Lac-Mégantic update: Immediate safety issues identified
Lac-Mégantic, Quebec, 19 July 2013—The Transportation Safety Board of Canada (TSB) has issued two urgent Safety Advisory Letters to Transport Canada (TC) in relation to its ongoing investigation into the Montreal, Maine & Atlantic Railway (MMA) train derailment on 6 July 2013 in Lac-Mégantic, Quebec.
Safety Advisory Letters
The first issue pertains to the securement of equipment and trains left unattended. The TSB investigation has determined that the braking force applied was insufficient to hold the train on the 1.2% descending slope, and is asking TC to review the Canadian Rail Operating Rules (CROR) 112 [Securing Equipment] and the related railway special instructions to ensure that equipment and trains left unattended are properly secured in order to prevent unintended movements.
The second issue concerns the securement of trains carrying dangerous goods. Given the importance of the safe movement of dangerous goods and the vulnerability of unattended equipment, the TSB is asking TC to review all railway operating procedures to ensure that trains carrying dangerous goods are not left unattended on a main track.
Work to date
The TSB continues to make progress in a number of parallel streams in the field phase of its investigation. Numerous investigators and other experts are working on site, at the headquarters in Gatineau, or at our engineering laboratory in Ottawa. This investigation remains the top priority for the TSB.
Locomotive event recorder
As previously mentioned, the TSB has downloaded key information from the locomotive event recorder and the sense and braking unit and the work is ongoing.
TSB investigators inspected the tracks, and conducted a site survey, photogrammetry and videography to determine track grade and position, and this information will be used for future calculations and computer modelling.
Investigators have conducted mechanical inspections and photographed 22 tank cars to date to document accident damage. Sample pieces of the tank cars are also being sent to the TSB laboratory in Ottawa for further metallurgical analysis.
The TSB is conducting 3D laser imaging with the assistance of the U.S. National Transportation Safety Board (NTSB) to record three-dimensional data of the accident scene and different pieces of the wreckage. The scanner will be used to create full-color still images and assist in computer modelling.
Samples were taken of the products inside selected tank cars to determine their exact properties. Shipping documents and train journals are being reviewed to ensure the information is accurate.
Investigators have conducted numerous interviews. They have interviewed the locomotive engineer and other employees from MMA, first responders such as firefighters, and officials from TC, among others. This important work continues, but it is important to note that under the Canadian Transportation Accident Investigation and Safety Board Act, all interviews are protected information and will not be publicly released.
We have collected data from Transport Canada in order to examine regulatory oversight. This will include aspects such as inspections and train operations (one-man crews), as well as MMA’s safety management systems to determine if there are any deficiencies that need attention.
Next of kin
TSB participated in a Sûreté du Québec briefing with the victims’ next of kin at which the TSB investigative process was explained. As per our investigative process, we committed to keep them informed during the investigation.
Visit the active investigation page for more information about this accident.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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