Lac-Mégantic runaway train and

derailment investigation summary

This summary of the Transportation Safety Board of Canada’s (TSB) Railway Investigation
Report R13D0054 contains a description of the accident, along with an overview of the
analysis and findings, the safety action taken to date, five key recommendations, and what
more needs to be done to help ensure an accident like this does not happen again.

The TSB is an independent agency that makes transportation safer by investigating marine,
pipeline, rail and air transportation accidents, and communicating the results to Canadians.
For more information, visit www.tsb-bst.gc.ca/Lac-Megantic-en
The accident brakes and air brakes. This gave the false
impression that the hand brakes alone
would hold the train.
On the evening of July 5, 2013, at about
10:50 p.m., a Montreal, Maine & Atlantic The engineer then contacted the rail traffic
Railway (MMA) train arrived at Nantes, controller in Farnham, Quebec, to advise
Quebec, carrying 7.7 million litres of pe- that the train was secure. Next, the engi-
troleum crude oil in 72 Class 111 tank cars. neer contacted the rail traffic controller in
Originating in New Town, North Dakota, Bangor, Maine, who controls movements
these were bound for Saint John, New for the crews east of Lac-Mégantic. During
Brunswick. this conversation, the engineer indicated
that the lead locomo-
tive had experienced
mechanical difficulties
throughout the trip,
and that excessive black
and white smoke was
coming from its smoke
stack. Because they
expected the smoke to
settle, it was agreed to
leave the train as it was
and deal with the situa-
tion the next morning.
In keeping with the railway’s practice,
after arriving in Nantes, the locomotive Shortly after the engineer left, the Nantes
engineer (engineer) parked the train on Fire Department responded to a 911 call
a descending grade on the main track. A reporting a fire on the train. After shutting
replacement engineer was scheduled to off the locomotive’s fuel supply, the fire-
continue the trip east in the morning. fighters moved the electrical breakers in-
side the cab to the off position, in keeping
The engineer applied hand brakes on all with railway instructions. They then met
five locomotives and two other cars, and with an MMA employee, a track foreman
shut down all but the lead locomotive. who had been dispatched to the scene but
Railway rules require hand brakes alone who did not have a locomotive operations
be capable of holding a train, and this background.
must be verified by a test. That night,
however, the locomotive air brakes were Once the fire was extinguished, the fire-
left on during the test, meaning the train fighters and the track foreman discussed
was being held by a combination of hand the train’s condition with the rail traffic

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controller in Farnham, and departed soon
afterward. With all the locomotives shut
Aftermath and
down, the air compressor no longer sup- emergency response
plied air to the air brake system. As air
leaked from the brake system, the main air
Almost all of the 63 derailed tank cars
reservoirs were slowly depleted, gradually
were damaged, and many had large
reducing the effectiveness of the locomo-
breaches. About six million litres of pe-
tive air brakes. Just before 1 a.m., the air
troleum crude oil was quickly released.
pressure had dropped to a point at which
The fire began almost immediately, and
the combination of locomotive air brakes
the ensuing blaze and explosions left 47
and hand brakes could no longer hold the
people dead. Another 2000 people were
train, and it began to roll downhill toward
forced from their homes, and much of the
Lac-Mégantic, just over seven miles away.
downtown core was destroyed.
As it moved down the grade, the train
The pileup of tank cars, combined with the
picked up speed, reaching a top speed of
large volume of burning petroleum crude
65 mph. It derailed near the centre of the
oil, made the firefighters’ job extremely
town at about 1:15 a.m.
difficult. Despite the challenges of a large
emergency, the response was well coordi-
nated, and the fire departments effectively
protected the site and ensured public
safety after the derailment.

Transportation Safety Board of Canada - 3

Key issues in the investigation
This investigation looked at many issues to find out what happened, why it happened,
and what needs to be done to prevent it from happening again. This section describes
some of these key issues.

