Director of Investigations for the Transportation Safety Board (TSB) of Canada, Kirby Jang, was among the keynote speakers at RISSB’s 2015 Rail Safety Conference.
Mr. Jang reviewed the catastrophic Lac-Mégantic rail accident and how his team at the TSB proceeded with their investigation on the incident. He detailed the factors leading up to the incident, how his team conducted their objective investigation, and their respective findings and recommendations on railway safety for the company involved as well as the other relevant industries.
The Transportation Safety Board of Canada
The Transportation Safety Board of Canada (or TSB) is an independent agency of the Government of Canada that is primarily focused on advancing transportation safety. The board investigates relevant transportation incidents and makes recommendations for safety in four transportation modes including marine, pipeline, air and rail.
Enacted on March 29 1990, the Canadian Transportation Accident Investigation and Safety Board Act exclusively created the TSB. The agency was formed as a result of several high-profile accidents which prompted the Government of Canada to create an independent investigatory body covering all transportation modes. The TSB runs an engineering laboratory in Ottawa, Ontario, with its headquarters in Gatineau, Quebec, with eight other regional offices where they deploy their respective investigators from.
Created under the Transportation Accident Investigation and Safety Board Act, the TSB is essentially tasked to work on major transportation incidents by conducting independent investigations, identifying safety deficiencies, enumerating cause and contributing factors, making recommendations, and reporting their findings publicly.
It is important to note however that the TSB does not assign fault or help determine any civil or criminal liability for any of their cases and their findings cannot be used in any legal or disciplinary procedures. However, their findings may be used by coroners and medical examiners in their investigations. Also, TSB recommendations are not mandatory so it is critical that they make compelling arguments for change to be implemented.
Currently, the rail and pipeline divisions which Kirby Jang leads has four major priority issues including on board video and voice recorders, following signal indications, railway crossing safety, and the transportation of flammable liquids by rail.
The Transportation Safety Board of Canada’s new watch list covers safety management oversight, a very prominent feature highlighted in the Lac-Mégantic accident. This refers to transportation companies who are not effectively managing their safety risks. Regulatory oversight and intervention has not always proven effective at changing companies’ unsafe acts and practices.
The night of the Lac-Mégantic rail accident
On 6 July, 2013, at around 1:15 a.m., an unattended freight train transporting 72 tank cars of approximately 7.7 million litres of petroleum crude oil rolled downhill and derailed from its mainline at the resort town of Lac-Mégantic, resulting in a deadly fire and explosion which destroyed a large area of the downtown’s core and caused the death of 47 local residents.
According to the animation presented by Mr. Jang during his talk, here are the details of what exactly happened the night of the Lac-Mégantic incident.
On the night of 5 July 2013, at around 10:50 p.m., a single-person-operated MMA train (Montreal, Maine, and Atlantic Railway) was parked on a descending grade on the main track right at the heart of the town of Lac-Mégantic.
After shutting down 4 of the locomotive brakes, the train’s engineer applied 7 handbrakes. As per railway rules, handbrakes alone must be capable of holding a train. But that must be verified by performing the “brake efficiency test”. During the test however, the locomotive brakes were left running, which meant that the train was actually being held by a combination of handbrakes and airbrakes, giving the engineer the wrong impression that the handbrakes alone were enough to hold the train.
Before leaving the train, the engineer contacted two rail traffic controllers: one in Quebec to inform them that the train was secure, and another in Bangor, Maine, to report the smoking lead locomotive that had been showing some problems throughout the trip and the difficulties it might present the next crew. With the excessive black and white smoke expected to settle, it was agreed to leave the train as it was and to deal with the situation the morning after.
Just a few minutes after the engineer left for the night, the Nantes fire department responded to a 911 call of a fire on the train. Firefighters successfully extinguished the blaze on the lead locomotive by shutting the fuel off. Following railway instructions, responders turned the electric brakes off. After discussing the situation with the rail traffic controller in Farnham and an MMA employee dispatched to the area, everyone left for the night.
With all the locomotive brakes shut down, the airbrake system started to lose pressure, causing the brakes to be less effective. Just before 1:00 a.m. air pressure on the train dropped to a point where the combination of airbrakes and handbrakes could no longer hold the train. With practically no brake holding the train, it started rolling downhill to the downtown area of Lac-Mégantic that was 7 miles away, picking up speed to up to 65 mph.
The train derailed at the crossing where almost all of the 7 million litres of crude oil began pouring into the streets and fire was almost instantaneous. The ensuing blaze and explosions tragically resulted in the death of 47 residents. In addition, more than 2,000 citizens were forced to evacuate from their homes and a huge part of the downtown Lac-Mégantic area was destroyed.
Why was there so much damage?
When the unattended freight train derailed on 6 July 2013 and rolled downhill at the town of Lac-Mégantic, 63 of the 72 tank cars carrying 7.7 million litres of petroleum crude oil broke from the main line—fire was almost instantaneous.
The TSB Director of Investigations Kirby Jang explained how in North America, the primary tank car implemented for use for dangerous goods is the TLT U.S. DOT-111 tank car, whose specifications have been designed many years ago. Most of the tank cars in Lac-Mégantic were built between 1980 and 2012.
Mr. Jang further explained how a tank car’s performance is assessed based on three categories, namely puncture resistance, top and bottom feedings protection, and thermal resistance. An inventory of the Lac-Mégantic accident revealed the following figures: 63 derailed cars, 60% shell punctures, 50 head punctures, 32 top feedings, pressure release devices, thermal tears, among others—and as such, one can only imagine the fire and destruction that the explosion from the tank cars of millions of crude oil could cause on the scene.
