Runaway and main-track derailment

Montreal, Maine & Atlantic Railway

Freight train MMA-002

Mile 0.23, Sherbrooke Subdivision

Lac-Mégantic, Quebec

06 July 2013

The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. This report is not created for use in the context of legal, disciplinary or other proceedings. See Ownership and use of content.

Summary

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Rail transportation safety investigation R13D0054 (Lac-Mégantic, Quebec)

On 06 July 2013, shortly before 0100 Eastern Daylight Time, eastward Montreal, Maine & Atlantic Railway freight train MMA-002, which was parked unattended for the night at Nantes, Quebec, started to roll. The train travelled approximately 7.2 miles, reaching a speed of 65 mph. At around 0115, when MMA-002 approached the centre of the town of Lac-Mégantic, Quebec, 63 tank cars carrying petroleum crude oil (UN 1267) and 2 box cars derailed. About 6 million litres of petroleum crude oil spilled. There were fires and explosions, which destroyed 40 buildings, 53 vehicles, and the railway tracks at the west end of Megantic Yard. Forty-seven people were fatally injured. There was environmental contamination of the downtown area and of the adjacent river and lake.

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1.0 Factual information

1.1 The accident

On 05 July 2013, at about 1355,Footnote 1 eastward Montreal, Maine & Atlantic Railway (MMA)Footnote 2 freight train MMA-002 (the train) departed Farnham (near Brookport, Mile 125.60 of the Sherbrooke Subdivision), Quebec, destined for Nantes (Mile 7.40 of the Sherbrooke Subdivision), Quebec, where it was to be re-crewed and was to continue on to Brownville Junction, Maine. The train’s final destination was Saint John, New Brunswick (Figure 1). The train consisted of 72 tank cars loaded with approximately 7.7 million litres of petroleum crude oil (UN 1267), 1 box car (buffer carFootnote 3), and the locomotive consist (5 head-end locomotives and 1 VB car Footnote 4). The train was controlled by a locomotive engineer (LE) who was operating alone and was positioned in the lead locomotive, MMA 5017. During the trip, the LE reported mechanical difficulties with the lead locomotive, which affected the train’s ability to maintain speed.

Figure 1. Montreal, Maine & Atlantic Railway (MMA) map (source: MMA, with TSB annotations)

At around 2250, the train arrived at Nantes, was brought to a stop using the automatic brakes, and was parked for the night on a descending grade on the main track. The LE applied the independent brakes to the locomotive consist. He then began to apply the hand brakes on the locomotive consist and the buffer car (7 cars in total), and shut down the 4 trailing locomotives. Subsequently, the LE released the automatic brakes and conducted a hand brake effectiveness test without releasing the locomotive independent brakes. The LE then contacted the rail traffic controller (RTC) responsible for train movements between Farnham and Megantic Station (Megantic), who was located in MMA’s yard office in Farnham, to indicate that the train was secured.

The LE then contacted the RTC in Bangor, Maine, who controlled movements of United States crews east of Megantic. During this conversation, the LE indicated that the lead locomotive had continued to experience mechanical difficulties throughout the trip and that excessive black and white smoke was now coming from its smoke stack. The LE expected that the condition would settle on its own. It was mutually agreed to leave the train as it was and that performance issues would be dealt with in the morning.

A taxi was called to transport the LE to a local hotel. When the taxi arrived to pick up the LE at about 2330, the taxi driver noted the smoke and mentioned that oil droplets from the locomotive were landing on the taxi’s windshield. The driver questioned whether the locomotive should be left in this condition. The LE indicated that he had informed MMA about the locomotive’s condition, and it had been agreed upon to leave it that way. The LE was then taken to the hotel in Lac-Mégantic and reported off-duty.

At 2340, a call was made to a 911 operator to report a fire on a train at Nantes. The Nantes Fire Department responded to the call and arrived on site, and the Sûreté du Quebec (SQ) called the Farnham RTC to inform the company of the fire. After MMA unsuccessfully attempted to contact an employee with LE and mechanical experience, an MMA track foreman was sent to meet with the fire department at Nantes. When the track foreman arrived on site, the firefighters indicated that the emergency fuel cut-off switch had been used to shut down the lead locomotive. This shutdown put out the fire by removing the fuel source. Firefighters also moved the electrical breakers inside the locomotive cab to the off position to eliminate a potential ignition source. These actions were in keeping with railway instructions.

Both the firefighters and the track foreman were in discussion with the Farnham RTC to report on the condition of the train. Subsequently, the fire department and the MMA track foreman left the scene.

With no locomotive running, the air in the train’s brake system slowly began to be depleted, resulting in a reduction in the retarding force holding the train. At about 0100 (July 06), the train started to roll downhill toward Lac-Mégantic, 7.2 miles away. At about 0115, the train derailed near the centre of town, releasing about 6 million litres of petroleum crude oil, which resulted in a large fire and multiple explosions.

The locomotive consist did not derail; rather, it separated from the rest of the train and then further separated into 2 sections. Data downloaded from the de la Gare Street crossing (located by Megantic Station) showed that the 2 sections were separated by 104 feet. Both continued travelling eastward onto the Moosehead Subdivision, coming to rest on an ascending grade in the eastern part of town and stopping approximately 475 feet apart. During the course of this entire sequence, the train passed through 13 level crossings.

After approximately 1.5 hours, while emergency and evacuation efforts were under way, the leading section of the locomotive consist rolled backwards toward downtown and contacted the trailing section; both sections travelled backwards an additional 106 feet. At approximately 0330, MMA officials secured the locomotive consist on the grade by re-tightening the hand brakes.

See Appendix A for more detailed information about the sequence of events.

1.2 Aftermat

As a result of the derailment and the ensuing fires and explosions, 47 people died, and about 2000 people were evacuated. Forty buildings and 53 vehicles were destroyed (Photo 1).

Photo 1. The Lac-Mégantic derailment site following the accident

The derailed tank cars contained about 6.7 million litres of petroleum crude oil, about 6 million litres of which were released, contaminating approximately 31 hectares of land. Crude oil migrated into the town’s sanitary and storm sewer systems by way of manholes. An estimated 100 000 litres of crude oil ended up in Mégantic Lake and the Chaudière River by way of surface flow, underground infiltration, and sewer systems. About 740 000 litres were recovered from the derailed tank cars.

The hydrocarbon recovery and cleanup operation began as soon as the fire was extinguished and the site was stabilized, approximately 2 days after the derailment. The assessment and remediation of the environment were performed using a combination of monitoring wells and exploratory trenches serviced by vacuum trucks under the guidance of a specialized engineering firm.

1.3 Weather

At 2300 on 05 July 2013, the temperature at the weather station in Sherbrooke, Quebec, approximately 95 km west of Lac-Mégantic, was 21.7 °C. The dew point was 20.5 °C, and wind speed was 5 km/h from the south. At 0100 on 06 July 2013, the temperature was 21.2 °C, with a dew point of 20.4 °C and wind speed of 0 km/h.

1.4 Subdivision information

The Sherbrooke and Moosehead Subdivisions were owned and operated by MMA. These subdivisions were previously owned by Quebec Southern Railway (QSR) and, prior to that, by Canadian Pacific Railway (CPR).

1.4.1 Sherbrooke Subdivision

The MMA Sherbrooke Subdivision was a single main track extending west from Megantic (Mile 0.00) to Brookport (Mile 125.60), Quebec, where it connected with the Adirondack and Newport Subdivisions, near Farnham. Train movements were controlled by the Occupancy Control System (OCS), as authorized by the Canadian Rail Operating Rules (CROR), and supervised by an RTC located in Farnham. Traffic on the Sherbrooke Subdivision consisted of 2 freight trains per day, for an annual tonnage of 4.5 million gross tons. The track was classified as Class 3Footnote 5 according to the Transport Canada–approved Track Safety Rules (TSR). The maximum allowable speed for freight trains was 40 mph. However, due to track conditions, the speed on the entire subdivision had been reduced with temporary slow orders, including:

25 mph between Mile 0.82 and Mile 93 (with 11 locations further reduced to 10 mph),

10 mph between Mile 93 and Mile 103.87, and

25 mph between Mile 103.87 and Mile 125.60 (with 2 locations further reduced to 10 mph).

The subdivision was equipped with 6 hot box detectors, the last one located at Mile 13.30. MMA-002 did not receive any alarms from these detectors.

Between Nantes and Megantic (Mile 7.40 to the lowest point near Mile 0.00), the average descending grade was 0.94%, and the steepest grade over the length of the train was 1.32% at Mile 1.03 (Figure 2). The elevation dropped approximately 360 feet between Nantes and Megantic. For the last 2 miles before the point of derailment, the track descended at a grade of approximately 1.30%. The maximum horizontal curvature of the track was 4.25°, which was at the derailment location (Engineering Laboratory Report LP167/2013).

Figure 2. Grade and elevation between Nantes and Megantic

Cautionary limitsFootnote 6 were in effect between Mile 0.82 and Mile 0.00, due to the presence of the yard at Megantic. Movements were to be made in accordance with CROR 94 and 105(c).Footnote 7 There was a permanent speed restriction of 10 mph over Frontenac Street (Mile 0.28) until the crossing was fully occupied.

1.4.2 Moosehead Subdivision

The Moosehead Subdivision was a single main track that extended east from Megantic (Mile 117.14) to Brownville Junction (Mile 0.00), where it connected with the Millinocket Subdivision. The track was classified as Class 3 according to the TSR. Movements departing Megantic and heading eastward on this subdivision encountered an ascending grade of approximately 1%. Further east at Vachon (Mile 114.10), Quebec, the closest siding to Lac-Mégantic, there was a 6470-foot passing track.

1.5 Rail traffic control

MMA had 2 RTCs on duty at all times (1 in Bangor and the other in Farnham), with duty periods of 12 hours, starting at 0600 and 1800. The Farnham RTC controlled movements west of Megantic, and the Bangor RTC controlled movements east of Megantic. The Farnham RTC on duty at the time of the accident was a qualified LE with previous experience securing trains at Nantes.

1.6 Personnel information

From Farnham to Nantes, MMA-002 was operated by 1 LE positioned in the lead locomotive as per single-person train operations (SPTO) special instructions. The LE was rules-qualified and met fitness and work/rest regulatory requirements. The LE’s 2 previous shifts were:

MMA-002 (eastbound from Farnham to Megantic) on 02 July 2013 from 1230 to 0030, and

MMA-001 (westbound from Megantic to Farnham) on 03 July 2013 from 0830 to 2030.

Both trips had been performed with a conductor.

