Lac-Mégantic rail disaster

The Lac-Mégantic rail disaster occurred in the town of Lac-Mégantic, Quebec, Canada, on July 6, 2013, at approximately 01:15 EDT, when an unattended 73-car Montreal, Maine and Atlantic Railway (MMA) freight train carrying Bakken Formation crude oil rolled down a 1.2% grade from Nantes and derailed downtown, resulting in the explosion and fire of multiple tank cars. Forty-seven people were killed. More than thirty buildings in Lac-Mégantic's town centre, roughly half of the downtown area, were destroyed, and all but three of the thirty-nine remaining buildings had to be demolished due to petroleum contamination of the townsite. Initial newspaper reports described a blast radius.

The Safety Board identified multiple causes for the accident, principally leaving a train unattended on a main line, failure to set enough handbrakes, and lack of a backup safety mechanism.

The death toll of 47 makes this the fourth-deadliest rail accident in Canadian history, and the deadliest involving a non-passenger train. It is also the deadliest rail accident since Canada's confederation in 1867. The last Canadian rail accident to have a higher death toll was the St-Hilaire train disaster in 1864, which killed 99.

Background

The route

The railway passing through Lac-Mégantic, Quebec, was owned by the United States-based Montreal, Maine and Atlantic Railway (MMA). The MMA has owned and operated a former Canadian Pacific Railway (CPR) main line since January 2003, between Saint-Jean-sur-Richelieu, Quebec, in the west and Brownville Junction, Maine, in the east.

The rail line through Lac-Mégantic and across Maine was built in the late 1880s as part of the final link in CPR's transcontinental system between Montreal and Saint John, New Brunswick, with the section east of Lac-Mégantic known as the International Railway of Maine. Until December 1994 the line hosted VIA Rail's ''Atlantic'' passenger train as well as CPR freight service. A 1970s proposal to reroute the line to bypass downtown Lac-Mégantic was never implemented because of cost. The rail line was owned by CPR until sold in segments in January 1995.

VIA Rail discontinued passenger service on the route in December 1994 owing to the pending change in ownership, as VIA regulations then prohibited its passenger trains from operating on tracks that were not owned by either of Canada's two national railway companies. The eastern half of the line between Brownville Junction and Saint John was sold to the industrial conglomerate J. D. Irving, which established two subsidiaries: the Eastern Maine Railway and New Brunswick Southern Railway (NBSR). The western half of the line between Brownville Junction toward Montreal was sold to Iron Road Railways (IRR), a U.S.-based company, which established a subsidiary called Canadian American Railroad.

IRR filed for bankruptcy for its subsidiary company in fall 2002. The former CPR main line from Saint-Jean-sur-Richelieu to Brownville Junction was sold to Rail World Inc. in January 2003. Rail World formed the MMA as a subsidiary and engaged in aggressive cost cutting for freight train operations and continued to defer maintenance on the tracks to the point where much of the track is now in marginal condition.

Transport Canada permits a railway to remain in service with as few as five solid ties and fourteen damaged ties in a section of track, provided trains are limited to on straight flat track. MMA failed to take advantage of millions of dollars of available federal/provincial 2:1 matching infrastructure grants under a 2007 program as track conditions on the MMA line in Quebec continued to deteriorate. By 2013, speed reductions were required on 23 portions of the line, including a limit at Sherbrooke yard and on an stretch east of Magog.

The train

The freight train, designated "MMA 2", was long and weighed . The train was composed of

* MMA C30-7 #5017 (ex- BN)
* a remote-control "VB" car (a former caboose) used to house the Locotrol equipment necessary for MMA's single-engineer train operation
* MMA C30-7 #5026 (ex-BN)
* CITX SD40-2 #3053 (ex- CP #5740)
* MMA C30-7 #5023 (ex-BN)
* CEFX SD40-2 #3166 (ex- UP #3360)
* a loaded box car used as a buffer car
* 72 non-pressure dangerous goods DOT-111 tank cars loaded with Bakken Formation crude oil (Class 3, UN 1267). Each tank car carried of crude oil.

The oil, shipped by World Fuel Services subsidiary Dakota Plains Holdings, Inc., from New Town, North Dakota, originated from the Bakken Formation. The destination was the Irving Oil Refinery in Saint John, New Brunswick. Shipment of the oil was contracted to CPR, which transported it on CPR tracks from North Dakota to the CPR yard in Côte-Saint-Luc, a Montreal suburb. CPR sub-contracted MMA to transport the oil from the CPR yard in Côte-Saint-Luc to the MMA yard in Brownville Junction. CPR also sub-contracted NBSR to transport it from the MMA yard in Brownville Junction to the final destination at the Saint John refinery. Ministry of Transport senior inspector Marc Grignon opined, “When the shipper is based outside Canada, the importer becomes the shipper.” Irving Oil Commercial G.P. was the shipper in this case. 3,830 rail cars of Bakken crude were shipped by 67 trains in the nine-month period preceding the derailment.

