An unmanned, half-mile-long train carrying tank cars full of highly flammable petroleum products barrels out of control toward a city, where it threatens to derail on a curve and kill everyone in its wake. Luckily, Denzel Washington and Chris Pine show up to halt the train at the last second, saving the day. That was the plot of the 2010 film Unstoppable.
In real life, however, in the small town of Lac-Mégantic, Quebec, Denzel and Chris never showed up. At around 1:00 a.m. on July 6, 2013—just over five years ago—an unmanned Montreal Maine and Atlantic Railway (MMA) train carrying seventy-two tank cars of highly combustible crude oil barreled out of control down a hill toward Lac-Mégantic reaching 65 m.p.h.—three times the typical speed. In the middle of town, the train hit a 10 m.p.h. curve and careened off the track, rupturing tanks and disgorging six million liters of crude. Within moments, the oil was burning, flowing down streets and into storm sewers, creating geysers of fire exploding from manholes. People tried to flee this flaming tsunami, with little luck: the resulting inferno obliterated most of downtown, destroying thirty buildings and incinerating forty-seven people.
You might think that five years after the warning set by this epic rail disaster, the United States would be tightening protections for rail transport of petroleum products—but you’d be wrong. Not only is the federal government taking steps to increase the nation’s use of petroleum fuels, including many that are transported by rail, but at the same time it is rolling back essential rail safety regulations. In the process, it is ignoring the multiple factors that led to the Lac-Mégantic disaster.
How Did Lac-Mégantic Happen?
The basic facts about what led to the disaster are unchallenged. The lead locomotive was having mechanical issues. Per instructions from MMA headquarters, Richard Harding, the engineer and sole crew-member on the giant train, applied seven hand brakes, set a separate set of air brakes on the lead locomotive, and then—once again, per instructions from MMA headquarters—took a taxi to a nearby hotel, leaving the lead locomotive running. The locomotive’s mechanical problems were to be handled in the morning.
Shortly before midnight, however, the lead locomotive—the engine still running and spewing oil from multiple leaks—caught fire. The local fire department arrived to extinguish the fire, and was instructed by the railroad to shut down the locomotive to keep more oil from flowing into the fire.
Minutes after the fire department left, the unmanned train began moving down the tracks. The air brakes, which had been powered by the locomotive, slowly discharged when the locomotive was shut down.
Minutes after the fire department left, the unmanned train began moving down the tracks. The air brakes, which had been powered by the locomotive, slowly discharged when the locomotive was shut down. The hand brakes that had been set couldn’t hold the giant train in place, however, and it was soon thundering down the incline toward Lac-Mégantic.
In the aftermath of the disaster, the Transportation Safety Board of Canada (TSB) conducted a thorough investigation and published a report. One of their thirty-four findings was that the seven handbrakes set by Harding weren’t enough to hold the train. The general rule was that one hand brake should be set for every ten cars, with two added on top of that. For the seventy-two cars, nine hand brakes should have been set, not seven.
For the Canadian government, the cause of the disaster was clear and simple: Harding hadn’t set enough hand brakes to hold the train on a hill where the disabled lead locomotive awaited repair the next day. And the action needed seemed just as evident: punish the wrongdoers. Canadian authorities arrested the engineer, Tom Harding, as well as traffic controller, Richard Labrie, and the manager of train operations, Jean Demaitre, and charged them with criminal negligence causing death—which carried a life-sentence—and marched them off to prison in handcuffs.
But the real reason this catastrophe happened isn’t that simple. While it is undisputed that Harding did not set enough hand brakes, experts on the causation of industrial disasters point to much more complex reasons for disasters such as Lac-Mégantic. For example, Professor Andrew Hopkins, emeritus professor of sociology at the Australian National University in Canberra, Australia, explains in Lessons from Longford, his study of an Australian gas plant disaster, that worker error should be the starting point, not the ending point of any incident investigation designed to prevent future incidents from occurring:
Human beings inevitably make errors and errors by operators must be expected. Thus, rather than focusing on the operators who make the errors, modern accident analysis looks for the conditions which make the errors possible. It is nearly always the case that there was a whole series of contributory factors which created an operator error and set up the situation which made the error critical. Accident analyses which aim to prevent a recurrence seek to identify these factors. From this perspective, errors are seen as consequence rather than principal causes.