On 05 July 2013, the LE awoke at approximately 0530 and reported for duty at 1330 for MMA-002. When the LE was at home in Farnham, he normally slept about 8 hours per night. When the LE laid over, he usually slept between 5 and 6 hours per night.

The LE was hired by CPR in January 1980, and qualified as an LE in 1986. In September 1996, he transferred to QSR when that company acquired the trackage from CPR. In January 2003, the LE transferred to MMA when QSR was purchased by Rail World, Inc. (RWI), MMA’s parent company. During this time, he completed hundreds of trips between Farnham and Lac-Mégantic and was familiar with the territory.

In the 12 months before the accident, the LE completed about 60 eastbound trips on MMA-002. About 20 of these trips were completed as a single-person train operator.

1.7 Train information

The tank cars originated in New Town, North Dakota, where they were picked up by CPR. At origin, the train consisted of 1 box car (the buffer) and 78 tank cars loaded with petroleum crude oil (UN 1267), a Class 3 flammable liquid.On 30 June 2013, when the train was in Harvey, North Dakota, 1 tank car was removed for a mechanical defect after the train received a safety inspection and a Class I air brake test.Footnote 8 This air brake test verifies the integrity and continuity of the brake pipe, as well as the brake rigging, the application, and the release of air brakes on each car.

The petroleum crude oil had been purchased by Irving Oil Commercial G.P. from World Fuel Services, Inc. (WFSI). The shipping documents indicated that the shipper was Western Petroleum Company (a subsidiary of WFSI) and the consignee was Irving Oil Ltd. (Irving).

The cars operated through Minneapolis, Minnesota, Milwaukee, Wisconsin, Chicago, Illinois, and Detroit, Michigan, and arrived in Canada through Windsor, Ontario. The cars travelled to Toronto, Ontario, and underwent a No. 1 air brake test by a certified car inspector on 04 July 2013. The cars departed Toronto as part of a mixed freight train, consisting of 2 locomotives and 120 cars, destined for Montréal. When the train arrived in Montréal, it underwent a routine safety and mechanical inspection in Saint-Luc Yard on 05 July 2013. Mechanical defects were identified on 5 tank cars, which were removed from the train. The remaining tank cars were then interchanged to MMA.

On the morning of 05 July 2013, the cars were taken to Farnham, where they received a brake continuity test and a mechanical inspection by Transport Canada (TC). Minor defects were noted on 2 cars, and these were corrected. Departing Farnham, the train was approximately 4700 feet long, weighed about 10 290 tons (Appendix B) and consisted of the following (Photo 2):

lead locomotive MMA 5017, General Electric Company (GE) C30-7; special-purpose caboose (VB car) VB 1; locomotive MMA 5026, GE C30-7; locomotive CITX 3053, General Motors (GM) SD-40; locomotive MMA 5023, GE C30-7; locomotive CEFX 3166, GM SD-40; buffer car CIBX 172032; and 72 tank cars.

Photo 2. MMA-002 at Brookport on 05 July 2013 (source: Richard Deuso, modified by the TSB)

1.8 Accident site information

The investigation focused on 3 locations (Figure 3):

Nantes, where the train was parked;

downtown Lac-Mégantic, where the train derailed; and

the ascending grade, east of Megantic, where the locomotive consist came to its final stop (Mile 116.41 of the Moosehead Subdivision).

Figure 3. The 3 locations that were the focal points of the investigation: Nantes, downtown Lac-Mégantic, and the location where the locomotives came to a stop (Mile 116.41 of the Moosehead Subdivision) (source: Google Earth, with TSB annotations)

1.8.1 Nantes

Railway lines at Nantes are located in a rural area where the main track and a siding run parallel and immediately adjacent to public highway 161. The average descending grade on the main track where the train was parked is 0.92%.Footnote 9 During site examination, a black oily residue was found on the surrounding vegetation and on the rails where the lead locomotive was parked (Photo 3).

The east siding switch was located at Mile 6.67, and the siding was 7160 feet long. At the time of the accident, several rail cars were being stored there. The siding was equipped with a special derail,Footnote 10 located approximately 230 feet west of the switch (Photo 3). A derail is a mechanical safety device that sits on top of the rail and is used to derail runaway equipment. This derail was locked in the derailing position to protect the main track from unintended movements out of the siding.

Photo 3. Oil residue on the ground and vegetation at Nantes. Note derail on adjacent siding track on left (view westward from the location where the lead locomotive was parked on the main track)

1.8.2 Lac-Mégantic derailment site

The MMA Megantic Station was located in a commercial district of Lac-Mégantic, where the Sherbrooke and Moosehead Subdivisions met. Frontenac Street, a main thoroughfare, ran through the centre of the town. The main track intersected with Frontenac Street just west of the Megantic West turnout and was maintained for a maximum speed of 15 mph. The turnout was located at Mile 0.23, with the switch points facing west (Photo 4).

Photo 4. Frontenac Street public grade crossing, looking eastward. The circled area denotes the location of the switch points and the frog for the Megantic West turnout (photo: Pierre Blondin, with TSB annotations)

The derailed equipment covered the main track, 3 adjacent yard tracks, and the west leg of the wye, which is a triangular arrangement of tracks that can be used for turning rail equipment (Photo 5).Footnote 11 At the time of the accident, there were box cars parked in yard tracks 1 and 2.

Photo 5. Eastward view of the location of the tracks in relation to the first derailed cars: main track (A), yard track 1 (B), yard track 2 (C), yard track 3 (D), and the west and east legs of the wye tracks (E and F)

The track and crossing infrastructure was damaged as follows:

The damage to the main track started approximately 20 feet east of Frontenac Street.

The main-track turnout, approximately 400 feet of main track, and an additional 2000 feet of yard and wye tracks, including 3 turnouts, were destroyed.

Approximately 500 feet from the crossing, the main track was shifted about 4 feet to the north.

Yard tracks 1 and 2 were demolished from the west-end turnout for about 600 and 500 feet, respectively.

Rails were curled and twisted, unsettled from tie plates, and moved randomly. Due to the severity of the fire, most track components were badly damaged.

The Frontenac Street southeast public-crossing cantilever mast and the control box were shattered. Road traffic lights, electrical wires, lighting posts, and other appliances were also damaged.

The derailed equipment at the Lac-Mégantic site consisted of 2 box cars and 63 loaded tank cars.

The derailed equipment came to rest as follows:

The buffer box car, which had a broken knuckle from a torsional overstress on the leading end (Engineering Laboratory Report LP184/2013), and the first 3 derailed tank cars were on their sides, jackknifed, and partially coupled. They came to rest close to each other and came in contact with the 7 box cars in yard track 2, derailing 1 of the standing box cars.

The fourth and fifth derailed tank cars were also on their sides, jackknifed, and resting between yard tracks 2 and 3, about 50 feet north of the main track. They were separated by 125 feet from the preceding cars and had struck a pile of rails stored in the yard.

The sixth and seventh derailed tank cars, still coupled together, came to rest near yard track 3, about 150 feet north of the main track.

The eighth derailed tank car was uncoupled and came to rest in a wooded area between yard track 3 and the west leg of the wye.

All of the remaining derailed tank cars came to rest in a large pileup toward the west leg of the wye, with the last derailed car coming to rest on the Frontenac Street crossing. The ninth and tenth cars stayed coupled and aligned with the roadbed. The next 53 cars came off their trucks, jackknifed, and were severely damaged. The debris from the derailed equipment was confined to the derailment site. Most of the wheel sets and trucks were found on the south side of the pileup, within approximately 400 feet from the Frontenac Street crossing. There were no reports of any pieces of tank cars being projected away from the downtown area.

The last 9 tank cars on the train were still coupled to the last derailed car, but did not derail.

Examination of the derailed equipment determined that a hand brake had been applied on the buffer car. No hand brakes were found to have been applied on any of the tank cars.

1.8.3 Location of the locomotive consist

The locomotive consist came to rest approximately 4400 feet east of the Lac-Mégantic derailment site, at Mile 116.41 of the Moosehead Subdivision (Photo 6).

Photo 6. Location of the locomotive consist (Mile 116.41 of the Moosehead Subdivision) in relation to the derailment site. The white arrows denote the route of the locomotive consist, which followed the main track.

At this location, the track ran parallel to d’Orsennens Street. During site examination, the following was noted:

There was no damage to the track between the derailment site and the location of the locomotives.

There was a black oily residue, similar to the residue observed at Nantes, on the ground adjacent to the lead locomotive (MMA 5017), as well as about 600 feet east of where the locomotives came to rest.

Hand brakes were applied on all 5 locomotives and the VB car.

There was severe wear on some of the brake shoes and various degrees of blueing Footnote 12 on most of the wheels.

on most of the wheels. One of the knuckles connecting the second locomotive (MMA 5026) and the third locomotive (CITX 3053) was broken, and a locomotive connector cable had been pinched between the knuckles (Photo 7), indicating that a separation had occurred and the consist had rejoined.

A broken piece of the knuckle was found under the second locomotive, approximately 15 feet from the coupling (Photo 8). The locomotive knuckle and pin failed in tensile overstress mode, initiating at pre-existing fatigue cracks (Engineering Laboratory Report LP184/2013).

Photo 7. Pinched connector cable between couplers of second and third locomotives (occurring after the accident) Photo 8. Broken locomotive knuckle segment found under the second locomotive

1.9 Train air brakes

Trains are equipped with 2 air brake systems: automatic and independent. The automatic brake system applies the brakes to each car and locomotive on the train, and is normally used during train operations to slow and stop the train. Each locomotive is equipped with an independent brake system, which only applies brakes on the locomotives. Independent brakes are not normally used during train operations, but are primarily used as a parking brake.

1.9.1 Automatic brakes

A train’s automatic braking system is supplied with air from compressors located on each operating locomotive. The air is stored in the locomotive’s main reservoir. This reservoir supplies approximately 90 pounds per square inch (psi) of air to a brake pipe that runs along the length of the entire train, connecting to each locomotive and individual car. Air pressure changes within this brake pipe activate the brakes on the entire train.

When an automatic brake application is required, the LE moves the automatic brake handle to the desired position. This action removes air from the brake pipe. As each car’s air brake valve senses a sufficient difference in pressure, air flows from a reservoir located on each car into that car’s brake cylinder, applying the brake shoes to the wheels.

In order to release the brakes, the LE moves the automatic brake handle to the release position. This action causes air to flow from the main reservoir on the locomotive into the brake pipe, restoring pressure to 90 psi. Sensing this, each car’s brake valve allows air to be released from its brake cylinder, and the shoes are removed from the wheels.

