Transportation disasters and what made them happen (Part 1)

Transportation disasters and what made them happen (Part 1)

 

Railway disasters are primarily caused by human error. The exceptions are those that are caused by landslides, earthquakes and floods that can unexpectantly occur.

For more than a hundred years, rail lines have threaded  their way through communities in Quebec and other provinces as they were the lifeblood  of local economies. People would dress in their Sunday best and hop a train to visit relatives and friends in other communities. Today the only connections that these towns have with the railways is when cargo trains pass though their towns. As far as the people in these towns are concerned, there is a diminished benefit having rail lines going through their towns. I remember being on short-line trains three occasions. Two of them were in B.C and one of them in Saskatchewan. On each of these trips, it was to go two three small towns.  Of course, that was a very long time ago. I also crossed Canada twice, all in a four-month period.

 

The Lac-Megantic railway disaster

 

Lac-Mégantic is a town in the Estrie region of Quebec, Canada. It is located 250 kilometres (155 miles) east of Montreal and is right next to on Lake Mégantic, a freshwater lake after which the town was named. It is a very beautiful town surrounded by rolling forested hills. By 2013, it had a population of 6000. Although the railway has declined in recent decades, Lac-Mégantic remains an important centre of agriculture, logging, lumber and pulp and paper. Its downtown area is approximately a block in length and has around sixteen buildings in that specific area.

 

The people in Lac-Mégantic were becoming increasingly worried about the state and path of a train track that wound through town, crisscrossing city streets and the now-destroyed downtown. Three-quarters of the town's population live within 500 metres of that rail line. Those trains were getting longer, carrying highly flammable crude oil in outdated containers and travelling on tracks that often needed repair. Reporters walked along the lines of Montreal, Maine & Atlantic Railway (MMAR) and found loose spikes and decayed rails along with other potential problems.  In June 2013, as much as 13,000 litres of diesel fuel spilled from the tank cars in Lac-Megantic. One would hope that government inspectors are the ones that inspect the rail tracks but it is the railway companies that do it and obviously, they are not doing a good job. I am sure that there are people in the small communities the trains pass who would like to make some extra money patrolling those lines around their communities.

 

It was in the downtown area of that town in which almost all of it was destroyed because of a railway disaster that occurred in the early hours of July 6, 2013.

 

MMAR aside from owing its engines and various train cars, also owns the railway tracks that run through the town for one kilometre which also includes the downtown area of Lac-Mégantic. 

 

On the night of July 5^th, the sole engineer (Mr.. Harding) of a 73-car train carrying tanker cars with crude oil inside them stopped his train and left his train unattended in an area of the tracks very close to the town of Nantes so that he could get some sleep in a hotel in Lac-Mégantic. I don’t see a problem about him taking some time off so that he could get some sleep because the last thing we would want to have happen is a train being operated by a sleepy driver.

When the taxi driver picked the engineer up to take him to the hotel, he saw more smoke than usual coming from the train. It would appear that Harding wasn't concerned.

However, a short time later, a fire was reported in either the lead engine or one of the other engines and the engineer was brought back to the train, according to the Transportation Safety Board of Canada (TSB). After the firefighters and the engineer had left the scene, the train on its own started to roll downhill with its load of 72 railway tanker cars carrying the crude oil along with four engines following the lead engine and a buffer car separating the last engine from the first tanker car. After going towards Lac-Mégantic that was 12 kilometres (7.4 miles) away, it began to speed up as the grade was steep to some degree. In fact, the tracks had an average downhill grade of 1.2% meaning that for every hundred metres distance, the tracks drop 1.2 metres. That is pretty steep. The total weight of the  1.5 kilometre long train was 9,975 metric tonnes. Soon after it reached the downtown area of Lac-Mégantic 18 minutes later, the five engines rounded the curve without any problems despite the speed because the weight each engine was approximately 195 metric tonnes and  because they had a lower centre of gravity which would keep them on the tracks. The buffer car and eight of the 72 tank cars didn't fare as well. They came off the tracks. Obviously, if the train was travelling 85 kilometres slower than 110 kilometres an hour, (the proper speed when going around that curve is 25 kilometres an hour) the accident wouldn't have happened. It hit the downtown area so fast, even the crossing signal lights didn't have time to switch on.