Fire in the locomotive Braking force

In October 2012, eight months before this The Canadian Rail Operating Rules required
accident, the lead locomotive was sent to that unattended equipment be left with a
MMA’s repair shop following an engine “sufficient” number of hand brakes ap-
failure. Given the significant time and cost of plied to prevent movement, and that the
a standard repair, and the pressure to return effectiveness of the hand brakes be tested.
the locomotive to service, the engine was MMA’s rules called for a minimum of nine
repaired with an epoxy-like material that hand brakes for a 72-car train. These rules
lacked the required strength and durability. also required that a train’s air brake sys-
This material failed in service, leading to tem not be depended upon to prevent an
engine surges and excessive black and white undesired movement.
smoke. Eventually, oil began to accumulate
Even more crucial is the requirement to test
in the body of the turbocharger, where it
the effectiveness of the hand brakes. That
overheated and caught fire on the night of
night, the engineer carried out the hand
the accident.
brake effectiveness test with the locomotive
air brakes still applied. As a result, the test
did not identify that an insufficient amount
of hand brake force had been applied to
secure the train.

The TSB concluded that, without the extra

force provided by the air brakes, a min-
imum of 17 and possibly as many as 26
hand brakes would have been needed to
secure the train, depending on the amount
of force with which they had been applied.

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Air brakes 101
Trains have two types of air brakes: auto- locomotive is shut off, the compressor no
matic brakes and independent brakes. longer supplies the system with air.
Automatic air brakes are used to slow or When air leaks from the various compo-
stop the entire train, and are controlled by nents, the pressure in the brake cylinders
means of a brake pipe connected to each gradually drops, and the amount of force
car and locomotive. Decreases in pressure being applied to the locomotive wheels
within this pipe cause air to flow into each by the independent brakes is reduced.
car’s control valve, which injects stored air Eventually, if the system is not recharged
into the brake cylinder, applying the brake with air, the brakes will become ineffective
shoes to the wheels. and provide no braking force.
By contrast, independent air brakes are When the air brake control valves sense
available only on locomotives. They are a drop in pressure in the brake pipe, they
activated by the direct injection of air into are designed to activate the brakes on
their brake cylinders, which then apply the each car. In this accident, however, the
brake shoes to the wheels. rate of leakage was slow and steady—ap-
proximately 1 pound per square inch per
Both independent brakes and auto- minute—and so the automatic brakes did
matic brakes are supplied with air from a not apply.
compressor on each locomotive. When a

Hand brakes 101

In addition to air brake systems, all loco-
motives and rail cars are
equipped with at least one
hand brake. This is a me-
chanical device that applies
brake shoes to the wheels to
prevent them from moving.
The effectiveness of hand
brakes depends on several
factors, including their age,
their maintained condition,
their application in conjunc-
tion with air brakes, and the
force exerted by the person
applying the hand brake,
which can vary widely.

Transportation Safety Board of Canada - 5

 Class 111 tank cars:
Damage and construction

All 72 tanks cars were Class 111, manufac-

tured between 1980 and 2012. Although
they met requirements in effect at the
time, they were built to an older standard,
and they lacked enhancements such as
a jacket, a full head shield, and thermal
protection.

Almost every car that derailed was

breached, some in multiple areas, includ-
ing shells, heads, top and bottom fittings,
and pressure relief devices. The exact
location and extent of the damage varied
depending on the orientation and speed
of the cars during the derailment.

When the tank cars were breached, the

petroleum crude oil was released, fuelling
the fire. The damage to the tank cars could
have been reduced by enhanced safety
features. This is why the TSB called for
tougher standards for tank cars carrying
flammable liquids.