So what were the latent conditions and contributory factors “which make the errors possible” that led to Lac-Mégantic? Both the TSB report and the later trial of the three men arrested revealed numerous problems, including the failure of supposedly redundant systems, inadequate maintenance procedures, reliance on one-man crews, inadequate training, problematic corporate culture, and weak regulatory oversight.
Failure of Redundant Systems
Hopkins and other experts on preventing incidents in highly complex systems like chemical plants, nuclear power plants, aircraft—and railroads—cite the need for redundant backup systems. In other words, a single failure should not lead to a catastrophe. And indeed, the train that crashed in Lac-Mégantic was equipped with numerous backups in case the hand brakes failed.
Unfortunately, one of the backups—the locomotive’s air brakes—was disabled once fire department shut down the lead locomotive. There was also an “automatic brake” system that holds the rail cars in place, but according to the TSB report, the rail company, MMA, instructed its staff not to use the automatic brakes because releasing them to start the train back up took too long. And another backup, the “penalty brake,” had been wired incorrectly.
As it turns out, the train was 50 percent heavier than regulations allowed, and the TSB report concluded that even the recommended nine brakes wouldn’t have been enough to hold the giant train in place.
And so, once the lead locomotive was shut down, holding the train in place depended solely on the seven hand brakes. But while it is undisputed that Harding set fewer hand brakes than guidelines indicated, the TSB report revealed that even that simple formula isn’t adequate. The actual number of hand brakes needed to secure a train depends on multiple complex factors, such as the grade the train is resting on and the train’s weight, as well as the number of cars. As it turns out, the train was 50 percent heavier than regulations allowed, and the TSB report concluded that even the recommended nine brakes wouldn’t have been enough to hold the giant train in place. Harding would have needed to apply somewhere between twelve and twenty-six hand brakes in order to reliably hold the train in place.
Inadequate Maintenance Procedures
It is human nature to delay maintenance procedures until they are absolutely unavoidable. Most people don’t change light bulbs until after they burn out, for example. But if you’re running a refinery, a steel mill—or a railroad—waiting for things to break down before you fix them isn’t a very safe way to operate. Industries that present the possibility of significant risk to public and worker safety need to have strong preventive maintenance programs.
In this case, the TSB report indicates that the lead locomotive had serious mechanical problems in the preceding months, but instead of making a lengthy standard repair, MMA decided to essentially glue the locomotive back together with an epoxy-like material that lacked the required strength and durability of a permanent repair. The Toronto Globe and Mail reported that “MMA, which declared bankruptcy after the derailment, had a reputation as one of the most aggressive cost-cutters in the rail industry.”
Furthermore, the TSB report states that the engineer who operated the locomotive before Harding knew that the lead locomotive had serious problems and reported it to his supervisor—who took no action.
Had the locomotive not broken down, it is unlikely that the disaster would have happened.
Reliance on One-Man Crews
Canadian trains had recently been allowed to run with one-man crews. And although witnesses for the Canadian government testified that there was no difference in safety between trains operated by one person and those operated by two, Quebec, North Shore and Labrador—the only other railway in Quebec that ran one-man crew operations—was required by Transport Canada, the regulatory authority, to impose sixty-nine conditions before it could operate trains with one man. MMA, on the other hand, only had to comply with a single condition—the addition of a rearview mirror to the driver’s side of the lead locomotive.
Figuring out the actual number of hand brakes needed to secure the train was a highly complex process, and MMA provided poor training and competency testing. The TSB report found that “Montreal, Maine & Atlantic Railway did not provide effective training or oversight to ensure that crews understood and complied with the complex rules governing train securement.”
Problematic Corporate Culture
The TSB report also noted that MMA had a weak safety culture that “contributed to the continuation of unsafe conditions and unsafe practices, and compromised Montreal, Maine & Atlantic Railway’s ability to effectively manage safety.” The company was “generally reactive in addressing safety issues” and “there were significant gaps between MMA’s operating instructions and how work was actually conducted in day-to-day operations.”