Some of the tanker cars ruptured and the hot burning fuel lit by some unknown flame, heated up one or several other rail tanks that hadn’t been ruptured until a gaseous mixture increased the pressure inside the tank or tanks and it or they finally exploded and created an enormous blast wave that destroyed many of the structures. Fueled by the crude oil, the fire was enormous as it burned furiously in the centre of Lac-Mégantic.

 

Most of the downtown buildings (forty of them) were destroyed by the enormous explosion and from the burning crude oil (a total of 6.5 million litres).  The loss of life may never fully be known but at the time of this writing, at least 47 bodies have been discovered and identified. If more were killed, their bodies may never be found because the heat from the inferno was so intense; their bodies may have completely vaporized. Many of these victims were inside the Musi-Café, a popular bar which was quite close to the tracks. As many as 2,000 residents had to be evacuated however several days later, 1,200 people living in that town were given permission to return to their 600 homes that previously were considered in the danger zone especially when some of the crude oil spilled into the basements of some of the nearby  homes.

 

What human errors were made prior to this disaster?

 

Why was only one engineer on board that train when it was being operated that night? The answer to that question is two-fold. The first reason is that the Canadian federal government last year ruled that the engines pulling the railway cars only need one person in the cab of the engine. That is a totally stupid ruling. For example, what happens if the sole person in the cab has a heart attack? Normally, he would let go of the lever that controls the speed and the train would finally stop. But suppose while falling forward, he still has the lever still in the same position it was at while the train is still speeding along the tracks. There would be no one else in the cab to stop the train. This was the first error because later, a fire occurred in the engine and had the engineer been in the cab (even if he was asleep) upon wakening (providing that there was a fire alarm in the cab) he might have been able to shut off whatever valve was controlling the fuel going to the engine.

 

The second reason for the disaster is that Ed Burkhardt, the president of  MMAR realized that with that government ruling, his railroad firm could save itself a great deal of money by using only one engineer in the lead engine so he decided that one engineer per train was sufficient  so his firm has been operating one-crew trains since 20912. Well, whatever savings he thinks he saved from accepting that ruling as being opportune, he will lose many, many millions more after he settles with the town of Lac-Mégantic—the owners of the stores and homes destroyed and the citizens who suffered from injuries and the loss of loved ones and of course, the loss of the engine and the tank cars and the thousands upon thousands of liters of crude oil.

 

MMAR is only one of two railroad companies that are allowed to operate their engines with only one person on board. Further, the practice of leaving an engine in operation unattended after the engine is stopped for the night is taboo in the United States and it is very rare that you will see such an operating engine unattended in Canada. Mr. Burkhardt said after the disaster, “Now, at no time have we had any safety problem or anything coming out of the use of single-man crews. There’s no aspect of the incident at Mégantic whatsoever that has anything to do with that, or to infrastructure.” He then added, “If we’d had five guys on that train, I think the results would have been the same.” If he had that many engineers on that train, at least one of them would have made sure that that handbrakes were applied and that the engine’s power wasn’t shut down so that the air brakes could still function.

 

The federal government of Canada made another foolish ruling. They said that it is not against the rules for the lone engineer to leave the lead engine unattended. Well we all know what happened then, don’t we. That was the third mistake involving this disaster.

 

After the fire in the engine was put out by the firemen, somehow, the engine having a life of its own, decided to head towards the town 12 kilometers (7.4 miles) away carrying death behind it.

 

Why can’t an engineer sleep in the cab when the train is stopped for the night? Why should he abandon his engine and sleep in a hotel? I can remember in days long gone, having ridden in a caboose that was at the end of a train. When the train would stop for the night, whoever was in the caboose could sleep on the bed and cook his own breakfast in the morning. In fact he could cook all his meals during his shift and he had a toilet, sink and shower in the caboose to boot.

 

Every train car, be they a box car or a tank car has a hand brake that can be used when the engine has stopped and isn’t going to be running for a while. Now not every car has to have it its hand brake in use but a sufficient number of them should be used, especially if the train is on a grade such as the 1.2 percent grade that the fatal train was parked on.