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Safety culture at MMA Transport Canada

An organization with a strong safety For several years, Transport Canada’s

culture is generally proactive when it regional office in Quebec had identified
comes to addressing safety issues. MMA MMA as a company with an elevated level
was generally reactive. There were also of risk that required more frequent inspec-
significant gaps between the company’s tions. Although MMA normally took correc-
operating instructions and how work was tive action once problems were identified, it
done day to day. This and other signs in was not uncommon for the same problems
MMA’s operations were indicative of a to reappear during subsequent inspections.
weak safety culture—one that contributed These problems included issues with train
to the continuation of unsafe conditions securement, training, and track conditions.
and unsafe practices, and significantly Transport Canada’s regional office in
compromised the company’s ability to Quebec, however, did not always follow up
manage risk. to ensure that these recurring problems
were effectively analyzed and that the
When the investigation looked carefully at
underlying conditions were fixed.
MMA’s operations, it found that employee
training, testing, and supervision were In addition, although MMA had devel-
not sufficient, particularly when it came oped a safety management system in
to the operation of hand brakes and the 2002, Transport Canada’s regional office in
securement of trains. Although MMA had Quebec did not audit it until 2010—even
some safety processes in place and had though this is Transport Canada’s respon-
developed a safety management system sibility, and despite clear indications (via
in 2002, the company did not begin to inspections) that the company’s safety
implement this safety management management system was not effective.
system until 2010—and by 2013, it was Transport Canada Headquarters in Ottawa,
still not functioning effectively. 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.

Transportation Safety Board of Canada - 7

Single-person crews Safety action following
the accident
The TSB looked very carefully at single-
person train operations, and at whether
having just one crew member played a role In the weeks and months after the accident,
in the accident. After looking at the circum- the TSB communicated critical safety infor-
stances that night, the investigation was mation on the securement of unattended
not able to conclude that having another trains, the classification of petroleum crude
crew member would have prevented the oil, rail conditions at Lac-Mégantic, and the
accident. employee training programs of short line
railways.
However, there are some clear lessons for
the system. If railways in Canada intend MMA, meanwhile, eliminated single-per-
to implement single-person train opera- son train operations, stopped moving unit
tions, then they need to examine all the trains of petroleum crude oil, and increased
risks and make sure measures are in place operating-rules testing and enforcement.
to mitigate those risks. Transport Canada, For its part, Transport Canada introduced
for its part, should consider a process to numerous initiatives, including an emer-
approve and monitor the railways’ plans gency directive prohibiting trains trans-
so as to assure safety. porting dangerous goods from operating
with single-person crews. Sections of the
Canadian Rail Operating Rules were also
Dangerous goods: rewritten, and new tank car standards have
been proposed.
Inadequate testing,
Considerable action was also undertaken in
monitoring, and transport the United States. The National Transporta-
tion Safety Board issued recommendations
The petroleum crude oil in the tank cars aimed at route planning for hazardous ma-
was more volatile than described on the terials trains, petroleum products response
shipping documents. If petroleum crude plans for worst-case spills, and the classi-
oil is not tested systematically and fre- fication of hazardous materials. The U.S.
quently, there is a risk of it being improp- Department of Transportation also issued
erly classified. The movement of these an emergency order strengthening train
improperly classified goods increases the securement rules, and a notice of proposed
risk to people, property, and the environ- rulemaking targeting, among other items,
ment. That is why the TSB issued a safety improved tank car standards.
advisory letter calling for changes.

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TSB Recommendations
In January 2014, the TSB made three recommendations aimed at addressing systemic
safety issues that posed a significant risk. Three months later, it followed up to assess the
action that had been taken by government and industry. In August 2014, the TSB made
two additional recommendations.

Recommendation Status
R14-05 (August 2014)
Transport Canada must take a more hands- NEW
on role when it comes to railways’ safety
management systems—making sure not
just that they exist, but that they are work-
ing and that they are effective.
R14-04 (August 2014)
Canadian railways must put in place NEW
additional physical defences to prevent
runaways.
R14-03 (January 2014) Fully Satisfactory
Emergency response assistance plans must (June 2014)
be created when large volumes of liquid
hydrocarbons, like oil, are shipped.
R14-02 (January 2014) Satisfactory Intent1
Railway companies should conduct stra- (June 2014)
tegic route-planning and enhance train
operations for all trains carrying danger-
ous goods.
R14-01 (January 2014) Satisfactory in Part2
Enhanced protection standards must be (July 2014)
put in place for Class 111 tank cars.
1
Railways must make progress on the development and implementation of new rules to improve their
operating practices for the safe transportation of dangerous goods.
2
Although progress has been made, more work is required. All older Class 111 tank cars must not transport
flammable liquids, and a more robust tank car standard with enhanced protection must be set for North
America.

