‘Weak safety culture’ faulted in fatal Quebec train derailment, fire
By Curtis Tate, McClatchy Washington Bureau, August 19, 2014
Aerial view of charred freight train in Lac-Megantic in Quebec, Canada. | TRANSPORTATION SAFETY BOARD OF CANADA
CHICAGO — Canadian safety investigators on Tuesday blamed a “weak safety culture” and inadequate government oversight for a crude oil train derailment last year in Lac-Megantic, Quebec, that killed 47 people.
In its nearly 200-page report, issued more than 13 months after the deadly crash, Canada’s Transportation Safety Board identified 18 contributing factors.
“Take any one of them out of the equation,” said Wendy Tadros, the board’s chairman, “and the accident may not have happened.”
Among other factors, the investigation found that the train’s sole engineer failed to apply a sufficient number of handbrakes after parking the train on a descending grade several miles from Lac-Megantic, and leaving it unattended for the night.
The engineer applied handbrakes to the train’s five locomotives and two other cars, but investigators concluded that he did not set handbrakes on any of the train’s 72 tank cars loaded with 2 million gallons of Bakken crude oil.
Investigators said the engineer should have set at least 17 handbrakes. Instead, he relied on another braking system in the lead locomotive to hold the train in place. But after local residents reported a fire on the locomotive later that night, firefighters shut the locomotive off, following instructions given by another railroad employee.
Not long after, the train began its runaway descent, reaching a top speed of 65 mph. The train derailed in the center of Lac-Megantic at a point where the maximum allowable speed was 15 mph.
Investigators said that the derailment caused 59 of the 63 tank cars that derailed to puncture, releasing 1.6 million gallons of flammable crude oil into the town, much of which burned. In addition to the 47 fatalities, 2,000 people were evacuated, and 40 buildings and 53 vehicles were destroyed.
The train’s engineer and two other railroad employees are set to go on trial next month. But Tadros noted that the investigation revealed “more than handbrakes, or what the engineer did or didn’t do.”
“Experience has taught us that even the most well-trained and motivated employees make mistakes,” she said.
The Quebec derailment set in motion regulatory changes on both sides of the border to improve the safety of trains carrying crude oil. Sixteen major derailments involving either crude oil or ethanol have occurred since 2006, according to the U.S. National Transportation Safety Board.
Tadros said the railroad relied on its employees to follow the rules and that regulators relied on the railroads to enforce their own rules. But she said that a complex system requires more attention to safety.
“It’s not enough for a company to have a safety management system on paper,” she said. “It has to work.”
Report Reveals Cost Cutting Measures At Heart Of Lac-Megantic Oil Train Disaster
2014-08-19, by Justin Mikulka
Today the Transportation Safety Board of Canada (TSB) released its final report on the July 6th, 2013 train derailment in Lac-Megantic, Quebec. The report produced a strong reaction from Keith Stewart, Greenpeace Canada’s Climate and Energy Campaign coordinator.
“This report is a searing indictment of Transport Canada’s failure to protect the public from a company that they knew was cutting corners on safety despite the fact that it was carrying increasing amounts of hazardous cargo. This lax approach to safety has allowed the unsafe transport of oil by rail to continue to grow even after the Lac Megantic disaster. It is time for the federal government to finally put community safety ahead of oil and rail company profits or we will see more tragedies, Stewart said.”
Throughout the report there is ample evidence to support Stewart’s position and plenty to show why the people of Lac-Megantic want the CEO of Montreal, Maine & Atlantic Railway (MMA), the rail company responsible for the accident, held accountable in place of the engineer and other low level employees currently facing charges.
At the press conference for the release of the report the TSB representatives often noted that they had found 18 factors that contributed to the actual crash and they were not willing to assign blame to anyone, claiming that wasn’t their role.
But several critical factors stand out and they are the result of MMA putting profits ahead of safety and Transport Canada (TC), the Canadian regulators responsible for overseeing rail safety, failing to do its job.
Engine Fire
The issue that set the whole chain of events into motion on July 6th was an engine fire in the unattended locomotive. As usual the engineer had left the train unattended with one locomotive running while shutting off the others. This locomotive supplied power to the air braking system. The locomotive caught on fire, the fire department was called and they put out the fire and shut off the locomotive in the process.
Today’s TSB report notes that the fire was due to an improper repair of a cam bearing. Instead of doing a costly replacement, the cam bearing was repaired with epoxy (polymeric material). As the report states:
This temporary repair had been performed using a polymeric material, which did not have the strength and durability required for this use.
Braking Failure
Once the locomotive was shut down due to the fire, it could no longer power the air brake system.
As previously reported on DeSmogBlog, this type of system has been described as “19th century technology” by a rail safety expert at the Federal Railroad Administration but as a whole the rail industry has not upgraded to newer technologies because of the costs involved.
