The Lac-Menganic rail disaster report contains a descriptive summery of the accident. The report also contains an overview of the analysis and results, the subsequent safety measures, which have been taken so far, and recommendations that should be followed to ensure that such terrible accident does not occur in future.
The Lac-Megantic rail disaster, like the name suggests, occurred in Lac-Megantic town, which is located in the Eastern Townships of Quebec. It was a fatal accident that involved the Maine and Atlantic Railway (MMA) train, which was transporting 7.7 million liters of crude oil packed in 72 class tank cars. According to the R13D0054 report issued by the Transportation Safety Board of Canada (TBS) after investigating the disaster, causes of the accident were numerous, some of which could have been prevented. The major cause to the disaster was the failure of the Locomotive engine. Prior to the departure, the locomotive engineer had parked the train in a descending order. This was aimed at keeping the train’s practices. In his operation, the engineer supplied the hand brakes on five locomotives and two cars. Then, the engineer shut them down forgetting the lead locomotive in the process. This was an omission that caused the train dearly. The engineer went further to keep the locomotive air brakes locked during the verification process. This error meant that the train could only be held by the combined hand and air brakes. Since the locomotives were shut down completely, the air compressor was prevented from supplying air to the brake system. Generally, anyone operating the train could experience a wrong impression because until the train gathers unusual speed, it could not still be held normally. Apparently, the initial sustainability of the train was wrong. Matters went wrong when the locomotive air brakes developed a gradual depletion to the reservoirs after air started to leak from within the brace tube. The end result was a massive drop on air pressure that made the train move out of control.
Basically, the combined air and hand breaks could not function any further due to inhibition caused by the leaked air. The end result was the rolling down of the train at a speed of 65 mph. Even though the rescue team was quick enough to release six million liters of petroleum crude oil, fire and explosion caught the train almost immediately because the petroleum was very volatile. Around 42 lives were consumed immediately while rising fear of possible loses of five more lives that went missing but were present at the scene (Stern n.p.). Much property was destroyed including sixty three derailed tanks and thirty buildings from the downtown. In addition, other three buildings from the nearby downtowns were left unsafe for human and hence, were later destroyed. Even though the pileups of tanks and large volume of petroleum crude oil gave the firefighters a heavy task to handle, their response was well coordinated; the fire was effectively protected ensuring safety of the site.
From a barrier and gap analysis perspectives, the determinants of the Lac-Magantic accident started to be evident from the point when excess black and white smoke was released by the train. The unusual smoke entailed concerns from all the corners. At this point, it could have been wise for an immediate action to be taken: urgent communication with the engineer to formulate supportive strategies could have saved the train. However, without a positive strategy, the locomotive engineer communicated to the rail traffic indicating that all is well and that the train is safe for the rest of the journey. Probably, the engineer wanted to correct the mistake he did when he was monitoring the train for transportation safety. Sooner, the engineer called again stating that the strange smoke was a result of mechanical difficulties that the train had been experiencing along the rail, and that it is just a matter of time as the smoke will eventually cease. At this point, matters were getting worse. In addition, it was advisable to leave the train in the current situation, without any change as an immediate eruption was feared. Then, it was agreed that the train would be corrected the following morning. Considerably, the train could have been stopped and the hand breaks could have been adjusted to take full control of the train, without considering the air breaks; this is a requirement of the railway traffic rules, which is safe enough to prevent the accident from occurring.
Fire in the Locomotive
Through event and casual factor charting technique, long time causes to the accident can be identified right from October 2012, approximately eight months before the disaster (Federman n.p.). This is when the lead locomotive was taken to the MMA for repair after an engine failure that developed in it. During the repair process, epixy-like material was used instead of the right material. Epixy-like material is not only low in strength but also in durability. Given enough money and time during the repair, probably, the accident could have been prevented. The epoxy-like material is evident as a long term effect of the accident because, after the repair, it failed several times leading to engine surges and hence progressive emission of the excess white and black smoke, which was evident until the point of the disaster. Few months after the repair, oil started to accumulate on the turbocharger. At the turbocharger, accumulated oil was heated up, which is the immediate cause of the fire that erupted immediately after the accident.
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According to the Canadian Rail Operating rules, unattended tools should be equipped with enough hand breaks to prevent unnecessary movements. The rules also demand that tests on the effectiveness of the train should be tested by the relevant train engineer to ensure that it is safe to be operated on the rail, without causing any harm to the general public and the environment as a whole. In addition, MMA’s rule qualifies a 72- car train safe for human only if it has nine plus hand breaks. The rules also state clearly that air breaks systems should not be relied on in preventing unwanted movements. Surprisingly, the locomotive was being operated in contradiction with these rules: the air brakes were combined with the hand breaks and used to prevent movements. In addition, the train was only using five hand breaks and two cars. Therefore, it is evident that adherence to the Canadian Rail Operating rules could have prevented the accident.
Similar to any other train, the locomotive had two types of brakes: the independent and automatic brakes. Automatic air brakes are used in slowing or stopping the train. They are controlled by a brake pipe that links the locomotive to every tank car. Decrease in air pressure in the pipes injects air into each tank car’s control valve, which then pushes air into the brake cylinder to apply the brake shoes to the wheels. During the air leakages from the air brake, pressure within the brake cylinders dropped gradually. This led to the reduction of the amount of force being applied to the locomotive by the independent brakes. When a train brake system is not recharged with air, the brakes become ineffective and hence do not apply braking force (Cruceanu 32). Tentatively, this situation made the train gain speed of 63 miles per hour – the momentum, with which the train moved downhill.
Safety Culture at MMA
An organization with strong safety culture is proactive in addressing matters that relate to safety. Generally, the MMA was reactive. Its safety culture was weak as demonstrated by the gaps between the day to day work performance and the operating instructions. Furthermore, during the inspection and testing process, training and supervisions were insufficiently conducted, especially on the operations of hand brakes. Occasionally, Transport Canada’s region office identified MMA with infectivity weakness indicating that it had an elevated risk levels that required frequent inspections in order to maintain safety. Unfortunately, the inspection of the train system was rarely done. The transportation office also lagged behind in making follow ups to ensure that the MMA took appropriate corrective action whenever a problem occurs. Therefore, this caused laxity on the side of MMA. In addition, the office did not intervene due to lack of information about the weakness of the former.
Damage and Construction
The 72 tank cars were manufactured differently between 1980 and 2012. All of them were Class 111 and hence met the required effect at the same time. However, they were constructed according to older standards. They lacked basic enhancements such as thermal protection, a full head shield and a jacket. The fire was fuelled by petroleum crude oil that was released when the tank cars were breached. Since the train was carrying flammable liquid, a barrier to more damages on the tank cars could have been an enhancement of safety features and tougher standards.
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The Lac-Megantic train disaster was not caused by the engineer as a party, neither was it caused by an organization or an action. The variety of factors contributed to the cause either in a way or two. Therefore, addressing the issue of safety needs a concentrated effort from the related parties such as the railway, shippers, regulators, tank car manufacturers, and refiners in the United States and Canada. In relation to this, the future transportation will only be safe if the safety deficiencies in the transportation department are adjusted appropriately.