aware of any weaknesses in oversight of regional railways in Quebec, and it did not intervene."
In response to the accident, the TSB made five recommendations:
Transport Canada must ensure that railways have a working and effective safety management system;
Canadian railways must put in place additional safeguards to prevent runaway trains;
Emergency response assistance plans must be created when large volumes of liquid hydrocarbons, like oil, are shipped;
Railway companies should conduct strategic route-planning and enhance train operations for all trains carrying dangerous goods; and
Enhanced protection standards for DOT-111 tank cars.
The first two recommendations were issued this month, the three others in January (see Shale Daily, Jan. 14). In June, the TSB said the third recommendation had been satisfactorily implemented, while the fourth was satisfactory in intent. Last month, the board found the fifth recommendation had been implemented satisfactorily in part.
Six months after the Lac-Megantic accident, a 90-car crude oil train loaded with Bakken crude heading to a refinery in Florida derailed in a rural area near Aliceville, AL. According to DOT, more than 20 cars derailed and at least 11 ignited, causing an explosion and fire. Although no one was injured in the incident, an undetermined amount of crude fouled a wetlands area, causing an estimated $3.9 million in damage.
On Dec. 30, 2013, a BNSF train carrying Bakken crude hit a grain train traveling in the opposite direction that had derailed earlier near Casselton, ND. The crash caused 21 cars carrying crude to derail, 18 of which subsequently ruptured and exploded (see Shale Daily, Dec. 31, 2013). There were no injuries, but about 1,400 were evacuated. Damage was estimated at $8 million.
Nine days after the derailment near Casselton, several cars of a Canadian National Railway (CN) train, including some loaded with crude oil and propane, derailed and caught fire near Plaster Rock, in the Canadian province of New Brunswick (see Shale Daily, Jan. 8).
Last May, two DOT agencies -- the Federal Railroad Administration (FRA) and the Pipeline and Hazardous Materials Safety Administration (PHMSA) -- issued a safety advisory strongly urging those shipping or offering Bakken crude to use tank car designs with the highest level of integrity available in their fleets, and to avoid using the DOT-111 railcars.
In a report also released in May, the American Fuel & Petrochemical Manufacturers (AFPM) said Bakken crude isn't significantly more dangerous than crude from other plays to transport by rail and poses a lower transport risk than other flammable liquids (see Shale Daily, May 15). But AFPM, which represents nearly all of the petroleum refiners and petrochemical manufacturers in the United States, conceded that Bakken crude may contain higher amounts of dissolved flammable gases compared to heavier crudes.
In June, the U.S. State Department said there could be a four-fold increase in the estimated number of deaths and injuries from rail accidents over a 10-year period if the Keystone XL pipeline isn't built (see Shale Daily, June 9). The pipeline would carry heavy crude from the Canadian oilsands from Morgan, MT, to Steele City, NE (see Shale Daily, May 7, 2012).
North Dakota energy officials reported in July that the amount of Bakken crude being shipped out of the play by rail is declining (see Shale Daily, July 16). According to the North Dakota Pipeline Authority, 59% of crude oil produced in the Bakken was transported out of the play in May, the most recent month where figures were available; the peak was once more than 70%.