1.9.2 Independent brakes

The independent brakes are also supplied with air from the main reservoir. When an independent brake application is required, the LE moves the independent brake handle, which in turn injects up to 75 psi of air pressure directly from the main reservoir into the brake cylinders of the locomotive. This causes the brake shoes to apply to the wheels (Figure 4).

Figure 4. Schematic of the locomotive air brake and hand brake

To release the independent brakes, the LE moves the independent brake handle to the release position. This causes air to be released from the locomotive’s brake cylinders, and the shoes are removed from the wheels.

1.9.3 Penalty brake application

A penalty brake application is similar to a full automatic brake application. However, this type of braking further reduces the brake pipe pressure to zero, requiring a moving train to stop and recharge the brake pipe. This type of braking occurs as a result of a “penalty” applied by the system, such as when the reset safety control (RSC) is not reset. This application occurs at a rate that does not deplete all of the air in each car's reservoir.

1.9.4 Emergency brake application

An emergency brake application is the maximum application of a train's air brakes, during which the brake pipe pressure is rapidly reduced to zero, either from a separation of the brake pipe or operator-initiated action. Following an emergency brake application, a train's entire air system is depleted.

Brake pipe pressure below 40 psi cannot be relied upon to initiate an emergency brake application.

1.9.5 Leakage

When locomotives are shut down, the air compressors are also shut down and no longer supply air to the train. Given that the system has many connections, which are prone to air leaks, the main reservoir pressure will slowly begin to drop soon afterward.

Because the main reservoir supplies air to the entire system, when its pressure falls to the level of that in the brake pipe, the pressure in both components will thereafter diminish at the same rate. This sequence also occurs when the main reservoir and brake pipe reach the same pressure as that in the brake cylinder, at which point all 3 will lose pressure at the same rate.

As the air in the brake cylinder decreases, the amount of force being applied to the locomotive wheels by the independent brakes is reduced. If the system is not recharged with air, the brakes on the locomotives will eventually become completely ineffective.

1.10 Train hand brakes

In addition to a train's air brake system, all locomotives and rail cars are equipped with at least 1 hand brake, which is a mechanical device that applies brake shoes to the wheels to prevent them from moving or to retard their motion (Photo 9). Typically, hand brakes consist of a hand brake assembly, which designates the B-end of each car. When the wheel on the hand brake assembly is tightened, the brakes are applied.

The effectiveness of hand brakes depends on several factors, including hand brake gearing system lubrication and lever adjustment. Also critical is the force exerted by the person applying the hand brake, which can vary widely from one person to another. For example, railway standards are based on an application of 125 pounds of force on the outside rim of the hand brake wheel. However, previous TSB investigations have noted that, on average, employees apply 80 to 100 foot-pounds of force.

Photo 9. Hand brake assembly and wheel at the B-end of a tank car

1.10.1 Hand brake requirements

1.10.1.1 Locomotives

There are no requirements for a locomotive to hold any other equipment when the hand brake is applied. On many locomotives, including the ones in this accident, when the hand brake is applied, only 2 of as many as 12 brake shoes are applied to the locomotive wheels.

For locomotives placed in service after 04 January 2004, the Federal Railroad Administration (FRA) in the United States requires that the hand brake(s) alone be capable of holding a locomotive on a 3% grade. This equates to a net braking ratioFootnote 13 of approximately 10%. Although there were no such requirements prior to 2004, locomotive manufacturers generally designed locomotive hand brakes to meet the 3% holding capacity.

1.10.1.2 Cars

According to Standard S-401 (Brake Design Requirements) of the Association of American Railroads' (AAR) Manual of Standards and Recommended Practices (MSRP), the force applied to the wheels by the brake shoes must be equal to about 10% of the car's gross load weight, with 125 pounds of force applied to the outside rim of the hand brake wheel.

Unlike hand brakes on many locomotives, hand brakes on cars normally apply all brake shoes (typically 8) to the wheels.

1.11 Hand brake effectiveness test

In order to verify that the hand brakes applied are sufficient to secure the train, crews were required to perform a hand brake effectiveness test, in accordance with CROR 112 (b), to ensure that the equipment will not move. After applying the hand brakes, the test is performed by releasing all of the air brakes and allowing the slack to adjust under gravity, or by attempting to move the equipment slightly with reasonable locomotive force.

If the hand brakes prevent the equipment from moving, then they are determined to be sufficient. If not, additional hand brakes must be applied and the process repeated until a successful effectiveness test has been completed.

Special instructions of some Canadian railway companies, including MMA, permitted the hand brakes on the locomotive consist to be included in the minimum required number of hand brakes. For example, if a company's special instructions required at least 10 hand brakes to be applied, and the train were operating with 4 locomotives, then only 6 hand brakes were required to be applied on the cars in addition to those on the locomotives. During an effectiveness test performed with hand brakes applied on the locomotive consist, the LE has to overcome the braking force on the locomotives before moving the rest of the train.

1.12 Rules and instructions on securing equipment

1.12.1 Rule 112 of the Canadian Rail Operating Rules

The CROR are the rules by which Canadian railways under federal jurisdiction operate, which include MMA's Canadian operations. At the time of the accident, CROR 112 stated the following, in part:

(a) When equipment is left at any point a sufficient number of hand brakes must be applied to prevent it from moving. Special instructions will indicate the minimum hand brake requirements for all locations where equipment is left. If equipment is left on a siding, it must be coupled to other equipment if any on such track unless it is necessary to provide separation at a public crossing at grade or elsewhere. Footnote 14

To ensure that there was sufficient retarding force to prevent a train or cars from moving unintentionally, CROR 112 required the effectiveness to be tested when hand brakes were used to secure the equipment. The rule stated:

(b) Before relying on the retarding force of the hand brake(s), whether leaving equipment or riding equipment to rest, the effectiveness of the hand brake(s) must be tested by fully applying the hand brake(s) and moving the cut of cars slightly to ensure sufficient retarding force is present to prevent the equipment from moving [. . .] Footnote 15

In addition to CROR 112, MMA employees were governed by the special instructions in MMA's General Special Instructions (GSIs) and Safety Rules.

Since MMA operated in former CPR territory, it adopted CPR's General Operating Instructions (GOIs).Footnote 16

1.12.2 Montreal, Maine & Atlantic Railway's General Special Instructions on Rule 112

Section 112-1 (Hand Brakes) in MMA's GSIs provided instructions on the minimum number of hand brakes required, and stated in part:

Crew members are responsible for securing standing equipment with hand brakes to prevent undesired movement. The air brake system must not be depended upon to prevent an undesired movement. […] Cars Handbrakes Cars Handbrakes 1 – 2 1 Hand Brake 50 - 59 7 Hand Brakes 3 – 9 2 Hand Brakes 60 - 69 8 Hand Brakes 10 – 19 3 Hand Brakes 70 - 79 9 Hand Brakes 20 – 29 4 Hand Brakes 80 - 89 10 Hand Brakes 30 – 39 5 Hand Brakes 90 - 99 11 Hand Brakes 40 – 49 6 Hand Brake 100 - 109 12 Hand Brakes Note: […] If conditions require, additional hand brakes must be applied to prevent undesirable movement.Footnote 17

The numbers in the table are commonly referred to by MMA employees as the “10% + 2” instruction.

Section 112-2 (Hand Brakes: Reduced Minimum Number, Designated Specific Locations) provided specific locations where the minimum number of hand brakes had been reduced. For example, at Sherbrooke, between cautionary limit signs, including the main track and sidings, and at Farnham, the minimum number of hand brakes equated to approximately 10%. For Megantic Yard, the required number was less than 10%.

1.12.3 Montreal, Maine & Atlantic Railway's Safety Rules on Rule 112

MMA's Safety Rule 9200 (Sufficient Number – Operating Hand Brakes) stated in part:

Employees must: a. Know how to operate the types of hand brakes with which various types of cars are equipped. […] c. Before attempting to operate handbrake, make visual inspection of brake wheel, lever, ratchet and chain. […] f. Be aware of and work within the limits of your physical capabilities and do not use excessive force to accomplish tasks. Past practices that do not conform to the rules are unacceptable.Footnote 18

MMA's Safety Rule 9210 stated in part:

h. All hand brakes shall be fully applied on all locomotives in the lead consist of an unattended train. i. When leaving railway equipment, the minimum number of hand brakes must be applied as indicated in the following chart.Footnote 19 Additional hand brakes may be required; factors which must be considered are: Total Number of Cars

Empties or Loads

Weather Conditions

Grade of Track […] k. In reference to the minimum number of hand brakes in the preceding chart, 19 it is acceptable to include the hand brakes applied on locomotives. […] m. There may be situations where all hand brakes should be applied. […] o. To ensure an adequate number of hand brakes are applied, release all air brakes and allow or cause the slack to adjust. It must be apparent when slack runs in or out, that the hand brakes are sufficient to prevent that cut of cars from moving. This must be done before uncoupling or before leaving equipment unattended.Footnote 20

1.12.4 Instructions of Class 1 railways regarding Rule 112 of the Canadian Rail Operating Rules

1.12.4.1 Canadian Pacific Railway

Prior to early 2013, CPR's instructions for determining the minimum number of hand brakes were to divide the number of cars to be left unattended by 10, and then add 2. The instructions also included the requirement to secure each locomotive left unattended with its hand brake. When a train was to be left unattended with the locomotive(s) attached, it was acceptable to include the locomotive hand brakes as part of the minimum required number of hand brakes.

Prior to the accident, CPR modified its hand brake instructions, no longer specifying the minimum number of hand brakes. Crews were responsible for evaluating their train and other operating conditions to determine the sufficient number of hand brakes and for testing their effectiveness before the equipment was left unattended.

In addition, section 2.0 of CPR's GOIs still stated that on light, heavy, and mountain grades,Footnote 21 a specific number of hand brakes (higher than the minimum) was required when a hand brake effectiveness test could not be performed. For example, on grades between 1.0% and 1.29%, hand brakes were required on 25% of the train. Additionally, in some territories, an increased number of hand brakes had to be applied when a movement was stopped on a grade.

1.12.4.2 Canadian National

At Canadian National (CN), the hand brake instructions in effect at the time of the accident for rail cars left unattended were:

Divide the number of cars on the train by 10 and add 1 additional hand brake, up to a maximum of 5 hand brakes.

If the hand brake effectiveness test is not successful, more hand brakes are required to ensure that the movement remains immobilized.

Certain locations outlined in CN's timetable required double (up to a maximum of 10) the number of hand brakes, depending on the track characteristics.

