A Perfect Collection of Failures. What went wrong at Lac Megantic
Hero to Villain
At first, the engineer of “MMA2”, the unit train which devastated the small city of Lac-Megantic in explosions and flame, was hailed a hero by his company, Montreal, Maine & Atlantic Railway. But as the company’s chairman Edward Burke faced angry Canadians at a press conference, the hero was beginning to look like an incompetent. Before any investigation had begun, Burke stated “It’s very questionable whether the handbrakes were properly applied on this train… As a matter of fact, I’ll say they weren’t or else we wouldn’t have had this incident.” But as Canada’s National Post news so appropriately stated, a “latticework of errors” typically come together, some years in the making, to cause these types of catastrophes.
A better way to understand it is through the industry famous “Swiss Cheese Model of accident causation” which explains how multiple events, rather than one, are nearly always at the heart of a disaster. Simply, each slice of the cheese represents a part of a system of operation; some slices may represent company policies, others the actions of individuals. The holes of a slice of Swiss Cheese represent the weaknesses or lack of safeguards in each. If you have an operationally strong system, you’ve got a block of cheddar cheese. But if you’ve got weaknesses in an operation – lack of communication, safety failures, mechanical failures, you’ve got Swiss Cheese. When several different “slices” of an operation line up where consecutive holes, or weaknesses, line up – a catastrophe happens. If any one slice had not lined up, the major event could have been avoided. The holes in this event, lined up all too well.
These weaknesses can be active – where something happens or someone does something - like pilot error in a plane; or latent – an underlying cause such as organizational influences, operational plan or policy, or other problems that may have been present for years yet had simply not yet resulted in a failure. In the Lac Megantic case, there were several weaknesses that lined up in fateful fashion. Not only were the “Active Failures” obvious in this disaster, so too were the “Latent Factors “.
Latent Cause #1 A Company in Crisis
During the late decade recession, Montreal, Maine & Atlantic Railroad was in financial crisis having already faced a downturn prior due to weakening paper and forestry industries in 2003 – a large product of transport for them. They sold off assets and laid-off employees throughout the decade. In 2010, MM&A became one of the few operators allowing for one engineer per train - rather than the typical two operator system - in efforts to cut costs.
The company was virtually bankrupt when the Bakken oil boom finally brought a new opportunity in early 2012 to salvage the ailing operation which had long been described by some of its prior clients as having an “exorbitant pricing structure, ineffective service, and annoying executives.” In court filings against the company in 2010 alleging that they were essentially denying Canadian shippers from free market competition through “maintaining a local monopoly”, it was further contended that MM&A was subject to ongoing complaints about “missed pickup and delivery deadlines as well as poor track maintenance”.
Properly put, the Canadian News outlet “La-Presse.ca” wrote “When a company cuts everywhere for years to recover profitability, inevitably, safety may be affected. Think of the possibilities: under-maintenance of old locomotives and railway , reducing the number of drivers, longer shifts, etc…”
Latent Cause #2 SPTO
One of the causes of the Lac-Megantic tragedy had been set in motion when Montreal, Maine and Atlantic Railway’s policies of operation changed just a year prior to the wreck. They were allowed by regulators from both Canada (Transport Canada) and the United States (Federal Railroad Administration) to conduct Single Person Train Operation (SPTO). This move was purely done as a cost cutting measure – a fact that is not in dispute. Criticism of this move came well before the Lac-Megantic derailment. One former MM&A employee stated in the Bangor Daily News in 2010 when it had initially moved to the SPTO that “so much could happen in a 12-hour shift on one of these trains, such as a washed-out track, downed trees or mechanical failure. What if the engineer onboard were to encounter a medical problem? Who is going to know about it? … if you have two people watching you can catch a mistake. It was all about cutting, cutting, cutting.”
Latent Cause #3 Company Policy
The next latent cause was what most Canadians, and Americans, would agree was an unbelievable MM&A policy. Two weeks after the accident, the Transportation Safety Board of Canada found that “MMA’s operating plan was to leave the train on the main track, unattended, with an unlocked locomotive cab, parked alongside a public highway where it was accessible to the general public, with no additional protection.” MM&A company policies clearly devalued the safety and security of its shipped goods.
Latent Cause #4 Parked on the Main Line
Though it was recommended by Canadian Rail rules that trains parking for the night do so on side tracks, there is no rule requiring it to do so. Parking on a side rail provides an extra safety measure against runaway trains, especially when they have what are called “derails.” “Derails” are track components that will automatically yet gently derail a train in the event it moves without the engineer’s prompting. In this case, box cars where occupying the side track which indeed had derails installed, and thus, the fateful train was left on a main track.
Latent Cause #5 SPTO – part 2, The Clear Signs of Danger
Worse, as the fire chief in Nantes stated in The Canadian Business Journal, he couldn’t believe “a train was left running and unattended in the hours before the disaster, when it had already just been in flames.” The engineer clearly knew the locomotive was spewing smoke from the engine when he left for his hotel in a taxi. Company policy allowed him to leave the train, but what is still unclear was what he was told to do. What seems clear is what he should have done, regardless of orders.