In 2009, in the United States, 69% of the tank car fleet were DOT-111 cars. In Canada, the same car (under the designation CTC-111A) represents close to 80% of the fleet. The National Transportation Safety Board (NTSB) noted that the cars "have a high incidence of tank failures during accidents", citing in 2009 their "inadequate design" as a factor in a fatal rail collision outside Rockford, Illinois. Even before the Lac-Mégantic accident, attempts were made to require redesign or replacement of existing cars in the U.S.; these were delayed amidst fierce lobbying from rail and petroleum industry groups concerned about the cost. Since 2011, the Canadian government has required tank cars with a thicker shell, though older models are still allowed to operate.

Freight trains operated by MMA were allowed (not "permitted", see below) by regulators in Canada (Transport Canada) and the United States (Federal Railroad Administration, or FRA) to have Single Person Train Operation ( SPTO, alternately OPTO) status (one operator). The "permit" process, which requires public input, was not followed. Transport Canada and the MMA entered into a negotiation process at the culmination of which, sometime before the second week of July 2012, the government allowed MMA to reduce their manpower to SPTO. An average of eighty tank cars per train was carried on the Lac-Mégantic route under the supervision of one person only. The Maine regulator had already allowed SPTO status before the first week of April 2012. The use of SPTO for MMA freight trains was a cost-cutting move for which the railroad has received much criticism.

In May 2010, former MMA engineer Jarod Briggs of Millinocket, Maine, explained to the ''Bangor Daily News'' that "so much could happen in a twelve-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 there is a fire engine or an ambulance needing to get by a train or a crossing when that happens, it could take hours." Briggs left MMA to work for another railway in 2007; while he described the lone crew member involved in the Lac-Mégantic derailment as "a very good engineer, one of the better on the property", he has long expressed safety concerns about MMA's overall train operations because "if you have two people watching you can catch a mistake. It was all about cutting, cutting, cutting."

The Transportation Safety Board of Canada (TSB) looked at whether SPTO played a role in the accident. After looking at the circumstances of the night of the derailment, the investigation was not able to conclude whether having another crew member would have prevented the accident.

Air brakes on the train are supplied with air from a compressor on each locomotive. When a locomotive is shut off, the compressor no longer supplies the brake system with air. An air brake pipe connects to each car and locomotive on the train. When air leaks from the various components, the air pressure drops. If the system is not recharged with air, the locomotive air brakes will become ineffective and provide no braking force. When the air brake control valves sense a drop in pressure in the brake pipe, they are designed to activate the brakes on each car. However, if the rate of leakage is slow and steady, the automatic brakes may not be applied as in the case of the Lac-Mégantic accident. However, it is the usual practice for an engineer parking a train, once the train is stopped, to apply the brakes on the cars in the train by releasing air from the train line, and allowing the air in the cars' reservoirs to apply the cars' brakes. Therefore, it would not matter if the automatic brakes applied themselves or not, as the car brakes would already be in the applied position. The train had locomotives that could automatically restart the air-brake system in the event of a brake failure, provided that these locomotives were not shut down, as they would be in this incident. Also, the TSB found that the "reset safety control" on the lead locomotive was not wired to set the entire train's brakes in the event of an engine failure.

In addition to air brake systems, all locomotives and rail cars are equipped with at least one hand brake. This is a mechanical 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 conjunction with air brakes, and the force exerted by the person applying the brake, which can vary widely. The TSB estimated that somewhere between 17 and 26 hand brakes would have been needed to secure the train. Had there been a two-man crew, they would have been able to perform a stabilization test, by releasing all air brakes and ensuring just the hand brakes would hold the train. Since there was only a one-man crew this test was not possible.

Chronology

Eight months before the derailment

In October 2012, the lead locomotive, a GE C30-7 designated #5017, was sent to MMA's repair shop following an engine failure. Because of the time and cost for a standard repair and the pressure to return the locomotive to service, the engine was repaired with an epoxy-like material that lacked the required strength and durability. This material failed in service, leading to engine surges and excessive black and white smoke. Eventually, oil began to accumulate in the body of the turbocharger, where it overheated and caught fire on the night of the derailment.

Events shortly before the derailment

The freight train "MMA 2" departed the CPR yard in Côte-Saint-Luc early in the day of July 5 and changed crews at the MMA yard in Farnham, Quebec. After departing Farnham, it stopped at about 23:00 at the designated MMA crew change point in Nantes, which is west of Lac-Mégantic.