 

The question that comes to the fore is; where the handbrakes previously applied in the tank cars that were speeding towards Lac-Mégantic?  The engineer that later left the engine to go to the hotel in  said that he applied the hand brakes but quite frankly, I have doubts about his statement especially since he has been suspended by the head of his railroad line and is under police investigation for his role in this accident. He could be charged with criminal negligence causing death because he had a duty to put the hand brakes on and if it is established that he didn’t do this, then he was solely responsible for the deaths that ensued. He certainly wasn’t suspended because he left the engine and went to a hotel to sleep. Further, since the engine was pulling the cars towards that town, they wouldn’t be going as fast as that train actually had been moving before it careened off the tracks if the hand brakes had been applied. Harding swore that he applied 11 of the handbrakes but if that is so, it is highly unlikely that the train would have been pulled by gravity towards its final destination. Assuming that those brakes weren’t put in use; that would have been the fourth fatal mistake made in this disaster.

 

How many hand brakes should be set for a train that comprises of 72 tank cars when the train is stopped for the night? In Alberta, in January 2012, more than a dozen coal cars hurtled down a slope and crashed into another train. In that incident, one handbrake was not sufficient to keep the train from moving on its own. It required a minimum of five. In an incident in 2011, a long train in Quebec was a runaway train because only 35 handbrakes were used when in fact as many as 57 were needed to be applied. The CEO of  MMAR said that Harding, the engineer had likely not set the appropriate number of handbrakes (if he really did set the 11 that he claims he set) and that is why the train cars moved so easily behind the engine. Railway experts have suggested the number should have been between eight and thirty. I hardly think that eight would be sufficient considering that the train was on a slope. Do you know what they say about experts?  An ex is a has been and a spurt is a drip under high pressure.  

 

There was another possible reason why the engine began pulling the tank cars on its own towards Lac-Mégantic. First of all there was a fire in the cab of the engine. Why did that happen? Apparently a fuel line ruptured. This is the fourth time a fuel line in one of MMAR’s engines had ruptured in the last eight years. In any case, while the firemen were fighting the fire in the cab, one of them shut down the engine which was the right thing to do since the fire was still out of control. Once the engine was shut down, the air pressure that operated the air brakes was automatically shut off. Now if the handbrakes had been previously applied, even the weight of the train on the gradual grade would not let the train roll down the tracks towards the next town at 101 kilometres an hour. With the weight of the train and the speed it was going, by the time it reached the town, it had gained millions of kilojoules of energy. If it had hit a large office building, it would have plowed right through the building.

 

The question that comes to the fore is; did anyone turn the engine power back on? Apparently not. That was the job of the engineer who climbed into the engine after he returned to the scene from his hotel or home in Nantes. If the engine was turned on again, the air brakes would automatically be applied again and the engine and the cars behind it wouldn’t have begun their fatal trip towards Lac-Mégantic. By not turning the engine power back on so that the air brakes would automatically be applied, that was the fifth mistake made that night. Of course, it is known that even when airbrakes are on, they tend to lose pressure after a while and that would put the train at risk. That is why it is important that the appropriate hand brakes be applied. The British Columbia Safety Authority manual suggests that nine hand brakes are sufficient foe a train that has between 70 and 79 cars and more handbrakes if the train is on a slope. I am not convinced that nine hand brakes are sufficient.

 

This problem of air and hand brakes is not uncommon. In Canada, there have been recorded instances where there have been as many as 12 runaway trains each year for the past ten years. This is proof that there is definitely something amiss in the railroad industry that needs to be fixed.    

 

It has been suggested that someone maliciously turned off the engine after it was turned it on again. Quite frankly, I have serious doubts about that actually happening. First of all, such a person would have to know which controls were needed to operate the engine. Did the train engineer forget to turn the engine back on again? I said that is probably what happened however with all the commotion going on with the firemen fighting the fire, he may have assumed that the firemen turned it back on if they had previously turn it off. Five minutes after the firemen left the cab of the engine, the engine on its own initiative began moving down the tracks with its cars attached behind it. If the power wasn’t turned on again by the engineer, then the engine without its power on was forced to move by gravity alone and that would drawn the train down the tracks towards Lac-Mégantic if the handbrakes weren’t applied. If this is what occurred, then the disaster that followed was a direct result of the power not being turned on so that the air hoses could keep the train in a braked position. That was the sixth mistake.