Without power to the air braking system, the braking system lost pressure over time and the train began to roll towards Lac-Megantic.
This wouldn’t have been an issue if the proper number of handbrakes had been applied. But the engineer had not applied enough handbrakes because he had not performed the hand brake effectiveness test properly and had left the locomotive air brakes on while conducting the test. The report notes the lack of training and oversight for that particular locomotive engineer (LE).
Furthermore, the LE was never tested on the procedures for performing a hand brake effectiveness test, nor did the company’s Operational Tests and Inspections (OTIS) Program confirm that hand brake effectiveness tests were being conducted correctly.
The report also notes that when MMA employees were tested for safety knowledge, they could take the tests home.
Requalification typically consisted of 1 day to complete the exam, and did not always involve classroom training. On many occasions, employees would take the exam home for completion.
However, in this case, there were not even questions on the test on this critical subject.
They did not have questions on the hand brake effectiveness test, the conditions requiring application of more than the minimum number of hand brakes, nor the stipulation that air brakes cannot be relied upon to prevent an undesired movement.
And they found this had been the situation since before the oil trains starting running.
Since 2009, no employee had been tested on CROR 112(b), which targeted the hand brake effectiveness test. In 2012, U.S. employees had been tested twice on that rule; both tests had resulted in a “Failure”.
Single Operator Risks
The report goes into detail about how MMA came to be operating oil trains with only one crew member. And while ultimately the regulators failed, some did raise flags about this. When MMA initially sought to move to single person train operations (SPTO) from the standard two person crew, it was noted that there were significant issues with their operations.
In July 2009, TC expressed a number of concerns that centred on deficiencies in MMA operations, including lack of consultation with employees in doing risk assessments, problems managing equipment, problems with remote-control operations, issues with rules compliance, issues with fatigue management, and a lack of investment in infrastructure maintenance.
Additionally the report notes that Transport Canada’s Quebec office expressed specific concerns in 2010.
TC Quebec Region reiterated its concern about MMA’s suitability as an SPTO candidate.
And yet despite the concerns and MMA’s poor track record, in 2012 they were allowed to start running single crew trains despite TC Quebec still expressing concern.
In February 2012, TC met with MMA and the RAC. TC advised MMA that TC did not approve SPTO. MMA only needed to comply with all applicable rules and regulations. TC Quebec Region remained concerned about the safety of SPTO on MMA.
Unsurprisingly, the additional training for employees who would be operating trains on their own was almost non-existent. And it was focused on the fact that for safety purposes, engineers were allowed to stop the trains and take naps.
The actual SPTO training for several LEs, including the accident LE, consisted of a short briefing in a manager’s office on the need to report to the RTC every 30 minutes, on the allowance for power naps, and on the need to bring the train to a stop to write clearances.
This report is a clear indictment of a system that allows for corporate profit over public safety. However, what also is clear from today’s press conference and from the regulatory situation in the United States is that nothing of significance has changed regarding the movement of oil by rail in the US and Canada.
A poorly maintained locomotive can still be left running and unattended. There still is no formal regulation on how many hand brakes need to be applied to secure a train.
Single person crews are still allowed and Burlington Northern Santa Fe, the company moving the most oil-by-rail in the U.S., is working to implement this as a practice despite the objections of the employees.
In short, the corporate profit before public safety approach is still standard operating procedure. And the oil trains are expected to return to the tracks through Lac-Megantic within a year.
Train tracks where the ill-fated train was parked. (c) Justin Mikulka.
Image Credit: Transportation Safety Board via flickr.
BNSF’s Proposal For One-Person Train Crews Concerns Rail Workers
By Ashley Gross, July 29, 2014
FILE – In this Nov. 6, 2013, file photo, a BNSF Railway train hauls crude oil near Wolf Point, Montana. | Matthew Brown AP Photo
Railroad workers are speaking out against a proposal by Burlington Northern Santa Fe Railway to have single-employee freight train crews. They say the idea is unsafe, especially in light of the increasing transportation of crude oil by rail.
The controversy stems from a tentative contract agreement BNSF has reached with one of its unions, the Sheet Metal, Air, Rail and Transportation Union. If union members approve that deal, BNSF could operate freight trains with just an engineer onboard. That engineer would have help from a so-called master conductor who would not be on the train.
The company says it would only use single-person crews on trains that have a computerized collision-avoidance system, and not on trains carrying crude oil or other hazardous materials. But some workers say the proposal is still too risky.
“To be safe in the communities that we’re running these trains through, you need to remove as many hazards as possible, not add one giant one, which is essentially what this is doing,” said Jen Wallis, a BNSF conductor who is not part of the union that will vote on the deal.