Trains with locomotives attached with at least 1 locomotive running can be left on the main track with only 1 locomotive hand brake applied, provided that there is brake continuity throughout the train, the automatic air brakes are fully applied and the independent brakes are applied. Footnote 22

In addition to the above instructions, CN special instructions for leaving trains or transfers unattended on mountain grade territory were as follows:

Every effort must be made, including RTC pre-planning, to avoid leaving trains or transfers in steep grades in excess of 0.75%.

When absolutely necessary, a sufficient number of hand brakes must be applied to prevent any unintended movement caused from possible brake cylinder leak-off.

The automatic air brakes must not be solely relied upon to secure equipment against undesired movement.

Stop with the least amount of air brake application possible.

Leave locomotives attached with brake pipe continuity throughout the train, and do not bleed off cars before applying hand brakes.

Apply 25% of the train hand brakes on grades between 0.75% and 0.9%, and apply 40% of the train hand brakes on grades up to 1.4%. Footnote 23

Crew members were required to communicate and confirm that they had left the train in accordance with these instructions, and the RTC was to be advised of the number of hand brakes applied.

1.13 Recorded information

1.13.1 Locomotive event recorder

A train's locomotive event recorder (LER) is analogous to a “black box” on an aircraft. The LER monitors and records a number of parameters, including throttle position, time, speed, and distance, as well as pressure within the brake pipe and locomotive brake cylinder. Changes in the brake pipe pressure cause each car to apply (or release) its air brake. In this accident, because the train was unattended, the LER was instrumental in providing key pieces of data.

Table 1 summarizes some important information obtained from the download of the LER on the lead locomotive. Brake pipe pressure is at its maximum at 95 psi (brakes fully released), and locomotive brake cylinder pressure is maximized at 70 psi (full independent brake application). Any drop in brake cylinder pressure indicates a reduction in retarding force.

Table 1. Locomotive event recorder information Time mph Brake pipe pressure (psi) Locomotive brake cylinder pressure (psi) Event 05 July 2013

2249:37 0 82 69 MMA-002 wa stopped at Nantes using a 13-psi automatic brake application, and the independent brakes were fully applied. 2303:48 0 94 69 The automatic brakes were released. The locomotive independent brakes remained fully applied. 2358:42 0 95 69 Lead locomotive MMA 5017 was shut down. 06 July 2013

0005:55 0 94 70 Brake pipe pressure began to decrease, and continued to decrease at an average rate of 1 psi per minute. 0013:55 0 79 69 Independent brake cylinder pressure began to decrease at the same rate as the brake pipe pressure. 0058:21 1 32 27 MMA-002 began to run away. 0115:30 65 16 14 The highest recorded speed of 65 mph was attained. 0115:31 65 0 14 Brake pipe pressure dropped to 0 psi as the cars began to derail. The locomotive consist separated into 2 sections. 0117:12 0 0 6 The first section stopped 5016 feet east of the point of derailment, at Mile 116.30 of the Moosehead Subdivision, on a 1% ascending grade. 0245:06 1 0 0 The first section of the locomotive consist began to move backwards (west) down the grade toward downtown Lac-Mégantic. 0246:23 8 0 0 The first section of the locomotive consist travelled 475 feet west and struck the stationary second section of the consist. 0246:42 0 0 0 The 2 sections rejoined and moved an additional 106 feet west before coming to a final stop.

1.13.2 Sense and braking unit

The sense and braking unit (SBU) is a device placed on the rear of the train and is connected to the train brake pipe. The SBU senses train movement, monitors brake pipe pressure, and sends the information to the locomotive, where it is displayed in the cab. The SBU can also be used to initiate an emergency brake application from the end of the train.

The SBU data from MMA-002 were downloaded (Engineering Laboratory Report LP132/2013). The SBU data and crossing download data were used to corroborate the LER data. An analysis of the SBU data determined that when the SBU first recorded movement (start-to-move) at Nantes, brake pipe pressure at the rear of the train was 29 psi. Approximately 16 minutes and 40 seconds after the train began to move, the brake pipe pressure at the rear of the train had diminished to 0 psi.

1.14 Brake testing conducted by the Transportation Safety Board

1.14.1 Air brake and hand brake tests using similar locomotives and tank cars

A train similar to MMA-002 was assembled to test braking system performance. The train consisted of 5 locomotives (2 GE C30-7s, 2 GE C39-8s, and 1 GM SD-40), 1 VB car, and 80 Class 111 tank cars. The first test was conducted to determine the time required to manually shut down the 4 trailing locomotives and apply hand brakes. The test results are summarized in Table 2.

Table 2. Time required to shut down the 4 trailing locomotives and apply hand brakes Number of locomotives shut down Number of hand brakes applied Time 4 7 9 minutes and 20 seconds 4 9 10 minutes and 55 seconds 4 18 17 minutes and 20 seconds

With the locomotives shut down, the brake pipe fully charged with air, the automatic brakes released, and the independent brakes applied, a second test was conducted to understand the effects of a normal loss of air on the brake system. The train brake pipe pressure as well as the locomotive brake cylinder pressure were monitored at different locations on the train. The test results were as follows:

After 30 minutes, the brake pipe pressure began to drop, and continued to drop at an average rate of approximately 1 psi per minute.

After 50 minutes, the locomotive brake cylinder pressure began to decrease at the same rate as the brake pipe pressure.

After 1 hour and 35 minutes, the brake cylinder pressure dropped to 27 psi, the point at which MMA-002 first began to roll.

Due to the slow decrease in brake pipe pressure, no automatic brake application occurred.

Also, when the electrical breakers were put in the off position, no penalty brake application occurred.

1.14.2 Air brake and hand brake tests on the occurrence locomotives

The locomotives from MMA-002 were moved to the siding at Vachon for examination and testing of the air brakes and hand brakes. This testing included a brake leakage test of the entire consist, a full brake system evaluation for each locomotive, and brake shoe force testing.

The first test determined that, starting from a fully charged brake system, the brake cylinder pressure dropped to 27 psi in 1 hour and 6 minutes due to air leakage.

The second test evaluated the braking performance of each locomotive and its components. Appendix C identifies the sources of measurable air leakage for each locomotive.

Locomotives are expected to leak air from their systems once they are shut down, yet the amount of time it takes for the independent brakes to leak off is highly variable. While leakage was noted, and was sometimes excessive on several components, it did not exceed the pressure-maintaining capabilities of the locomotives, and the combined leakage was within industry norms. Nevertheless, as a result of the above tests, 5 valves, including the quick release brake (QRB) valve, were removed for further analysis. The majority of the defects with the valves were related to the age and condition of their internal components (rubber seals, O-rings, return springs, etc.). See Engineering Laboratory Report LP185/2013 for complete details on the condition of the valves.

1.14.2.1 Quick release brake valve

On GE C30-7 locomotives, the brake cylinder for the brake shoes applied by the hand brake is equipped with a QRB valve. The QRB valve is normally tripped during the application of the hand brake by the brake chain. When tripped, the QRB valve removes air from the brake cylinder so that an effective hand brake can be applied (Photo 10 and Photo 11).

Photo 10. QRB valve used to exhaust brake cylinder air during hand brake application Photo 11. As the hand brake is tightened, the upward movement is intended to activate the release mechanism on the QRB valve.

The QRB valve on the second locomotive (MMA 5026) did not trip to exhaust brake cylinder air when tested. An examination of the valve showed wear and damage to the QRB valve's lifter and inside surface of the retaining disc. In addition, the examination showed that non-standard repairs had been applied to the valve's release mechanism in an attempt to keep the valve working.

If the QRB valve does not trip, the hand brakes will not provide any braking effort. To ensure that the hand brakes remain operational on these locomotives, MMA issued Summary Operating Bulletin 2-276, which stated in part:

The hand brake will not tighten if the air from the R#2 brake cylinder is not exhausted. The handbrake chain will tighten and it may appear that the handbrake is set however if the R#2 brake cylinder is in the “out” position, the handbrake is not applied. On C-30-7 locomotives if an air exhaust is not heard while tightening the handbrake the QRB valve may be malfunctioning or out of adjustment. It is possible to manually operate the valve from the ground on the right side of the locomotive. The QRB valve and handle is located directly adjacent to the handbrake chain, mounted on the top of the front truck between axles 2 and 3. A crew member can manually trip the valve by use of the lever located on the valve. After tripping the QRB valve the handbrake must immediately be re-tightened.Footnote 24

The LE was not aware of this instruction.

1.14.2.2 Examination of the wheels and brake shoes on the locomotive consist

The wheels and brake shoes on the locomotives were examined. The brake shoes were measured to analyze the wear that had occurred during the runaway and to determine the amount of braking force that was being applied (Engineering Laboratory Report LP182/2013). The following was determined:

Some of the brake shoes had worn through the lining to the backing plate.

The pattern of wheel blueing (Photo 12) and brake shoe lining wear indicated that the independent brakes had been providing most of the retarding brake force for the train.

Not all of the wheels subjected to hand brake force (2 per locomotive) showed full tread blueing or excessive brake shoe lining wear. This pattern indicated that these hand brakes had not been, or could not be, applied securely.

Photo 12. Blueing of locomotive wheel due to heat

1.14.2.3 Brake shoe force testing on the locomotive consist

An examination of the brake shoe force generated by the locomotive consist was performed with both air brakes and hand brakes (Engineering Laboratory Report 187/2013). Using a coefficient of friction of 0.38 and 100 foot-pounds of torque,Footnote 25 the following was determined:

The total retarding brake force required to hold the train on the grade where it was parked at Nantes was calculated to be approximately 146 700 pounds.

Before applying the hand brakes, the total retarding brake force generated by the independent brakes was approximately 249 760 pounds.

After applying the hand brakes (and activating the QRB valves on those locomotives so equipped), the total retarding brake force generated by the independent brakes was approximately 215 500 pounds.

The total retarding brake force generated by the 7 hand brakes on the train (taking into consideration that the QRB valve did not trip on MMA 5026) was approximately 48 600 pounds. Had the QRB valve been operative, the total retarding brake force would have increased by 4830 pounds.

At a brake cylinder pressure of 27 psi, when the train first began to move, the retarding brake force of the independent brakes was reduced to approximately 97 400 pounds.

The average brake ratio of the locomotive hand brakes was approximately 3.8% (range of 3.0% to 4.7%). The average retarding brake force generated by the locomotive hand brakes was approximately 5590 pounds per locomotive. (When 80 foot-pounds of torque were applied, the average retarding brake force was 4360 pounds per locomotive.)

The brake ratio of the VB car was 19.2%.