 

There are no rules that state that the cabs of these engines must be locked when they are left unattended. If however, if the cab was locked and the firemen had not been able to get another engineer to turn off the engine so that they could fight the fire, the engine would have been destroyed and the fire may have caused the tank cars carrying the crude oil to rupture and one or more eventually explode and Nantes would be the victim instead of Lac-Mégantic. Now here is the quandary.

 

Suppose a former engineer who was fired has a grudge against his employer. He could sneak into an unattended unlocked cab of an engine and create all kinds of havoc. I am not suggesting that this is what actually happened with respect to the Lac-Mégantic disaster but the potential of such an event could really happen. Having no rule that states that unattended engine cabs don`t have to be locked is the height of stupidity. We don`t leave our unattended vehicles unlocked unless of course we are totally stupid so why are the cabs of railway engines left unlocked? This question is academic when you consider that if a second engineer was in the unlocked engine, there would be no need to lock it. What should be locked however are the controls to the engine and not the door to the engine.

 

What kind of tank car is built for transporting flammable liquids? Technically there is no official tank car for transporting crude oil. Those firms that want crude oil transported by rail just use whatever tank car is available, whether it's a tank car built for ethanol, or a car built for gasoline or corn oil or any other product. However, those tank cars are different when used to transport propane which for obvious reasons are much more protected.

 

It has been learned that the tank cars involved in the disaster were an older type that regulators have criticized for years. The surviving cars that were pulled from the blast had stenciled markings indicating they were the type that have been described as prone to puncturing because of their thin metal shells. Over the years, regulators have tried to limit their use, citing poor design.

 

DOT-111 is a North American specification for tank cars designed to carry liquids, such as crude oil. The design has been criticized on safety grounds. The train in the Lac-Mégantic derailment of 2013 was made up of 72 of these kinds of cars.

 

They have a minimum plate thickness of ⁷⁄₁₆ inches (11 mm) and a maximum capacity of 34,500 US gallons (131,000 l; 28,700 imperial gallons). Tanks may be constructed from carbon steel, aluminum alloy, high alloy steel or nickel plate steel by fusion welding. Up to 80% of the Canadian fleet and 69% of U.S. rail tank cars are DOT-111 type. DOT-111A cars are equipped with AAR Type E top and bottom shelf Janney couplers designed to maintain vertical alignment to prevent couplers from overriding and puncturing the tank end frames.

 

During a number of accident investigations over a period of years, the U.S. National Transportation Safety Board has noted that DOT-111 tank cars have a high incidence of tank failures during accidents. Admittedly, such accidents are rare. There are 1.6 million tank car shipments made every year in North America without accidental release by an accident. This amounts to 1 release of the tank’s fluids to every 34,000 shipments. There was also no loss of the fluid in the tanks when any train was travelling less than five miles an hour. Of course, the train heading  towards Lac-Mégantic was moving much faster than that speed and that is why some of the DOT-111 tank cars ruptured.    

 

Transport Canada officials have confirmed that rail companies face no regulatory hurdles for hauling western Canadian crude oil to markets.  CN railway has moved some 3.2 million barrels of crude in 2011, and is expected to hit 19.2 million barrels by the end of 2012, using the same 640 barrels-per-car ratio. The company has said it could eventually handle 200,000 barrels a day or more.

 

The question that must be on your minds by now is; why aren’t the tank cars that carry oil of any kind more protected such as propane tank cars? The answer is obvious. The cost would be prohibitive and considering the fact that tank car accidents are extremely rare, the use of the DOT-111 tank cars will be the ones that will continue to be used.

 

As a result of an accident in Cherry Valley, Illinois in 2009, the Association of American Railroads studied several options for increasing the crashworthiness of DOT-111 tank car designs and published new construction standards in a Casualty Prevention Circular, with the intent to revise the AAR Manual for Standards and Recommended Practices for tank cars that are used to transport ethanol and crude oil. Beginning on October 1, 2011, the new AAR standard for DOT-111 tank cars requires tank heads and shells to be constructed of thicker steel. The new specification also requires that heads and shells be constructed of normalized steel, and in all cases ¹⁄₂-inch (13 mm) thick half head shields must be provided. The AAR has also mandated a more robust housing or rollover skid for protection of top fittings. The new standards only apply to newly manufactured cars; there is no requirement to retrofit, repurpose, or retire existing DOT-111A cars built to the older design.