The engineer, Tom Harding, parked the train on the main line by setting the brakes and followed standard procedure by shutting down four of the five locomotives. Harding, who was the lone crew member under the MMA's work rules, which had been discussed with Transport Canada, could not park the train on the adjacent siding because MMA used it routinely to store empty boxcars for Tafisa, a particleboard factory in Lac-Mégantic's industrial park. The Nantes siding has a derail that could have stopped the train from accidentally departing. According to Transport Canada, it is unusual to leave an unattended train parked on a main line, but there were no regulations against it.

Harding left the lead locomotive No. 5017 running to keep air pressure supplied to the train's air brakes and also applied a number of hand brakes. Yves Bourdon, a member of MMA's board of directors, stated that the air brakes of all locomotives and freight cars had been activated, as well as hand brakes on 5 locomotives and 10 of the 72 freight cars. However, the TSB agrees with a July 6 statement to police by Harding that he set hand brakes on just the five locomotive engines, a buffer car, and a car housing the remote control apparatus. Harding also attempted a brake test but incorrectly left the locomotive air brakes on; this gave the false impression that the hand brakes alone would hold the train.

Harding contacted the rail traffic controller in Farnham to advise them that the train was secure. Next, he contacted the rail traffic controller in Bangor, Maine, to report that the lead locomotive had experienced mechanical difficulties throughout the trip and that excessive black and white smoke was coming from its smoke stack. Expecting the smoke to settle, they agreed to deal with the situation the following morning.

Section 112 of the Canadian Rail Operating Rules states "when equipment is left at any point a sufficient number of hand brakes must be applied to prevent it from moving" and "the effectiveness of the hand brakes must be tested” before relying on their retarding force. The engineer tests the hand brakes by seeing if the train budges when trying to push and pull the train with locomotive power. If a train is left on an incline, the number of handbrakes needed to hold the train increases. It takes 2–3 minutes per car to set the hand brakes. The track from Nantes to Lac-Mégantic is downhill on a 1.2% grade. Nantes is above sea level, Lac Mégantic is lower at . The MMA claimed that its braking policy required the activation of hand brakes on the five locomotives and 11 freight cars, or 20.5% of the total train. However, the TSB confirmed evidence in the criminal charges citing MMA procedures requiring nine brakes to hold a 70–79 car train. The TSB concluded that a minimum 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. Transport Canada does not validate the special instructions of a railway company or give any specific guidance on how many brakes must be applied for parked freight trains. While Transport Canada had repeatedly reprimanded MMA from 2004 to 2009 and in 2011 and 2012 for violations of CROR Section 112 handbrake requirements on parked trains in Nantes, no fines had been issued for the infractions.

The TSB found that MMA's operating plan was to leave the train parked on the main line, unattended, with an unlocked locomotive cab, alongside a public highway where it was accessible to the general public, with no additional protection. However, there were no rules against leaving a train unlocked, running and unattended, even if it contained dangerous materials and was stopped on the main line, on a slope, in the vicinity of a residential area.

After finishing his work, Harding departed by taxi for a local hotel, l'Eau Berge in downtown Lac-Mégantic, for the night. En route, the engineer told the taxi driver that he felt unsafe leaving a locomotive running while it was spitting oil and thick, black smoke. He said he wanted to call the U.S. office of MMA (in Hermon, Maine) as they would be able to give him other directives. Taxi driver André Turcotte described the engineer as covered in droplets of oil, which also covered the taxi's windscreen.

Witnesses recall seeing the train seemingly unattended and in distress around 22:45 that night. People driving on the road that parallels the rail line near Nantes recall seeing the train and having to slow down as they passed the locomotives where there was a thick dark blue cloud of diesel smoke being emitted as well as sparks coming out of a locomotive's exhaust, due to a broken piston in its diesel engine. According to the TSB, the MMA's rail traffic controller was warned of the train having technical difficulties while the train was still in Nantes on the evening of Friday, July 5.

After the engineer had departed, the Nantes Fire Department as well as a police officer from the Sûreté du Québec's Lac-Mégantic detachment responded to a 911 call from a citizen at 23:50 who reported a fire on the first locomotive; according to Nantes Fire Chief Patrick Lambert, "We shut down the engine before fighting the fire. Our protocol calls for us to shut down an engine because it is the only way to stop the fuel from circulating into the fire." The fire department extinguished the blaze and notified the Montreal, Maine and Atlantic Railway's rail traffic controller in Farnham. MMA did not grant permission to the engineer to return to the scene, instead summoning a track maintenance foreman unfamiliar with the operation of railway air brakes. By 00:13 two MMA track maintenance employees had arrived from Lac-Mégantic; the Nantes firefighters left the scene as the MMA employees confirmed to the police officer and to the Farnham rail traffic controller that the train was safe.