Wallis says there’s nothing in the contract that prevents BNSF from using one-person crews to haul hazardous materials.
People have been paying close attention to rail safety in the wake of the deadly rail disaster in Quebec last year that killed 47 people. That train had one employee on duty who left it unmanned when the accident occurred.
The Federal Railroad Administration in the U.S. has said it plans to issue a rule requiring two-person crews on crude oil trains. Union officials did not return calls for comment.
Repost from the Bakersfield Californian [Editor: this is a MUST READ article, a comprehensive and graphic description of first-responder requirements and readiness. Someone needs to interview first responders in each of our Bay Area refinery towns, ask every single question referenced in this article, and lay out similar scenarios for the all-too-imaginable catastrophes that threaten our communities. – RS]
Increased oil train traffic raises potential for safety challenges
By John Cox, Californian staff writer | May 17, 2014
Bakersfield High School is seen in the background behind the rail cars that go through town as viewed from the overpass on Oak Street. By Casey Christie / The Californian
First responders think of the rail yard by Bakersfield High School when they envision the worst-case scenario in Kern County’s drive to become a major destination for Midwestern oil trains. If a derailment there punctures and ignites a string of tank cars, the fireball’s heat will be felt a mile away and flames will be a hundred feet high. Thick acrid black smoke will cover an area from downtown to Valley Plaza mall. Burning oil will flow through storm drains and sewers, possibly shooting flames up through manholes.
Some 3,000 BHS students and staff would have to be evacuated immediately. Depending on how many tank cars ignite, whole neighborhoods may have to be cleared, including patients and employees at 194-bed Mercy Hospital. State and county fire officials say local 911 call centers will be inundated, and overtaxed city and county firefighters, police and emergency medical services will have to call for help from neighboring counties and state agencies.
While the potential for such an accident has sparked urgency around the state and the country, it has attracted little notice locally — despite two ongoing oil car offloading projects that would push Kern from its current average of receiving a single mile-long oil train delivery about once a month, to one every six hours.
One project is Dallas-based Alon USA Energy Inc.’s proposed oil car offloading facility at the company’s Rosedale Highway refinery. The other is being developed near Taft by Plains All American Pipeline LP, based in Houston.
Kern’s two projects, and three others proposed around the state, would greatly reduce California’s thirst for foreign crude. State energy officials say the five projects should increase the amount of crude California gets by rail from less than 1 percent of the state’s supply last year to nearly a quarter by 2016.
But officials who have studied the BHS derailment scenario say more time and money should be invested in coordinated drills and additional equipment to prepare for what could be a uniquely difficult and potentially disastrous oil accident.
Bakersfield High Principal David Reese met late last year with representatives of Alon, which hopes to start bringing mile-long “unit trains” — two per day — through the rail yard near campus.
He said Alon’s people told him about plans for double-lined tank cars and other safety measures “to make me feel better” about the project. But he still worries.
“I told them, ‘You may assure me but I continue to be concerned about the safety of my students and staff with any new (rail) project that comes within the vicinity of the school,'” he said.
Alon declined to comment for this story.
Both projects aim to capitalize on the current price difference between light crude on the global market and Bakken Shale oil found in and around North Dakota. Thanks to the nation’s shale boom, the Midwest’s ability to produce oil has outpaced its capacity to transport it cheaper and more safely by pipeline. The resulting overabundance has depressed prices and prompted more train shipments.
There are no oil pipelines over the Rockies; rail is the next best mode of shipping oil to the West Coast. Kern County is viewed as an ideal place for offloading crude because of its oil infrastructure and experience with energy projects. Two facilities are proposed in Northern California, in Beniciaand Pittsburg; [emphasis added] the other would be to the south, in Wilmington.
A local refinery, Kern Oil & Refining Co., has accepted Bakken oil at its East Panama Lane plant since at least 2012. The California Energy Commission says Kern Oil receives one unit train every four to six weeks.
NATIONAL CHANGES
Shipments of Bakken present special safety concerns. The oil has been found to be highly volatile, and the common mode of transporting it — in quick-loading trains of 100 or more cars carrying more than 3 million gallons per shipment — rules out the traditional safety practice of placing an inert car as a buffer between two containing dangerous materials.
The dangers of shipping Bakken crude by unit train have been evident in several fiery derailments over the past year. One in July in Lac-Megantic, Quebec, Canada, killed 47 people and destroyed 30 buildings when a 74-car runaway train jumped the tracks at 63 mph.
The U.S. Department of Transportation said 99.9 percent of U.S. oil rail cars reached their destination without incident last year. Two of its divisions, the Federal Railroad Administration and the Pipeline and Hazardous Materials Safety Administration, have issued emergency orders, safety advisories and special inspections relating to oil car shipments. New rules on tank car standards and operational controls for “high-hazard flammable trains” are in the federal pipeline.