 

This makes me wonder if the firms that own the older models will really want to spend millions of dollars replacing their older models with the more expensive ones considering that train derailments are extremely rare.

 

These freight trains are essentially two-kilometre-long mobile warehouses, travelling across the country passing hundreds of thousands of backyards and running through dozens of downtown areas of small towns in Quebec, Maine, Northern Vermont and New Brunswick. And when they travel too fast over crumbling rail, they become missiles—a derailment waiting to happen. Human error; such as poor maintenance of engines, tank cars and rails, an over-reliance on technology and staff cuts at various railroads are contributing factors for almost all of these serious accidents.

 

When you look at the products they're carrying on the rails such as chlorine, anhydrous ammonia, propane, gasoline and other sorts of dangerous commodities through urban areas—it's scary and I say that with some authority since my home is half a block from the speeding freight trains that whizz by carrying these dangerous products. All of us that live that close to these flying missiles are at risk which we all have to endure if great care isn’t undertaken to make those trains and their rails safe.

 

If the occurrence like that which happened on the night of July 6^th in Lac-Mégantic; occurred in my area which is primarily residential, at least a thousand of us would have been killed and if the tank car that ruptured was carrying deadly chlorine, all 60,000 of us in our small community that is a suburb of Mississauga, Ontario would have died within minutes before we could escape the deadly fumes. Chlorine fumes are so deadly, in 1979 in Mississauga (where my home is) as many as 200,000 people had to be evacuated because after a train derailment (many miles away from our home) a huge oil fire put at risk a nearby rail tank full of chlorine. 

 

Some critics believe even the most dangerous accidents are predictable and preventable. And they're not happy that the railroad industry is allowed to write its own rules and rewrite recommendations from the investigating body before accident reports are published. That is no different than the driver of a car who caused an accident writing is own police report that eventually shows up on the desk of his insurer.

 

I think the government of Canada is far too cozy with the railways and the rail industry that emphasizes profits over safety since there's little or no deterrent when there's an accident. The rail industry is different than the air industry in this sense. If an airline crashes one of their planes, they may not be selling tickets for a while. However, if the railroad industry crashes a freight train, the shippers will still keep shipping.

 

Ensuring safety compliance is the job of Transport Canada. During an era of deregulation, the railways slowly chipped away at powers previously held by Transport Canada, has become more of an auditor of safety reports filed by the railways than inspector of their operations. Since 2001, Transport Canada's 150 rail inspectors have spent more time auditing railway safety reports filed by the railways and less time spot-checking rail, car and locomotive safety. For Transport Canada to do audits and to assess compliance is very nice, but what happens when a railroad company is out of compliance?

 

The Transportation Safety Board searches for the cause of an accident. It may make recommendations to prevent such accidents from happening again, but it is powerless to legislate those changes. It is also forbidden from laying blame or pointing fingers. Imagine if you will a complaint bureau in a police force that investigates police wrongdoings being unable to lay charges against the police officers who committed the crimes. Worse yet, the law permits the railroad companies to police and regulate themselves since it has a hands-off approach with its relationship with these companies. Federal inspectors don’t do blitz inspections to determining what train cars and engines have problems. They leave that to the railroad industry.

 

As part of the federal deficit cutting strategy, the Harper government is reducing spending on rail safety to $33.8 million this year from $36.8 millio9n last year. However, the Lac-Mégantic debacle wake-up call has been brought to the attention of this sleepy government which is now taking another look at the dangers of transporting dangerous freight by rail. I hope they act in taking over the responsibility of governing the railroad industry since it has been determined by government auditors that non-compliance by the railroad industry with existing federal rules is evidence of a consistent non-adherence to those rules. 

On December 30, 1999, two CN crew members were killed when a train derailed near Mont-Saint-Hilaire, Quebec and collided with another, spilling 2.7 million litres of hydrocarbons, which caught fire, damaged property and the environment, and forced the evacuation of 350 families.