1.14.3 Hand brake and air brake testing on tank cars

The air brakes and hand brakes of the 9 tank cars that did not derail were tested and met AAR requirements. The average retarding brake force generated by the hand brakes at 80 foot-pounds of torque was approximately 6920 pounds per car. At 100 foot-pounds of torque, the brake force was approximately 8650 pounds per car.

1.14.4 Testing of the sense and braking unit

Testing was conducted on a rail car to evaluate how the rate of brake pipe leakage affected the car's air brake system. Following simulated brake pipe leakage, the car's brake pipe pressure dropped 5 psi (to 85 psi) in 7 minutes. The car's air brakes did not engage. The car was then recharged to 90 psi, and the test was repeated. In this test, the brake pipe was reduced by 80 psi (to 10 psi) in 75 minutes. The car's air brakes again did not engage.

A turbine-equipped SBU,Footnote 26 similar to the one used on MMA-002, was then tested to determine what effect the brake pipe air lost through the SBU would have on the car's air brake system. The venting of air through the SBU caused the air brakes on a single car to engage almost immediately.

Testing was then conducted with a turbine-equipped SBU on a train with 2 locomotives and 71 cars. The test showed that a similar rate of brake pipe air loss through the SBU would initiate a brake application on a train that was 5 cars or fewer, but not on a train longer than 5 cars. Similar to the single-car test, this test demonstrated that brake pipe air pressure on an entire train can be reduced to 0 psi at a slow rate and result in no brake application on the cars.

1.14.5 Additional hand brake testing on tank cars

Railways require that air brakes be fully released on cars prior to the application of hand brakes. However, in some instances, such as when a train is stopped on a grade, it is not possible to release the air brakes before applying the hand brakes. Testing was conducted on a cut of tank cars to determine the effect on the hand brakes from the 13-psi automatic brake application on MMA-002 at Nantes. It was determined that when the hand brakes were applied after an air brake application, more brake force was applied to the wheels. The extent of the additional force was relative to the extent of the brake application. Through this testing, it was also determined that an air brake application of 13 psi would result in hand brake forces approximately 40% higher than the same application without air brakes applied.

1.14.6 Previous brake testing for other occurrences

The TSB investigated other runaway train occurrences where extensive hand brake tests were conducted (TSB Rail Investigations R95C0282, R96C0172, and R11Q0056). It was determined that an average of 65 foot-pounds to 80 foot-pounds of torque had been applied on the hand brakes. In one occurrence, the air brakes leaked off and released after approximately 7 hours due to weather conditions. In another occurrence, the majority of the brake cylinders of the cars leaked off after approximately 1 hour following an emergency brake application due to their poor condition. See Appendix D for more information on previous brake testing for other occurrences.

1.14.7 Wiring of the locomotive reset safety control

New locomotives manufactured since 1986 must be equipped with a reset safety control (RSC). The RSC is a vigilance system that activates alarms and then applies a penalty brake application if it is not reset by the LE, or the controls are not being manipulated within a predetermined time interval. There are no standards for the installation of RSCs. Usually, when the electrical breaker on an RSC is opened or the main electrical power is shut off on a locomotive, a penalty brake application will result. However, when the electrical power was shut off on MMA 5017 at Nantes, the RSC did not create a penalty brake application.

The 3 GE locomotives on MMA-002 were built before 1986 and were retrofitted with an RSC by a previous owner. The locomotives were examined by the TSB (Engineering Laboratory Report LP233/2013), and the following was determined:

The wiring modifications on the 3 locomotives were not consistent, and the penalty brake performance for all 3 locomotives was different.

Locomotive MMA 5017 did not produce a penalty brake application under any of the power loss conditions tested. The RSC had been connected directly to the battery. Therefore, the RSC would remain powered even when the main electrical cut-off switch was opened.

Testing of 5 other GE locomotives owned by MMA showed similar variations. In total, no penalty brake application occurred when the electrical breakers were opened on 5 of the 8 locomotives tested. Since there is no requirement for the RSC to initiate a penalty brake application in the event that the power to the device is cut, there is no requirement for this function to be verified during shop inspections.

1.15 Lead locomotive MMA 5017

Lead locomotive MMA 5017 was a GE model C30-7 that had been placed in service in 1979. It was equipped with a 16-cylinder, turbocharged 4-stroke diesel engine, and generated 3000 horsepower. The locomotive had 2 three-axle trucks and a 26 L-type air brake system. The overall weight of MMA 5017 was approximately 195 tons.

1.15.1 Engine repair and fire on locomotive MMA 5017

On 07 October 2012, MMA 5017 entered the shop in Derby, Maine, after an engine failure. It was determined that several power assemblies as well as cam segments had been damaged as a result of an articulated rod failure on one of its power assemblies. The engine block had also been damaged at the same cam bearing. On 15 March 2013, the locomotive was returned to the shop, where an oil leak was found at the same cam bearing bore. To repair the leak, the cam bearing mounting bolt at the cam bearing bore was tightened.

On 04 July 2013, MMA 5017 was in the lead position of MMA-001, being operated by another LE. On the trip from Nantes to Farnham, MMA 5017 was having engine problems. The engine was surging, which was reported by fax to the shop in Derby that day, and verbally to Farnham management the next morning. No action was taken, and MMA 5017 remained in service.

On 05 July 2013, with MMA 5017 in the lead position of MMA-002, the LE reported to the RTC upon departure that there were problems with the engine surging when the throttle was at full. During the trip to Nantes, the engine continued to surge, affecting the LE's ability to maintain a consistent speed. Upon arrival, heavy black and white smoke, as well as oil droplets, were observed coming from the lead locomotive. At 2340, shortly after the LE's departure, a fire ignited in the locomotive smoke stack (Photo 13).

Photo 13. Locomotive fire at Nantes (source: Nancy Cameron)

Following the accident, the locomotive consist was moved from Lac-Mégantic to a maintenance facility in Saint John for examination. A partial engine teardown of MMA 5017 was conducted (see Engineering Laboratory Report LP181/2013 for complete details). It was determined that the cam bearing had fractured when the mounting bolt was over-tightened after the cam bearing had been installed as part of a non-standard repair to the engine block. This temporary repair had been performed using a polymeric material, which did not have the strength and durability required for this use (Photo 14). Failure of the cam bearing reduced the engine oil supply to the valve train at the top of the associated power assembly. The decreased lubrication led to valve damage and eventually to a punctured piston crown. The damaged valves and piston crown allowed engine oil to flow into the cylinder and the intake and exhaust manifolds. Some of the engine oil collected in the body of the turbocharger. The engine fire later occurred in the exhaust stack due to the build-up and ignition of engine oil in the body of the turbocharger.

Photo 14. Polymeric material applied to cam bearing bore and fractured cam bearing

1.15.2 Abnormal engine conditions

MMA's Safety Rule 9126 stated:

When there is an abnormal condition such as noise, smoke or odor coming from engine, the engine should be shut down. Employees must immediately leave the engine room and shut down the engine by emergency “shut down” button at the control stand, control panel or fueling location on either side of the locomotive. Footnote 27

1.16 Defences to prevent runaway trains

Runaways can best be avoided by selecting a location that would limit the distance travelled by an uncontrolled movement (bowl-shaped tracks for switching) or by ensuring that trains are not left unattended by performance of crew-to-crew exchanges. Due to many factors, such as mechanical breakdowns and severe weather conditions, railways have developed rules regarding the safe securement of equipment. In addition, there are physical defences that provide additional levels of safety, such as:

Derails—These are usually placed on secondary tracks, and in some cases in sidings, and set in the derailing position to protect the main track from cars that may be rolling uncontrolled. In locations such as the main track, where there are no permanent derails, portable derails weighing about 40 pounds can be carried in a locomotive cab. They can be easily applied by an LE and can provide a physical defence to prevent uncontrolled movements. Portable derails are not commonly used when securing trains on the main track.

Chocking devices—These portable devices weigh as little as 20 pounds, and can be applied to the rail, directly against the leading wheels of a train. They provide temporary blocking of that equipment. Chocking devices are more commonly used when securing trains on other than main track.

Mechanical emergency device—This device activates the braking system of a stopped train in the case of an undesired movement. It consists of a clamp that attaches to the rail and to the lead locomotive air brake hose. If the train begins to move, the hose detaches from the locomotive, the brake pipe air is vented, and the emergency brakes are activated.

Electronically controlled pneumatic (ECP) brakes—This braking system is an alternative to conventional air brakes. The system sends electrical signals to the cars, instantaneously applying the brakes (quick response braking); it does not rely on the flow of air from the locomotive to each car to activate the brakes. Information is also exchanged between the locomotives and each car. When the system senses that the brake pipe pressure has dropped below 50 psi, a “low brake pressure condition” message is initiated. This message results in all of the ECP-equipped cars and the ECP-equipped locomotives automatically applying their brakes in emergency.

Auto-start systems (also known as hot starts) can be installed on locomotives to automatically shut down and restart locomotives for fuel conservation and to protect critical systems. Locomotives equipped with auto-start will automatically shut down when they are idling for a set time and will automatically restart when certain parameters are met, such as when locomotive brake cylinder pressure falls below a prescribed level and when main reservoir pressure falls below 100 psi. However, the auto-start feature would be nullified if the locomotive is set to isolate, or if it has been shut down manually.

Some of the locomotives used by MMA were equipped with an auto-start system, including locomotives CITX 3053 and CEFX 3166. MMA's Summary Operating Bulletin 2-276 states:

(L) Hot Starts/Locomotive Shut Down: Unless equipped with a working Hot Start, when temperature is above 45 degrees, Engineers must shut down locomotives that will be idling for periods in excess of 15 minutes [....] Footnote 28

When MMA crews were leaving trains at Nantes, most would leave the lead locomotive running and shut down all others, including those equipped with the auto-start system. On the night of the accident, the LE manually shut down locomotives CITX 3053 and CEFX 3166.

Operating instructions adopted by MMA on locomotive auto-start systems highlight the importance of ensuring that trains are properly secured and tested, as it is expected that main reservoir, brake pipe, and brake cylinder pressures will eventually leak off.

The RSC can be upgraded to include a built-in runaway protection feature that initiates an alarm as soon as it detects a movement of 0.5 mph. If the RSC is not reset, a penalty brake application is initiated.

As the SBU, along with the input and display unit (IDU) in the locomotive, serves as a monitor for the air pressure, manufacturers indicated that, with a software update, SBUs could be set up to apply a penalty or emergency brake application before the brake pressure becomes too low to provide effective braking.

