CARS National Railway Day Presentation

Lac-Mégantic derailment

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Kathy Fox
Chair, Transportation Safety Board of Canada
Ottawa, Ontario, November 4, 2014

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Good afternoon. Thank you very much for the invitation to speak at this auspicious event that commemorates the day the last spike was driven into the Canadian Pacific Railway on Nov. 7, 1885. Although my professional background has been in aviation, I grew up in a railway family. Both my father and his father worked for Canadian Pacific Railway . I criss-crossed this country multiple times by train before I was 18. I have a real respect for the vision, courage and perseverance of our forefathers who built the railway infrastructure in this country. And I certainly appreciate the significant economic importance of safe, efficient rail transportation—both passenger and freight—to this country, now and in the future.


My presentation today will look at a number of areas:

  • About the TSB
  • What happened the night of July 6, 2013?
  • TSB recommendations
  • What needs to change?
  • Conclusions

About the TSB

The TSB is an independent federal government agency. Our mandate is to advance safety by conducting independent investigations into four federally regulated modes of transportation: marine, pipeline, rail, and air.

To that end, we conduct independent investigations, identify safety deficiencies, identify causes and contributing factors, make recommendations, and make our reports public.

It is also important to note that it is not the function of the TSB to assign blame or determine civil or criminal liability.

The accident

Early on the morning of July 6, 2013, a Montreal, Maine & Atlantic train carrying 7.7 million litres of petroleum crude oil in 72 DOT class 111 tank cars, derailed in the town of Lac-Mégantic, Quebec. 63 tank cars derailed. Almost all of these were damaged, and many had large breaches. About six million litres of petroleum crude oil were quickly released—described as a 4 foot wave of oil. A fire began almost immediately, and the ensuing blaze and explosions left 47 people dead. Another 2000 people were forced from their homes, and much of the downtown core was destroyed.


Here’s a short animation putting it all together and explaining why the train ran away that night. Run time is about 3 minutes.

So, those are the basic facts: a crude oil train parked on a main track on a descending grade, with the lead locomotive running and 7 hand brakes set. A fire begins in an engine that had been causing problems for days. Emergency responders shut off the engine, but then the air holding the locomotive brakes leaks off. Without enough force from the hand brakes, the train begins its tragic descent downhill.

Findings as to cause and contributing factors

When you first look at an accident, there’s a tendency to focus only on the basic facts: what happened? But our investigations must also look at the context. And in Lac-Mégantic, that context was about more than hand brakes or what the locomotive engineer did or didn’t do that night. In all, we found 18 distinct causes and contributing factors, many of them influencing one another.

You can see they cover six broad areas: train securement, the fire in the locomotive, the derailment, tank cars, the operator MMA and the regulator Transport Canada. Take any one of them out of the equation, and this accident may not have happened.

Now let’s look at some of these in depth, and at what the TSB would like to see done.

Tank cars

As I said earlier, almost every car that derailed was breached, some in multiple areas, including 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. All 72 tank cars were DOT Class 111s, manufactured between 1980 and 2012, and all met the requirements in effect at the time they were built.

However, they were lacking additional protection designed to minimize consequences of an accident—such as a jacket, a full-height head shield or thermal protection.

Enhanced safety features could have reduced the damage to the tank cars. This is why the TSB called for tougher standards for tank cars carrying flammable liquids.

TSB recommendations

In January 2014, the TSB made 3 recommendations aimed at addressing systemic safety issues that posed a significant risk. Three months later, we followed up to assess the action that had been taken by government and industry.

In August 2014, the TSB made two additional recommendations.


A safety management system, or SMS, is a formal, documented process required by Transport Canada’s regulations. SMS requires management to anticipate what might go wrong and to develop and execute a plan to reduce the impact of potential problems. For example, what kind of dangers could result from a railway company changing the type of goods it transports—from, say, canola oil to crude oil? And what action might be taken to address those dangers?

MMA, however, did not implement SMS as intended by the regulator—and Transport Canada’s Quebec Regional Office did not verify the company’s safety management system before 2010, even though inspections clearly indicated that the system was not functioning. Meanwhile, TC’s headquarters in Ottawa did not effectively monitor the activities of the Regional Office. It was therefore not aware of weaknesses in the monitoring of regional railway companies in Quebec, and did not intervene.


An SMS relies on a strong safety culture, one that is proactive in addressing the potential dangers. By contrast, MMA had a rather reactive approach, and therefore a weak safety culture. For the most part, its primary defence was to rely on its employees to follow the rules. Complex systems, though, require more; they need to have defences in depth. That’s the rationale behind the last recommendation we made: Canadian railways must put in place additional physical defences to prevent runaways.

“This must never happen again”

One very common sentiment to emerge from a tragedy such as this is that it must never be allowed to happen again. That’s admirable—and it’s possible. But it will require hard work, and the combined efforts of:

  • Transport Canada
  • railway companies
  • shippers
  • tank car manufacturers, and
  • refineries in Canada and the United States
  • U.S. regulatory agencies (FRA and PHMSA)

Since that night…

Since that night, there have been other accidents involving breached tank cars and dangerous goods. For example:

  • On 7 January 2014, a CN train derailed 19 cars and the remote locomotive near Plaster Rock, New Brunswick. Nine of the cars were carrying crude oil and liquefied petroleum gas. Approximately 150 people were evacuated due to the resulting fire.
  • On 7 October 2014, a CN train derailed 26 cars, including six tank cars carrying dangerous goods near Clair, Saskatchewan. Two of those tank cars, carrying petroleum distillates, were breached and released product, resulting in a fire.

These investigations are still ongoing, and so I cannot comment on potential causes and contributing factors. But we do know that DOT 111 tank cars were also involved in several other occurrences south of the border: a derailment in rural Alabama last November, which spilled crude oil and resulted in a huge fireball; and a month later, in Casselton, North Dakota, when fires from derailed tank cars forced residents from their homes.

In Canada, the Transport Minister has already ordered that the oldest DOT 111 tank cars be removed from service in transporting liquid hydrocarbons, and has set a 3-year timeframe for the replacement and/or retrofit of tank cars carrying crude oil and ethanol that do not meet the CPC-1232 standard.

While the Board is generally pleased with the quick and strong actions being taken to address the safety deficiencies identified in the Lac-Mégantic investigation, much more still needs to be done. In particular, the standards for tank cars carrying flammable liquids must be further upgraded. Both TC and the US Department of Transportation have since proposed improved specifications for public consultation. However there are still gaps, and inconsistencies between the Canadian and US proposals. For instance, the U.S. DOT has put forth three options for tank car specifications—each one achieving a different level of safety—and none exactly matching the Transport Canada proposal. We also note differences in the performance-based design requirements, as well as in retrofit requirements. The TSB believes that these differences must be addressed as it is important that federal regulations in both countries be harmonized to the greatest extent possible given that North America is an integrated market. It is also important that governments make the right choices with respect to public safety, and not give in in the face of industry pushback to more stringent safety standards. We have therefore urged regulatory agencies on both sides of the border to adopt the highest possible standards for the construction of these tank cars, and that replacement/retrofitting be done as soon as possible.


The tragedy in Lac-Mégantic was not caused by one single person, action, or process. There were 18 causes and contributing factors. Complex systems require more than just relying on rules-compliance; they need defences in depth. To address the safety issues, a concerted effort will be required from the regulators, the railways, shippers, tank car manufacturers, and refiners in Canada and the United States.

The TSB will continue to monitor the outstanding recommendations, and to report publicly on any progress—or lack of progress—until all the safety deficiencies have been adequately addressed.