R13D0054 Lac-Megantic: Audio clips
TSB Chair, Wendy Tadros, speaks about the TSB investigation into the accident at Lac-Mégantic, Quebec, on 6 July 2013.
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The goals of the investigation
Clip 1: Our report and recommendations are aimed at moving Canada's railways toward a safer future.
Clip 2: Our investigation was complex, but our goal is simple: to improve rail safety in Canada. Governments, railways and shippers need to do everything in their power to ensure there is never another Lac-Mégantic.
TSB's new recommendations
Clip 3: The first recommendation calls for physical defences to ensure trains will not run away. The second calls on Transport Canada to make sure railways are really managing safety.
Clip 4: On July 5, 2013, a crude oil train was left unattended at Nantes, Quebec, on a main tack on a descending grade, with only the lead locomotive running and 7 hand brakes set. A fire began in the locomotive engine that had been causing problems for days. Emergency responders shut off the engine as per railway instructions, and subsequently, the air holding the locomotive brakes leaked. Without enough force from the hand brakes, the train began its tragic descent downhill where it derailed in Lac-Mégantic. The ensuing explosion and fire left 47 people dead.
Clip 5: Accidents never come down to a single individual, a single action or a single factor. You have to look at the whole context. In our investigation, we found 18 factors contributed.
Clip 6: The chain of causes and contributing factors goes beyond the actions of any single person.
Montreal, Maine & Atlantic Railway
Clip 7: We found MMA was a company with a weak safety culture -- it did not effectively manage changes to its operations.
Clip 8: MMA did not have a functioning safety management system and it did not manage the risk of moving more and more crude oil.
Clip 9: It's the role of government to provide checks and balances. Transport Canada knew about many of the problems at MMA, but they did not always follow through to make sure the railway was operating safely.
Single-person train operations
Clip 10: The TSB looked very carefully at single-person train operations. We could not determine whether an another crew member that night would have prevented the accident.
Safety management systems
Clip 11: When it came to SMS, Transport Canada required MMA to have one, but they did not push to ensure it was being used to identify risk and manage safety.
Clip 12: On that night, 7 hand brakes were applied. To secure the train, we determined that it would have taken at least 17 and possibly as many as 26. But more important than the number of hand brakes, is a brake effectiveness test to ensure a train will hold. This test was not done properly that night.
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