Among the deficiencies found by the TSB, it noted that CN's paperwork on the dangerous goods carried by the two trains involved was wrong; a car that supposedly had only residue of sodium chlorate was actually loaded with toxic material. When that car was punctured and began leaking in the accident, everyone exposed had to be decontaminated. Ottawa had however promised in December 2012, to put together a system to measure and report on these carriers compliance with the laws for transporting dangerous freight. The system won’t be ready until June of 2014.  

Shoddy record keeping and needlessly exposing emergency responders and the public to danger becomes a recurring theme in TSB reports.

On May 12, 2003, emergency responders weren't aware of three containers with dangerous goods on a derailed train near Drummondville, again because of bad paperwork. On February 7, 2004, twenty-seven CN freight cars, including a pressure tank car loaded with chlorine, derailed near Montmagny, Quebec. Rail and cars were damaged, but there were no injuries or dangerous spills, which was lucky. Meanwhile, it was determined that CN had misidentified the location of the cars with dangerous goods.

CN and CP had both said that they were taking steps to improve their safety record, including spending more money on rail, track and tie replacement, hiring new employees to maintain and operate equipment and infrastructure, and investing in new, safer technology and in educational programs to improve safety at crossings.

Whatever caused the parked MMAR train to begin rolling, driverless, toward the town in the early hours of the morning of July 6^th, the accident has spawned scrutiny of the railway’s safety record. MMAR has a very bad safety record. The number of accidents and other incidents it has had in the past is alarming considering that it has a very short rail line of only 820 kilometres. MMAR’s rate of 11.87 is more than three times the national rate of 3.36. From 2003 until the end of 2012, MMAR had an average rate of 33.81 accidents and incidents per million track miles travelled which is far more than the national average over the same time-period. I should point out that our two major railway companies, Canadian National and Canadian Pacific have a horrendous record of accidents, albeit, almost all of them are minor. Over the last decade, CN had 5,968 accidents and CP had 4,891 accidents. I should point out to you that those two railway companies have thousands of railway tracks that are located from one end of Canada to the other end.

 

Part of the problem is that MMAR as a rule only transports crude oil and since crude oil is much heavier than non-fluid freight, it puts a greater stress on the railroad tracks, especially the wooden ties keeping the rails in line so it follows that there is a greater risk to the trains if the rails are not regularly checked and fixed when necessary. This may explain why the train derailed at Lac-Mégantic. Coupled with the speed of the train and the weight of the oil, it follows that the tracks may not have been able to withstand the impact of the wheels on the rails.

 

This recent debacle has shown us the pitfalls of old-fashioned regional train networks that transport 50,000-barrel loads of oil in each train over long distances.

 

NDP transport critic Olivia Chow suggested that the Canadian government should hold emergency hearings on rail safety in light of the tragedy. Larry Miller, an Ontario MP who is the Conservative chairman of the House of Commons transport committee said in response on the 12^th of July;

 

“It’s not urgent to review a critical audit exposing weaknesses in Transport Canada’s oversight of the transportation of dangerous goods because there’s no proof the report is relevant in the wake of the Lac-Megantic train disaster. Obviously, it’s our job in government to make sure that all modes of transportation are done safely. But is there an urgency just because of this derailment? Again the answer to that is no. In order to have a meeting or conduct something, you need a subject and right now we don’t have a subject.” unquote

 

You can be sure that if he lost loved ones in the Lac-Mégantic disaster, he would be screaming for emergency meetings. I will tell you what the subject he claims doesn’t exist really is. There is a desperate need for the government to have better control over our railroads and railway companies. Until that happens, there will be more accidents and more needless deaths because of stupidity that seems to thrive in that industry.

 

Here is the cruel irony of this recent horrendous event. If any one of the proper procedures and standards had been applied, the disaster would not have happened. Hopefully, lessons will be learned from these mistakes.

 UPDATE: Soon after this article was published, CP rail announced that its engineers will be required to lock the doors to their engines when they intend to leave them and they also will forbid their engineers from leaving the engines unattended when the train is carrying dangerous goods while on a main track. In February 2014, the CN rail announced that it will phase out its fleet of 183 older tank cars used to transport diesel fuel over the next four years and replace them with new ones that meet the latest regulatory standards.