Transportation Safety Board of Canada - 9

Findings
Investigations conducted by the TSB are complex—an accident is never caused by just
one factor. This report identifies 18 distinct causes and contributing factors, many of
them influencing one another.

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… Findings
This report also contains 16 findings as to risk. Although these did not lead directly to
the accident, they are related to unsafe acts, unsafe conditions, or safety issues with the
potential to degrade rail safety. Some of the risks that need to be addressed are:

• the continuing risk of leaving trains • the risk of not planning and analyzing
unattended routes on which dangerous goods are
carried
• the risk of implementing single-person
train operations • the risk of not having emergency
response assistance plans in place
• the risk of not systematically testing
petroleum crude oil • the risk of Transport Canada not ensur-
ing that safety management systems
work effectively

Conclusion
The tragedy in Lac-Mégantic was not States. Although this investigation is
caused by one single person, action or complete, the TSB will continue to mon-
organization. Many factors played a role, itor the five recommendations, and to
and addressing the safety issues will take report publicly on any progress—or lack
a concerted effort from regulators, rail- of progress—until all of the safety defi-
ways, shippers, tank car manufacturers, ciencies have been corrected.
and refiners in Canada and the United

Transportation Safety Board of Canada - 11

Transportation Safety Board of Canada

200 Promenade du Portage Call toll-free in Canada: 1-800-387-3557

Place du Centre, 4th floor Call from outside Canada: +1 819-994-3741
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Email: communications@bst-tsb.gc.ca
© Her Majesty the Queen in Right of Canada, as represented by the Minister of Public Works and
Government Services Canada, 2014

Cat. No. TU4-25/1-2014E

978-1-100-24802-8

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List of significant events
1. Locomotive engineer (engineer) parked the train on a descending grade on the
main track
2. Engineer applied hand brakes on all five locomotives and two other cars
3. All engines shut down except at the lead locomotive
4. Locomotive air brakes were left on during test of hand brakes
5. Train was being held by a combination of hand and air brakes
6. False impression that the hand brakes alone would hold the train
7. Locomotive had experienced mechanical difficulties throughout a trip
8. Train left as-it until the next morning
9. Fire on the train
10. Shutting off the locomotive’s fuel supply
11. Electrical breakers inside the cab was turned off
12. Fire on train extinguished
13. Air compressor not supplying air to the air brake system
14. Locomotive air brakes have reduced effectiveness
15. Air brakes, and hand brakes could not hold the train securely on the incline
16. Train rolls downhill toward Lac-Mégantic
17. Train picked up speed, reaching a top speed of 65 mph derailed near the centre of
the town at about 1:15 a.m.
18. Fire, and explosions due to derailment
19. 47 people dead and another 2000 people evacuated, and downtown Lac-Megantic
destroyed
20. Engine was repaired with an epoxy-like material that lacked the required strength
and durability
21. Epoxy-like material failed in service
22. Engine surges abruptly and excessive black and white smoke was coming from
smoke stack
23. Oil began to accumulate in the body of the turbocharger
24. Accumulated oil in the body of the turbocharger overheated
25. Test failed to identify insufficient amount of hand brake force had been applied
to secure the train
26. Rate of air leakage from air brake system was slow and steady
27. Automatic air brakes did not apply
28. All 72 tanks cars were Class 111
29. Tank cars lacked enhancements such as a jacket, a full head shield, and thermal
protection.
30. Employee training, testing, and supervision were not sufficient, particularly when
it came to the operation of hand brakes and the securement of trains
31. Safety management system not functioning effectively