The TSB emergency response
Mr. Jang expounded on how the investigation team was immediately deployed to the occurrence site to carry out their investigation. Of course, it should be pointed out that the TSB investigates only when an occurrence carries a high probability that it can help advance transportation safety and minimise (or eliminate, if possible) risks to people, property and the environment.
On the night of the Lac-Mégantic incident, the provincial police were immediately dispatched as soon as 911 calls were made. With the mutual aid agreement between the 80 municipalities, thousands of firefighters were deployed on the site over the next few days, primarily focused on evacuating the residents and preventing the fire from spreading farther.
As one cannot fight petroleum-fueled fire with water, the TSB had to transport a special fire-retardant foam from the Ultramar refinery in Lévis. The use of the said foam considerably helped the firefighters put the fire out.
Mr. Jang was quick to point out how well coordinated the emergency response was, with the Lac-Mégantic fire chief essentially designated as the incident commander. The TSB director admired how the unified command system and proper distribution of emergency tasks among the various agencies contributed to the entire effort being harmoniously carried out and implemented.
The TSB deployment activities and challenges
Mr Jang confirmed that the Lac-Mégantic incident was by far the largest investigation he’s handled in his career. As such, he and his TSB team was bombarded with a number of challenges that he needed to resolve for the successful completion of the investigation.
- Jurisdiction Coverage. One of the largest challenges that Mr. Jang faced in the Lac-Mégantic was on the matter of jurisdiction. At the national level, the company involved was an American business operating on Canadian soil, which means various provincial and federal organisations were involved and had interests with the incident.
- Parallel Criminal Investigation. The Lac-Mégantic incident was obviously treated as a crime scene where parallel criminal investigations were carried out. Many parts of the area where the incident happened had to be cordoned off as there was a need to preserve evidence.
- Temperature and Location. It should also be pointed out that the Lac-Mégantic disaster happened in the middle of summer where temperatures rose to around 40°C, making it more difficult and strenuous for the responders on site to go about their duties.
- Workers’ Occupational Safety. The TSB likewise had to keep into consideration the occupational safety of all the workers involved, ensuring that everyone had appropriate personal protective equipment on. They had to make sure policemen, firefighters, engineers, and all the other workers were properly protected against the hazards of the investigation that included physical, chemical, heat, biohazards, and other minute particles.
- Media Coverage. The Lac-Mégantic rail accident was a huge media story. TSB was overwhelmed with the large number of information requests and third-party experts that swarmed the area. As an investigation agency, the TSB needed to talk factually about what happened without getting into any speculations or analyses. They had to implement some damage control to ensure that every information that the media publicized was objective and concrete instead of being purely theoretical.
- Complex Investigation. The TSB had to examine all aspects of the incident in detail from the train operation to the train brakes, the use of single-person train operator, tracking equipment maintenance, tank car performance, product characteristics, the properties of crude oil, etc.
- Logistics. Because Lac-Mégantic is a small resort town, finding decent hotel accommodations for the thousands of the emergency responders deployed for the accident was a big challenge. Meetings and other briefings had to be conducted at the command post.
- Communications. Right after news of the incident reached the TBS, several communications advisers were immediately deployed to the site. Live media events had to be organised, and this went nonstop for the next few days and over the three-week period after the tragedy.
Keeping the people informed
TSB Director of Investigations Kirby Jang admitted that part of their responsibilities during an investigation is keeping the public well informed. To do this, they had an active investigation page on their website that was regularly updated in terms of statistics and figures related to the incident. Questions and other queries were also accommodated and answered through TSB’s social media accounts.
Over the 13-month course of the Lac-Mégantic incident investigation, the TSB made sure that they were able to promptly hand out safety communications, advisory and information letters, and recommendations prior to releasing their final report.
As for the Lac-Mégantic, the TSB sent out a safety advisory to Transport Canada on 19 July 2013 to consider reviewing pertinent railway operating procedures to make sure that when a train is carrying dangerous goods, it should not be left on the main track unattended.
Another urgent safety advisory was sent out by the TSB to Transport Canada to review the Canadian Rail Operating Rule 112 and all the other relevant instructions on ensuring that trains left unattended must be properly secured to prevent any untoward movements.
Other safety advisories issued by the TSB included those that recommended the identification of the properties of the petroleum crude oil and their proper categorization to ensure that they are being transported in the appropriate container, monitoring programs for the classification of gases and liquids, and implementation of proper railway training for all workers.
In closing his talk at the Rail Safety 2015 Conference, Kirby Jang enumerated the specific recommendations that the TSB submitted in its August 2013 report:
- Proper auditing of safety management systems. The TSB suggested that Transport Canada must regularly check their railways’ safety management systems and ensure that they are working effectively and that they are being implemented as designed.
- Enhanced protection standards for Class 111 tank cars. The TSB recommended all DOT-111 tank cars to be retired, noting that the tank cars used in the Lac-Mégantic incident were old DOT-111 railcars.
- Route planning analysis. The TSB proposed that railway companies conduct strategic route planning as well improve on train operations particularly for those trains carrying dangerous goods. This could mean identifying and using those routes with less risk for those operations with multiple routes available or identifying ways to medicate the risks along those operations with single routes available.
- Creation of emergency response assistance plans. The TSB wants regulators to put Emergency Response Assistance Plans in place in the event that accidents and other untoward incidents happen when transporting hazardous materials, ensuring that appropriate emergency equipment and personnel are readily available along the route.
- Physical defences to prevent runaways. The TSB advised Transport Canada to require the use of wheel chocks for parked trains or the installation of state-of-the-art braking technology to keep parked trains in place.