1.17 Track information

1.17.1 Particulars of the track

In the vicinity of the derailment, the track was continuous welded rail (CWR). The rail was secured with 2 spikes per tie plate in tangent track, and 3 spikes per tie plate in the curves. Most of the rail was Algoma Steel 115-pound RE rolled between 1966 and 1971, except in some curves, where the high rail was rolled and installed in 2003. The rail was laid on 14-inch double-shouldered tie plates. There were approximately 3200 hardwood ties per mile. Every second tie was box-anchored. The ballast consisted mainly of crushed rock and was generally in good condition. There was insufficient ballast, or ballast fouling, noted at 10 locations over a 10-mile distance.

1.17.2 In-train forces, vehicle dynamics, and derailment speed

MMA-002 ran away eastward and, when approaching Megantic Station, encountered a reverse curve configuration beginning with a 1.5°, left-hand, 670-foot curve with a maximum superelevation Footnote 29 of 1 inch, followed by a 60-foot tangent section of track, then a 4.25° right-hand, 1200-foot curve. This curve had a 230-foot-long entry spiral, starting approximately 100 feet west of the Frontenac Street public grade crossing. After the crossing, the turnout at Megantic West provided access to Megantic Yard and its wye tracks. The turnout was a No. 11, 115-pound, left-hand-operated turnoutFootnote 30 at the end of the entry spiral.

For the right-hand curve section in the vicinity of the derailment, the superelevation (1 inch to 1 ½ inches) corresponded to a balanced speedFootnote 31 of between 18 mph and 22 mph. An analysis of the derailment speeds estimated that 10 cars derailed below 40 mph, 5 of which derailed below 30 mph (Engineering Laboratory Report LP039/2014) (Figure 5). Recorded data showed that the derailment took approximately 1 minute (Engineering Laboratory Report LP136/2013).

Figure 5. Estimated speed at which each car derailed if the third or fourth car was the first to derail Footnote 32

At the time of the derailment, the train was near the Megantic West turnout. The train was analyzed to assess the in-train forces as it transitioned from the downhill grade of 1.26% to the relatively flat terrain of 0.2% at Megantic. A vehicle dynamics simulation of a Class 111 tank car negotiating the curve at Megantic Station was also conducted (see Engineering Laboratory Report LP188/2013 for complete details). It was determined that a combination of the centrifugal force and the dynamic forces generated by the track geometry conditions at a speed of 65 mph was sufficient to cause the derailment. With extremely high lateral forces on the high rail, gauge widening could occur. Furthermore, with complete unloading on the low rail, wheel lift could occur. Either of these conditions or a combination could cause track damage and a derailment.

1.17.3 Track inspections by Montreal, Maine & Atlantic Railway

The main track was regularly inspected as per the TSR. Prior to the accident, MMA performed these track inspections:

Visual inspection by a track maintenance employee in a hi-rail vehicle was performed on 05 July 2013. During this inspection, no exceptions were noted in the vicinity of the derailment.

Monthly turnout inspections were performed as required. The most recent turnout inspection was performed on 21 June 2013, and no defects were noted.

The track was tested annually for internal rail defects using an automated rail flaw detection system. The most recent rail flaw testing was on 19 September 2012, and no defects were noted in the vicinity of the derailment.

The track geometry was last tested by a track geometry car on 21 August 2012 (Appendix E).

In the immediate area of the rail joints located between the Frontenac Street public grade crossing and the Megantic West turnout, the track geometry readings for surface, cross-level, gauge, and alignment were measured.

The track geometry readings met the maximum allowable limits for 15 mph. According to the TSR, to operate as Class 2 track, the track had to be improved to meet the 25-mph criteria (within 72 hours after the passage of the track geometry car). Consequently, following the August 2012 track geometry test, the rail joints were lifted to correct the geometry irregularities and restore the track to Class 2 criteria. The fouled ballast was not replaced, and was not compacted with heavy machinery.

1.17.4 Post-accident track examination

The TSB examined sections of track over approximately 30 miles on each side of the town of Lac-Mégantic (that is, between Mile 106.00 of the Moosehead Subdivision and Mile 18.00 of the Sherbrooke Subdivision). The following was observed:

The rail surface had microcracks, corrugation, and multiple signs of wheel slippage and crushed rail head.

The rail head on the low rail (that is, inside of the curve) of many curves was flattened and worn.

The vertical rail wear exceeded the acceptable wear limits at Miles 106.60, 107.50, 110.40, 115.56, and 116.25 of the Moosehead Subdivision, and at Miles 3.00, 16.15, 17.50, and 17.60 of the Sherbrooke Subdivision. The vertical wear was as much as 25 mm (1 inch) in some areas.

Lateral rail wear could not be accurately measured because of crushed rail head and loss of rail profile condition. At Mile 110.55 of the Moosehead Subdivision, the lateral part of the rail head on the field side was completely worn.

In the curve at Mile 17.60 of the Sherbrooke Subdivision, the rail showed signs of track buckling (for example, the rail undulated laterally, and the ties had shifted sideways).

At rail joints with significant vertical rail wear, there was damage to the joint bars due to wheel load impacts (that is, contact with wheel flanges). Wheel flange contacts were observed in the area of the derailment (Photo 15).

Photo 15. Damaged rail joint bar due to contact with wheel flanges

1.17.5 Rail wear standards at Montreal, Maine & Atlantic Railway

MMA's track standards were based on standards previously developed by the Bangor & Aroostook RailroadFootnote 33 (that is, System Track Standards, Part I, for track maintenance limits, and Part II for construction and maintenance practices).

For rail wear, System Track Standards, Part I, Section 113.5 (b), specifies in part:

(1) VERTICAL HEAD WEAR

115 RE ¾”– Then limit track speed to 25 mph […] (2) GAGE WEAR (is measured five-eighths of an inch below the top of the rail head)

115 RE ¾”– Then limit track speed to 25 mphFootnote 34

At MMA, when the vertical rail wear exceeded the limits set out in its Rail Wear Standard, a temporary slow order of 25 mph was placed on the track. This track section would also be identified for its rail replacement program. MMA did not have a vertical head wear limit specific to jointed rail.

In comparison, the rail wear standards for Canadian Class 1 railways are:

CN's track standards are summarized in Engineering Track Standard (ETS) TS 1.0 – General 13 and 14, June 2011 edition. Based on these standards, the vertical wear limit for 115-pound rail is 16 mm (5/8 inch) for CWR, and 8 mm for jointed rails. For jointed track, high-clearance joint bars must be used to avoid any contact between the wheel flange and joint bar. Rail wear standards do not require replacement of the rail, as long as the wear limit has not been reached. However, the sum of the vertical and flange wear shall not exceed 21 mm (13/16 inch). A speed restriction may be placed and additional inspection frequency specified if rail is worn beyond the limits and is to be left in the track. The condition of rail (for example, shells, spalls, corrugation) must also be taken into consideration if the rail is left in the track. Footnote 35

CPR's track standards are summarized in the Red Book of Track Requirements. These standards specify that the vertical wear limit of 115-pound RE rail is 17 mm (11/16 inch). A varying amount of combined vertical and flange wear is allowed, up to a maximum of 23 mm (7/8 inch). Where rail wear has resulted in joint bars being heavily affected by wheel flanges, the joint must be welded, or a high-clearance bar or compatible worn bar must be applied. Train speed must be restricted to a speed as near as possible to equilibrium speed until the joint is welded or a high-clearance bar is applied. Footnote 36

1.17.6 Laboratory examination of track components

A No. 11 rail-bound manganese frog and other track components were recovered and sent to the TSB Laboratory for examination (Engineering Laboratory Report LP151/2013). It was determined that the wing rails and other components were damaged due to overstress fractures. It was also determined that the vertical rail wear was within allowable limits, and that there were no pre-existing defects or fatigue cracks on the fracture surfaces.

1.18 Class 111 tank cars

In 2013, there were approximately 228 000 Class 111 tank cars in service in North America, of which over 141 000 were being used to transport dangerous goods (DGs). Of those, 98 000 were used to carry Class 3 DGs (flammable liquids). The majority of these tank cars were general-service cars (Figure 6). The specifications applicable to these cars are listed in TC safety standard CAN/CGSB-43.147Footnote 37 and the U.S. Code of Federal Regulations Title 49 (49 CFR), paragraph 179.200,Footnote 38 for Canada and the United States, respectively.

Figure 6. Tank car components

1.18.1 Examination of the derailed tank cars

The 63 derailed tank cars were examined in the field (Engineering Laboratory Report LP149/2013), and the following was determined:

All tank cars were manufactured to United States Department of Transportation (DOT) specification 111A100W1 between 1980 and 2012, and 78% were built in the 5 years prior to the accident.

All tank cars had been ordered before 01 October 2011.

None of the tank cars were equipped with head shields, jackets, or thermal protection.

The shells of 52 tank cars and the heads of 44 tank cars were made of non-normalized steel. Footnote 39

The shells of 11 tank cars and the heads of 19 tank cars were made of normalized steel.

All 63 derailed tank cars were in compliance with the specification requirement that was in effect at the time of their approval and construction.

The stencilling or stamped markings on some of the tank cars was not legible due to fire and impact damage. Furthermore, some tank car identification plates had been affixed with low-melting-point fasteners and had separated from the tank during the post-derailment fire.

1.18.2 Tank car damage assessment

An assessment of the damage sustained by the 63 derailed tank cars revealed that 59 (94%) were breached and released crude oil due to tank damage. The location and extent of the damage varied, depending on the orientation and speed of the cars during the derailment. Many cars sustained damage in multiple locations (Table 3).

Table 3. Distribution of damage on derailed tank cars Tank car shells 37 cars Tank car heads 31 cars Top fittings and protective housings 20 cars Pressure relief devices 12 cars Bottom outlet valves 7 cars Thermal tears 4 cars Manway covers 2 cars

Three-dimensional (3D) laser scanning was performed on selected derailed tank cars (Engineering Laboratory Report LP165/2013). Analysis of the data revealed that the shells of the tank cars exhibited impact damage ranging from localized buckles to large-scale buckling, and sustained significant reductions in volume (for example, close to 40% reduction in volume was sustained by the most deformed tank) (Photo 16).

Photo 16. 3D laser scan of badly deformed tank

1.18.2.1 Damage to stub sills and couplers

Stub sills are located at each end of a tank. For cars so equipped, the tank not only carries the product, but is also used as the primary structural member to carry in-train forces. The stub sills contain draft gear components that help absorb in-train dynamic buff (push) and draft (pull) forces, as well as coupler vertical forces (Photo 17).

The field examination showed the following:

Five tank cars had no impact damage to either the stub sill or coupler.

Fifty-eight tank cars exhibited at least 1 damaged stub sill or coupler.

Forty-six tank cars were damaged at both ends of the car, including damage to the stub sill or coupler.