The MMA has alleged that the lead locomotive was tampered with after Harding had left; that the diesel engine was shut down, thereby disabling the compressor powering the air brakes, which allowed the train to roll downhill from Nantes into Lac-Mégantic once the air pressure dropped in the reservoirs on the cars. Teamsters Canada Rail Conference vice-president Doug Finnson disputed this theory, stating that the key braking system on a stopped, unsupervised train are the hand brakes, which are completely independent from the motor-powered compressor that feeds the air brakes.

Derailment and explosion

With all the locomotives shut down, the air compressor no longer supplied air to the air brake system. As air leaked from the brake system, the main air reservoirs were slowly depleted, gradually reducing the effectiveness of the locomotive air brakes. At 00:56, the air pressure had dropped to a point at which the combination of locomotive air brakes and hand brakes could no longer hold the train, and it began to roll downhill toward Lac-Mégantic, just over away. A witness recalled watching the train moving slowly toward Lac-Mégantic without the locomotive lights on. The track was not equipped with track circuits to alert the rail traffic controller to the presence of a runaway train. About ten minutes before the derailment occurred, firefighter Jean-Luc Montminy who was heading home after helping put out the fire on the original locomotive of the train, was stopped at a railway crossing located on Quebec Route 161, located just south-east of where the train began to roll. He stated that the crossing had activated and was warning of an oncoming train, but after waiting for some time, he heard no horn or any signal that a train was approaching. Thinking that the crossing was malfunctioning, he proceeded over the intersection when just as he had finished crossing, a train without its headlights or horn passed through at a very fast speed. Montminy recognized that it was the same train he had responded to hours earlier, and quickly returned to Nantes to inform other firefighters about what he had just witnessed. Gathering momentum on the long downhill slope, the train entered the town of Lac-Mégantic at high speed. The TSB's final report concluded that the train was travelling at , more than six times the typical speed for that location. The rail line in this area is on a curve and has a speed limit for trains of as it is located at the west end of the Mégantic rail yard.

Just before the derailment, witnesses recalled observing the train passing through the crossing at an excessive speed with no locomotive lights, "infernal" noise and sparks being emitted from the wheels. It was also stated by witnesses that since the train was going so fast, the flashing lights or bells on the crossing signals did not activate. Gilles Fluet, a Musi-Café patron who was leaving the site just before the derailment, said the wheels were emitting much white smoke. The runaway train passed behind him moving at highway speed. Travelling with no signals, the train jumped the track, sending a river of burning oil into the lake. "It was moving at a hellish speed ... no lights, no signals, nothing at all. There was no warning. It was a black blob that came out of nowhere. I realized they were oil tankers and they were going to blow up, so I yelled that to my friends and I got out of there. If we had stayed where we were, we would have been roasted."

The unmanned train derailed in downtown Lac-Mégantic at 01:14, in an area near the level crossing where the rail line crosses Frontenac Street, the town's main street. This location is approximately northwest of the railway bridge over the Chaudière River and is also immediately north of the town's central business district.

People on the terrace at Musi-Café—a bar located next to the centre of the explosions—saw the tank cars leave the track and fled as a blanket of oil generated a ball of fire three times the height of the downtown buildings. Between four and six explosions were reported initially as tank cars ruptured and crude oil escaped along the train's trajectory. Heat from the fires was felt as far as away. People jumped from the third floor of buildings in the central business district to escape the fire. As the blazing oil flowed over the ground, it entered the town's storm sewer and emerged as huge fires towering from other storm sewer drains, manholes, and even chimneys and basements of buildings in the area.

The Musi-Café tavern owner says that some employees and patrons felt the tremors of the train and thought it was an earthquake. They went out and started running. Other patrons and employees told some survivors that the tremors were an earthquake and that it would be better to stay under a table. Of those who went out, not all survived. Some were not able to outrun a "tsunami of fire".

The 5 locomotives and the VB car were found intact, separated from the rest of the train, outside the central part of town, still on track, but far from the crash scene. The 6-car lead group had apparently decoupled from the rest of the train, continued rolling down the track, crossed the river bridge, traveled through a sharp right bend, and came to rest about southwest of the derailment site (). The equipment that derailed included 63 of the 72 tank cars as well as the buffer car. Nine tank cars at the rear of the train remained on the track and did not explode; emergency responders took them away from the derailment site while the fire was still burning. Almost all of the derailed tank cars were damaged, many having large breaches. About six million litres of petroleum crude oil were quickly released; the fire began almost immediately.

Emergency response

Around 150 firefighters were deployed to the scene, described as looking like a "war zone". Some were called in from as far away as the city of Sherbrooke, Quebec, and as many as eight trucks carrying 30 firefighters were dispatched from Franklin County, Maine, United States ( Chesterville, Eustis, Farmington, New Vineyard, Phillips, Rangeley and Strong). The fire was contained and prevented from spreading further in the early afternoon.

The local hospital went to Code Orange, anticipating a high number of casualties and requesting reinforcements from other medical centres, but they received no seriously injured patients. A Canadian Red Cross