The TSB report also criticized the railroad’s regulatory body, Transport Canada (and more specifically, their Quebec division), for weak oversight of MMA, despite the fact that “for several years, MMA had been identified as a railway company with an elevated level of risk requiring more frequent inspections.” For example, Transport Canada had not been aware of significant operational changes by the company—such as its order not to use the automatic brake—and did not provide the necessary oversight of these changes. Transport Canada also never followed up on their order that that MMA conduct a risk assessment of single-operator trains.
Lessons Not Learned
While the United States has never experienced a rail disaster the size of Lac-Mégantic, there is little to prevent the same thing happening in the United States today. About 25 million Americans currently live near railroad tracks carrying oil trains. Meanwhile, the federal government on one hand is increasingly emphasizing the use of hazardous fossil fuels—especially highly volatile Bakken crude oil—and on the other hand is reducing government oversight by rolling back “burdensome” environmental and safety regulations.
About 25 million Americans currently live near railroad tracks carrying oil trains.
In the time since Lac-Mégantic, the United States has witnessed several smaller incidents that could be harbingers of worse to come.
In 2013, in North Dakota, a mile-long train carrying crude oil derailed and exploded, triggering a “giant fireball” after colliding with another train. In 2014, a train carrying highly volatile crude oil derailed in downtown Lynchburg, Virginia, spilling 30,000 gallons of flaming oil into the James River. In 2015, a 109-car oil train derailed and exploded in West Virginia. And just this past June, 230,000 gallons of crude oil were spilled into floodwaters in Iowa when 14 of 32 oil tanker cars derailed. Luckily, the oil did not ignite.
And while the United States has never experienced a rail disaster the size of Lac-Mégantic, citizens of South Carolina experienced a similar disaster in 2005 when two Norfolk Southern trains carrying deadly chlorine collided near the Avondale Mills plant in Graniteville. Nine people were killed and over 250 people were treated for toxic chlorine exposure. Seven of the nine who died were millworkers at the nearby Avondale mill who choked to death on a cloud of chlorine gas that had escaped the derailed train cars. One of the dead was found in her home.
U.S. Regulators May Be Backsliding to Disaster
Despite the lessons of Lac-Mégantic and other recent petroleum train disasters, the U.S. federal government has been scaling back rather than increasing rail safety protections.
And the problem is not going away. As Justin Mikulka writes in DeSmog Blog, “Canada just reported record levels of oil-by-rail movements for April of this year. And that number is likely to increase significantly in the next several years, as the oil industry there continues to face pipeline constraints. U.S. oil-by-rail movements are increasing too.”
Several actions over the past eighteen months indicate that the Trump administration does not take rail safety seriously:
- A final rule requiring all trains have at least two crew members was sent to the White House’s Office of Management and Budget for approval in December 2016. But shortly after Trump’s inauguration, the rule was returned to the Federal Railroad Administration (FRA), and has now been placed in the inactive long-term regulatory agenda. (Shortly after the Lac-Mégantic incident, the Canadian government issued an emergency order that banned one-person crews on trains carrying hazardous cargo such as crude oil.)
- Under intense industry pressure, the Department of Transportation’s Pipeline and Hazardous Materials Safety Administration (PHMSA) repealed a requirement that by 2021, oil trains be equipped with advanced electronically controlled pneumatic (ECP) train brakes that stop rail cars much more effectively than the traditional air brake systems (which were invented around the time of the Civil War).
- A rule proposed by PHMSA during the Obama administration that would require crude oil to be stabilized by removing the volatile natural gas liquids is likely to die because although it would eliminate the “bomb train” phenomena, it would require oil companies to build stabilization infrastructure where the oil is loaded onto trains.
- The FRA abandoned plans to require sleep apnea screening for truck train engineers (as well as truck drivers), “a decision that safety experts say puts millions of lives at risk,” according to CBS News Moneywatch.
If Americans are to escape the disaster that killed forty-seven Canadians five years ago, we need to pay attention to the protections that are being weakened and eliminated by the Trump administration to the great pleasure of the railroads and oil companies. The lives and health of millions of Americans depends on it.
Cover photo: “Freight train burning in Lac-Megantic, Quebec,” 7/6/2013. Source: Transportation Safety Board of Canada/Flickr.