The last 2 derailed cars exhibited significant impact damage to their stub sills and couplers.

Nine tank cars exhibited separations at the stub sill attachments (Photo 18).

Photo 17. Complete stub sill Photo 18. Damaged stub sill

1.18.2.2 Damage to tank car shells

More than half of the tank cars (37 cars) released product due to impact damage to their shells (Photo 19). Other tank car shell damage included deformed/dented shells with no breach, as well as breaches due to thermal tears.

Photo 19. Tank cars with breaches to their shells (colour indicates relative size of breach: orange = large, yellow = medium, blue = small). The relative size of the breaches is also identified in Appendix B.

1.18.2.3 Damage to tank car heads

All but 4 of the 63 derailed cars exhibited some form of impact damage (for example, denting or breach) in the top portion of at least one head (Photo 20). About half of the tank cars (31) released product due to damage to the tank car head.

Photo 20. Head puncture due to rail impact

1.18.2.4 Damage to top fittings and housings

The majority of the tank cars with damaged top fittings came to rest on their sides or upside down, allowing the product to flow from the damaged top fittings and feed the pool fire.

The top fittings of 32 of the 63 tank cars were housed in a ¾-inch-thick steel circular protective housing designed to provide top discontinuity protection in accordance with applicable AAR requirementsFootnote 40 (Photo 21).

The top fittings of the remaining 31 tank cars were located in a hinged housing that did not have to meet any of the top discontinuity protection requirements (Photo 22).

Photo 21. Protective housing providing top discontinuity protection for tank car fittings (removed cover) Photo 22. Hinged housing for tank car fittings

The field examination determined the following:

The top fittings were breached on 4 of the 27 cars (15%) that were equipped with top discontinuity protection housings and that sustained impact damage.

The top fittings were breached on 16 of the 26 cars (62%) that were equipped with a hinged housing and that sustained impact damage.

1.18.2.5 Damage to manway covers

A manway cover is used to seal the large opening at the top of the tank (Photo 23). This opening is used by personnel to gain entry into the tank for inspection and maintenance activities and, in Class 111 tank cars, may also be used to load product into the tank car. The manway cover is secured to the manway nozzle using a hinge and typically 6 to 8 bolts. It is sealed by tightening the bolts onto a manway cover gasket.

Photo 23. Manway cover and opening

The field examination determined the following:

The manway gaskets on most of the derailed tank cars were damaged by extended exposure to the post-derailment fire.

The manway cover of 2 cars had separated as a result of impact damage.

The manway cover hinges, bolts, or lugs of 22 tank cars exhibited impact damage that may have compromised their seals.

1.18.2.6 Damage to pressure relief devices

All 63 derailed tank cars were equipped with at least 1 reclosing pressure relief device (PRD),Footnote 41 as per the federal regulations.Footnote 42 The start-to-discharge (STD) pressureFootnote 43 of these PRDs was either 75 psi (on 48 tank cars) or 165 psi (on 15 tank cars). In addition to different STD pressures, PRDs are designed with different flow capacities.Footnote 44 A PRD that can discharge product at greater than 27 000 cubic feet per minute (CFM) is considered to have high flow capacity. In this accident, 13 of the 15 PRDs with STD pressure of 165 psi had flow capacities of about 38 900 CFM.

The field examination determined the following:

Most of the cars with damaged PRDs came to rest on their sides or upside down, putting the PRD in contact with the liquid space inside the tank; product flowed from the damaged PRD and fed the pool fire.

On 32 cars, the PRD was fastened to the top unloading nozzle assembly within the top discontinuity protection housing. The PRD of 3 of these 32 cars, or 9%, were breached.

On the 31 other cars, the PRD was fastened to a safety valve nozzle attached to the top of the tank (Photo 24). The PRDs of 9 of these, or 29%, were breached.

Photo 24. Pressure relief device

1.18.2.7 Damage to bottom outlet valves

Federal regulations require that tank cars equipped with bottom outlet valves (BOVs) be built to prevent damage to the valve and the subsequent loss of product during a derailment. Design features include various combinations of breakaway designs and skid protection structures around the valve, as well as a locking arrangement to ensure that the BOV stays closed during transit (Photo 25). The AAR Manual of Standards and Recommended Practices (MSRP) specification M-1002, Appendix E, section 10.1.2.8, specifies that BOV handles, unless stowed separately, must either be designed to bend or break free on impact or be positioned so that the handles, in the closed position, are above the bottom surface of the skid protection.

The field examination determined the following:

There were 36 tank cars with sheared-off BOV nozzles (Photo 26).

Seven of these tank cars had damaged or missing BOV handles, resulting in the ball valve being open or partially open, which led to a release of product.

Six tank cars were equipped with internal plug-type BOVs. None of these BOVs were breached.

The BOV handle assemblies of 43 tank cars were deformed, impact-damaged, or missing.

Photo 25. Bottom outlet valve

Photo 26. Bottom outlet valve with sheared off nozzle

1.18.2.8 Damage due to thermal tears

A thermal tear occurs when a tank car is exposed to elevated temperatures such as that from a post-derailment fire. As the temperature inside the tank rises, the product vapourizes, causing an increase in both its internal pressure and the stresses in the tank wall. If the pressure is not relieved, the tank ruptures. Ruptures involving the sudden release of built-up pressure can result in large explosions and fire.

Thermal protection helps delay the rate at which the internal tank temperature rises. It typically consists of an insulating material applied to the exterior of the tank and covered by a steel jacket. Federal regulations specify when thermal protection is required, as well as the performance standard it has to meet (for example, prevention of tank failure for at least 100 minutes in a pool fire and at least 30 minutes in a torch fire). Most general-service Class 111 tank cars are not required to have thermal protection.

Examination of the 63 derailed tank cars showed the following:

None of the cars were equipped with thermal protection.

Four cars that had sustained only minor impact damage due to the derailment experienced thermal tears, resulting in an energetic release.

The length of the thermal tears ranged from 1.6 m to 4.4 m. No fragments of tank material were separated as a result of the thermal tears.

All of the thermal tears were situated in the vapour space, and the PRDs were located in the liquid space.

The car with the largest thermal tear (4.4 m) (Photo 27) was equipped with a PRD with an STD pressure of 75 psi, whereas the car with the smallest thermal tear (1.6 m) had a 165-psi PRD.

Two tank cars experienced a thermal tear within approximately 20 minutes after the fire began.

Photo 27. Thermal tear

1.18.2.9 Damage due to burn-through

Thirteen tank cars had localized loss of tank material in the form of a burn-throughFootnote 45 as a result of extreme fire damage (Photo 28). In the regions around these perforations, there were jagged edges and the tank material exhibited reduced wall thickness, and in some cases, contained brittle cracks.

Photo 28. Burn-through

1.18.2.10 Metallurgical examination of tank cars

Selected samples were taken from tank cars involved in the derailment and sent for metallurgical analysis (Engineering Laboratory Report LP168/2013). At least 1 tank car from each car builder was selected.

It was determined that the tank car material generally met all applicable specifications at the time of manufacture. The sample examination did not find any material deficiency that would have affected the performance of the tank cars during the derailment.

1.18.3 Regulatory activities related to Class 111 tank cars

Following a TSB investigationFootnote 46 into an accident in August 2004 involving a petroleum product unit train near Lévis, Quebec, the Board recommended that:

The Department of Transport extend the safety provisions of the construction standards applicable to 286 000-pound cars to all new non-pressurized tank cars carrying dangerous goods.

TSB Recommendation R07-04 (issued 2007)

Subsequently, an AAR task force examined improvements to tank car safety, and the AAR tank car standards were amended (Casualty Prevention Circular No. CPC-1232)Footnote 47 to incorporate a number of enhancements to all Class 111 tank cars built after 01 October 2011 for the transportation of crude oil and ethanol in PG I or PG II. These enhancements include construction of the tank cars to 286 000-pound standards, protection of the service equipment on the top shell, use of reclosing PRDs, use of normalized steel for tank shells and heads, increased minimum thickness for all tank cars not jacketed and insulated, and at least ½-inch half-head shields. As all of the tank cars had been built before October 2011, none were subject to the requirements of AAR Circular No. CPC-1232.

In 2011, the AAR petitioned Canadian and U.S. regulators to adopt these changes in regulations.

In 2012, following the Cherry Valley, Illinois, investigation,Footnote 48 the NTSB recommended that the Pipeline and Hazardous Materials Safety Administration (PHMSA):

Require that all newly manufactured and existing general service cars authorized for the transportation of denatured fuel ethanol and crude oil in Packing Groups I and II have enhanced tank head and shell puncture resistance systems and top fittings protection that exceeds existing design requirements for DOT-111 tank cars.

NTSB Recommendation R-12-5

In the same investigation, the NTSB recommended that the AAR:

Review the design requirements in the Association of American Railroads Manual of Standards and Recommended Practices C-III, “Specifications for Tank Cars for Attaching Center Sills or Draft Sills,” and revise those requirements as needed to ensure that appropriate distances between the welds attaching the draft sill to the reinforcement pads and the welds attaching the reinforcement pads to the tank are maintained in all directions in accidents, including the longitudinal direction.

NTSB Recommendation R-12-9

In September 2013, PHMSAannounced its intent to propose a regulation Footnote 49 adopting new tank car requirements in the Hazardous Materials Regulations (49 CFR). PHMSA requested comments from stakeholders on the AAR's 2011 Class 111 tank car improvements.

In November 2013, both the AAR and the American Short Line and Regional Railroad Association (ASLRRA) expressed support for even more stringent tank car standards. They called for additional improvements to tank cars transporting flammable liquids (including PG III flammable liquids), retrofitting of existing tank cars in flammable liquid service, and aggressive phase-out of tank cars that cannot meet retrofit requirements. The tank car improvements include modifications such as:

tank car jackets, for added puncture resistance;

full-height head shields;

thermal protection blanket or coatings in conjunction with jackets;

high-capacity PRDs;

reconfiguration of the BOV handles; and

possible designation of a new tank car class.

In January 2014, TC proposedFootnote 50 adopting AAR's 2011 Class 111 tank car improvements in the Transportation of Dangerous Goods Regulations (TDG Regulations).

In January 2014, TSB Recommendation R14-01 called for enhanced protection standards for tank cars used to transport flammable liquids. See section 4.1.2.1 for further details.

1.19 Dangerous goods

The transportation of dangerous goodsFootnote 51 (DGs) is governed in CanadaFootnote 52 and the United StatesFootnote 53 by federal regulations, which are based on the United Nations Recommendations on the Transport of Dangerous Goods.