Further, after the fire was extinguished and MM&A employees arrived at the scene, they either did not realize the main locomotive had been powered down or they simply did not check. They left the broken train and went home. They were the last line in the weaknesses of operation, the last slice in the latent holes of the Swiss Cheese model – the final hole of failures which allowed a rolling bomb to slowly grind its way to its final destination.
Active Cause #1 The Handbrakes
Also still under investigation is the question of the number of handbrakes applied by the sole engineer upon stopping for the night in Nantes. According to Canadian Operating Rules, “when equipment is left at any point a sufficient number of hand brakes must be applied to prevent it from moving”. However, Canadian federal rules don’t expressly state how many hand brakes must be used to provide a fail-safe. It is left up to carriers to provide such standards – if they choose to do so. At first report, the company claimed that 5 brakes were applied on the locomotives and another 10 applied on 72 of the following tank cars. Days later, they blamed the engineer for “not properly applying some of the handbrakes.” Regardless of the truth, clearly, something in the process of applying handbrakes went wrong. Active Cause #2 The Broken Piston.
The smoking, oil sputtering locomotive the engineer brought into Nantes was suffering from a broken piston. Though this aspect of the accident is still under investigation, it clearly was the cause of the fire in the engine that the Nantes Fire Department initially responded to which then led to their turning the locomotive off.
Active Cause #3 The Shutdown of the Engine.
The shutdown of the locomotive and loss of air brake pressure was the direct cause of the accident. Without faulting the fire department, who clearly needed to shut down power to the locomotive to stop the flow of diesel fuel to the engine, it was this powering down that served as the active and direct cause of the July 5th explosion. Powering down the locomotive released pressure on the powerful airbrakes that kept the train in position. But not only was it common sense for the Nantes Fire Department to shut down the engine, it was MM&A policy too.
The Nantes Fire Department had been trained by the Montreal, Maine & Atlantic railway to handle fires on its line. In the previous eight years, it had fought four fires on company trains. The Fire Chief said that shutting down the engine is the standard operating procedure dictated by MM&A. Despite this, for a short time after the disaster, MM&A officials were implying that in fact it was the Nantes Fire Department who was responsible for the disaster. They quickly reversed this tactic after realizing their own policy.
What about the Bakken Oil Cargo? Active Cause, Latent Cause, or…
Blame was quickly being placed immediately after the Lac Megantic accident. And finding itself in the crosshairs of blame was the cargo – Bakken crude Oil. Additionally, World Fuel Services, a subsidiary of Dakota Plains Holdings, (the primary shipper of the crude) was and is being targeted as well. They had contracted the shipping job to the Canadian Pacific Railway, who then subcontracted the job to MM&A. A more complete discussion of the nature of Bakken crude oil, and shale oil in general follows in the article “Bakken Blitz.” (see page 47)
Indeed, shale oil, and Bakken crude to be specific, is a type of crude oil with unique characteristics. But to the point of the question some in both Canada and the U.S. are asking, was the Bakken Crude carried by the MM&A unit train a leading factor in the destruction seen at Lac-Megantic? Here is where fact and opinion cross lines. On the one hand, crude oil usually does not ignite nor burn in the manner the oil did during this event. But the actual cause of this ignition is still being investigated where speculation runs the gambit of possibilities: The oil may have been contaminated by flammable chemicals used during the fracking process itself; a propane tank very near the derailment may have first exploded, thus igniting the cargo; high temperature in Quebec that day could have led to a cargo ripe for ignition. But the leading assumption is that the oil itself, which is assumed to contain high levels of the highly flammable chemical hydrogen sulphide, was the cause for the explosive blaze.
If this is indeed fact, and the oil which was shipped from our region is more flammable than other crude oil, then the opinion that it should be labelled as a “Latent Cause” of the tragedy seems reasonable. But on the other hand, the opinion that, regardless of whether the crude is highly explosive or was properly labelled (discussed in the next article), should be a “non-point”, is equally valid. It still would have been shipped in the same manner, through the same location, and subject to the same alignment of failures created mostly by MM&A. In further opinion that could be argued as fact, the Bakken, its producers, and certainly its workers, are the creators of a product. Like any producer of a flammable substance would sell its product and have it shipped, once that product leaves their hands, the care and safety with which it is handled lies squarely as the burden of the shipper, or the subcontracted shipper – in this case, MM&A. A total safety breakdown occurred, one that was replete with organizational influences, lack of oversight, and deteriorated preconditions. Then finally, a set of specific actions which brought these breakdowns in alignment led to the disaster. It was a complete collection of failures.
By Eric Sharpe, Editor, Energy Ink Magazine. January 1st, 2014.
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