1.19.1 Class 3 – Flammable liquids

Flammable liquids in Class 3 are DGs whose vapours form an ignitable mixture with air at or below a temperature of 60 °C. Flammable liquids can pose serious hazards due to their volatility and flammability, which are determined respectively by the initial boiling pointFootnote 54 and by flashpoint.Footnote 55

Given that volatility and flammability of flammable liquids vary widely, they are grouped together based on these characteristics so that different requirements, including packaging, storage, handling, and transportation, can be established. According to the TDG Regulations, Class 3s are divided into 3 packing groups (PGs), ranging from PG I (highest hazard) to PG III (lowest hazard):

PG I, if the flammable liquid has an initial boiling point of 35 °C or less at an absolute pressure of 101.3 kPa and any flashpoint.

PG II, if the flammable liquid has an initial boiling point greater than 35 °C at an absolute pressure of 101.3 kPa and a flashpoint less than 23 °C.

PG III, if the criteria for inclusion in PG I or PG II are not met.

The PG is established by determining a flammable liquid's flashpoint and boiling point.

1.19.2 Petroleum crude oil

Petroleum crude oil is a Class 3 flammable liquid with a wide range of flammability and volatility characteristics, and is therefore assigned to one of the 3 PGs. It is most prominently qualified in terms of its sulphur content (sweet to sour) and density (light to heavy).

The density of petroleum crude oil is described in terms of its American Petroleum Institute (API) gravityFootnote 56 (expressed in degrees), whereby a higher number indicates lower density. The thresholds defining “light,” “medium,” and “heavy” crude oil vary by the product's region of origin and by the organization making the determination.Footnote 57

1.19.2.1 Testing of crude oil samples

Crude oil samples were collected from 9 tank cars on MMA-002 that did not derail. Samples were also taken from 2 tank cars in Farnham that were part of another MMA unit train (MMA-874). This train was transporting petroleum crude oil from the same origin.

All crude oil samples were collected at atmospheric pressure and tested for characteristics relevant to the classification of the petroleum crude oil and to its behaviour and effects during the post-accident spill and fire. The level of hazard posed by the petroleum crude on MMA-002 had not been accurately documented, as the samples that were tested had the properties of a flammable liquid of Class 3, PG II. It was concluded that the large quantities of spilled crude oil, the rapid rate of release, and the oil's high volatility and low viscosity were the major contributors to the large post-derailment fireballs and pool fire. There was no indication that the crude oil's properties had been affected by contamination from fracturing process fluid additives. No detectable levels of hydrogen sulphide gas were found at the derailment site. See Appendix F for a summary of the test results of the crude oil samples, and Engineering Laboratory Report LP148/2013 for further details.

1.19.3 Regulatory requirements for classification and packaging

The federal regulationsFootnote 58 require DGs to be properly classified and packagedFootnote 59 before they are offered for transport. For flammable liquids, the classification consists of determining the primary class, subsidiary class, UN number, proper shipping name, and PG. Once a DG is properly classified, an authorized container must be selected.

For DGs imported into Canada, the Transportation of Dangerous Goods RegulationsFootnote 60 (TDG Regulations) require the importer (consignor)Footnote 61 to ensure that the DGs have the correct classification before they are transported in Canada. For flammable liquids, the TDG Regulations also permitFootnote 62 a consignor to use a classification that was determined by a previous consignor or the manufacturer.

The TDG Regulations allow dangerous goods to be included in PG I if the packing group is unknown, and in PG II if it is known (or reasonably believed) to be PG II or III.Footnote 63 They also contain provisions in case of detected or suspected classification errors.

1.19.4 Safety data sheets

A safety data sheet (SDS)Footnote 64 is produced by chemical manufacturers, distributors or suppliers pursuant to federal hazardous products legislation and standards.Footnote 65 The primary purpose of the SDS is to communicate the dangers of the hazardous chemical product. It contains detailed information about the nature of the hazardous product, including physical and chemical properties, and health, safety, fire and environmental hazards. Although not required by federal law, an SDS may also include other information, such as DG classification and transportation information.

Some products, such as petroleum crude oil, contain many ingredients whose concentrations can vary depending on the product's origin and vintage. Common industry practice, as permitted by federal hazardous products legislation, is to prepare and provide generic, representative SDSs that apply to products having similar characteristics.

The petroleum crude oil transported by MMA-002 originated from oil wells belonging to 11 different producers in the Bakken shale formation in North Dakota. WFSI provided 10 different SDSs representing the petroleum crude oil in the train (Appendix G). The classification of the petroleum crude oil for the purpose of transportation was not based on SDS information.

There was no specific practice or procedure to either verify that each SDS accurately reflected the properties of the product or family of products it represented, or that the products were properly classified for transport. Further, where there were multiple SDSs for products having similar characteristics, there was no review to compare and reconcile the provided information for consistency.

1.19.5 Transportation of petroleum crude oil from North Dakota toward New Brunswick

1.19.5.1 Transportation of petroleum crude oil by road

The petroleum crude oil was loaded in DOT-407Footnote 66 cargo tank trucks operated by Prairie Field Services at each product supplier facility, and transported by road to the rail loading facility at New Town, North Dakota, operated by Strobel Starostka Transfer, LLC (SST).

The shipping documents indicated that the shipper was the product's supplier and that the consignee was WFSI. The product was described on the majority of the shipping documents as UN 1267, petroleum crude oil, Class 3, PG II.Footnote 67 The majority of producers in the Bakken region considered crude oil from the region as PG II product, and had cargo tank truck shipping documents preprinted to reflect this designation.

There was no practice, procedure, or activity to verify, confirm, or validate the classification of the product transported by cargo tank trucks from the suppliers' facilities to the rail loading facility. The product was not being tested for the purpose of classification for transportation by road.

SST's standard operating procedures were to collect and test (on a monthly basis) composite samples representing the product being shipped from New Town. The tests primarily determined sulphur content, API gravity, boiling point, and the presence of light-end gases. The testing was performed primarily for quality assurance and control purposes and to establish the product's market value. The product's flashpoint was not being determined.

1.19.5.2 Transportation of petroleum crude oil by rail

At the New Town rail loading facility, the product was transloaded directly from the cargo tank trucks into Class 111Footnote 68 rail tank cars, with about 3 truckloads filling 1 tank car. The tank cars were leased by the Western Petroleum Company. The product was loaded, offered for transport, and being transported from New Town to Saint John pursuant to the applicable provisions of the United States Code of Federal Regulations, Title 49 (49 CFR).Footnote 69

The shipping documents for the tank cars identified the shipper as Western Petroleum Company and the consignee as Irving Oil Ltd. The product was identified as UN 1267, petroleum crude oil, Class 3, PG III.

The tank car shipping documents were generated by CPR based on the shipper's instructions. These instructions were provided by SST on behalf of the shipper, using CPR's web-based bill-of-lading instruction system. The shipper had no procedure to verify, validate, or confirm the classification of the DGs being offered for transport, or to reconcile the shipping document information of the tank cars being offered for transport with those of the inbound product transloaded into those tank cars prior to releasing the tank cars to CPR.

The characteristics of the product for the purpose of classification for transportation by rail were not tested prior to being offered for transport. At destination, Irving sampled petroleum crude oil based on the volume of product being unloaded. Tests at an on-site laboratory determined density (which is used to calculate the API gravity), Reid vapour pressure, and whether bottom sediment or water were present.

This testing was performed for quality assurance and control purposes, and the product's flashpoint and initial boiling point were not determined. Irving relied on its suppliers to determine the classification of imported petroleum crude oil, as permitted by the TDG Regulations.Footnote 70

1.20 Route planning and analysis for trains carrying dangerous goods

The frequency and consequences of derailments are dependent on several operational factors, such as train speed, rail integrity, braking systems, and emergency response.

Train speed is a factor because the energy dissipated during a derailment depends on the kinetic energy of the train in movement, and thus on its speed and mass. TSB data on main-track derailments from 2003 to 2012 indicate that higher derailment speeds are significantly associated with a higher number of derailed cars; the number of derailed cars is an indicator of accident severity. Speed reduction has the potential to reduce the severity and consequences of derailments, but would not necessarily result in a reduction in the number of derailments. This is because track maintenance standards are less stringent for lower classes of track.

In January 1990, the AAR issued Circular OT-55, Recommended Railroad Operating Practices for Transportation of Hazardous Materials. Circular OT-55 gave the rail industry guidance on railroad operating practices for the transport of selected dangerous goods, including poisonous-by-inhalation (PIH) or toxic-by-inhalation (TIH) products and radioactive materials. It also identified technical and handling requirements for “key trains” and “key routes.” Key trains were restricted to 50 mph, and main tracks on key routes had to be inspected by rail defect detection cars and track geometry inspection cars (or be subject to an equivalent level of inspection) at least twice per year, and all sidings at least once per year. Following the Lac-Mégantic accident, the definition of a “key train” was expanded in Circular OT-55-N.Footnote 71

Route planning and analysis involves a comprehensive, system-wide review of all operations, infrastructure, traffic, and other factors affecting the safety of train movements. Factors to be considered in selecting the route that presents the fewest overall safety risks include hazards related to the nature of the product, the volume being transported, the handling of the product, railway infrastructure characteristics (for example, signalling, track class, crossings, wayside systems, traffic density), passenger traffic (that is, shared track), geography, environmentally sensitive areas, population density, and emergency response capability along the route. Route planning and analysis, as well as periodic assessments of the safety risks along the selected route, are critical to enhancing rail transportation safety because they allow the identified vulnerabilities to be proactively addressed (Figure 7).

Figure 7. Approximate route of the tank cars on MMA-002, which travelled through Toronto and Montréal en route to Lac-Mégantic

In January 2014, TSB Recommendation R14-02 called for route planning and analysis, as well as periodic risk assessments, for trains carrying dangerous goods. See section 4.1.2.2 for further details.

1.21 Emergency response

The Lac-Mégantic Fire Department was notified by 911 calls immediately after the accident. Given the size of the fire, the city's emergency response plan was put into effect. The first general alarm was sounded at 0119 on 06 July 2013. The first fire rescue vehicle and the SQ arrived at the accident site at about 0122 on 06 July 2013.

The Lac-Mégantic Fire Department and the Nantes and Saint-Augustin-de-Woburn fire departments have intermunicipal mutual aid agreements to allow joint action in case of major disasters. More than 1000 firefighters from 80 different municipalities in Quebec, and from 6 counties in the state of Maine, participated in the response, which was reported to be the largest fire response in recent Quebec history. At any given time, approximately 150 firefighters were on site. Initial firefighting efforts focused on evacuating people and 