Locally operating companies Union Pacific Railroad Co. and BNSF Railway Co. signed an agreement with the DOT to voluntarily lower train speeds, have more frequent inspections, make new investments in brake technology and conduct additional first-responder training.
Until new federal rules take effect next year, railroads can only urge their customers to use tank cars meeting the higher standards.
“UP does not choose the tank car,” Union Pacific spokesman Aaron Hunt wrote in an email. “We encourage our shippers to retrofit or phase out older cars.”
The San Joaquin Valley Railroad Co., owned by Connecticut-based Genesee & Wyoming Inc., is a short line that carries Kern Oil’s oil shipments and would serve the Plains project but not Alon’s. A spokesman said SJVR is working with the larger railroads to upgrade its line, and the company inspects tracks ahead of every unit train arrival, among other measures designed just for oil shipments.
STATE LEVEL PROPOSALS
Gov. Jerry Brown has proposed a big change in the way California protects against and responds to oil spills.
His 2014-15 budget calls for $6.7 million in new spending on the state’s Oil Spill Prevention and Administration Fund to add 38 inland positions, a 15 percent staffing increase. Currently the agency focuses on ocean shipments, which have been the norm for out-of-state oil deliveries in California.
To help pay for the expansion, Brown wants to expand a 6.5 cent-per-barrel fee to not only marine terminals but all oil headed for California refineries.
“We’ll have a more robust response capability,” said Thomas Cullen, an administrator at the Office of Spill Prevention and Response, which is within the state Department of Fish and Wildlife.
A representative of the oil trade group Western States Petroleum Association criticized the proposal March 19 at a legislative joint hearing in Sacramento. Lobbyist Ed Manning said OSPR lacks inland reach, and that giving such responsibilities to an agency with primarily marine experience “doesn’t really respond to the problem.”
WSPA President Catherine Reheis-Boyd has emphasized the group has not taken a position on Brown’s OSPR proposal.
Also at the state capitol, Assemblyman Roger Dickinson, D-Sacramento, has forwarded legislation requiring railroads to give first responders more information about incoming oil shipments and publicly share spill contingency plans. The bill, AB 380, would also direct state grants toward local contingency planning and training. It is pending before the Senate Environmental Quality Committee.
LOCAL PREPARATIONS
In recent years Kern County has conducted large-scale, multi-agency emergency drills to prepare for an earthquake, disease outbreak and Isabella Dam break. There has not been a single oil spill drill.
Emergency service officials say that’s not as bad as it sounds because disasters share common actions — notification, evacuation, decontamination.
Nevertheless, State Fire and Rescue Chief Kim Zagaris, County Fire Chief Brian Marshall and Kern Emergency Services Manager Georgianna Armstrong support the idea of local oil spill drills involving public safety agencies, hospitals and others.
Kern County is well-versed at handling hazardous materials. Some local officials say an oil accident may actually be less dangerous than the release of toxic chemicals, which also travel through the county on a regular basis.
There have been recent accidents, but all were relatively minor.
Federal records list 18 oil or other hazardous material spills on Kern County railroads in the last 10 years. No one was injured; together the accidents caused $752,000 in property damage.
Most involved chemicals such as sodium hydroxide and hydrochloric acid. Only two resulted in crude oil spills, both in 2013 in the 93305 ZIP code in the city of Bakersfield. Together they spilled a little more than a gallon of oil.
But the risk of spills rises significantly as the volume of oil passing through the county grows.
“The volume is a big deal,” Bakersfield Fire Chief Douglas R. Greener said. “Potentially, if you have a train derail, you could see numerous cars of the same type of material leaking all at once.”
Kern County firefighters are better prepared for an oil spill than many other first responders around the state. They train on an actual oil tanker and have special tools to mend rail car punctures and gashes. The county fire department has several trucks carrying spray foam that suffocates industrial fires.
But Chief Marshall acknowledged a bad rail accident could strain the department’s resources.
He has been speaking with Alon about securing additional firefighting equipment and foam to ensure an appropriate response to any oil train derailment related to the company’s proposed offloading facility.
What comes of those talks is expected to be included in an upcoming environmental review of the project.
“We recognize the need to increase our industrial firefighting program,” Marshall said.
Chief Zagaris said Kern’s proximity to on-call emergency agencies in Tulare, Kings and Los Angeles counties may come in handy under the Bakersfield High spill scenario, which is based on fire officials’ assessments and reports from several similar incidents over the past year.
He and Marshall would not estimate how many people would require evacuation in the event of a disaster near the school, or what specific levels of emergency response might become necessary.
But Zagaris said local public safety officials would almost certainly require outside help to assess injuries, transfer people in need of medical care, secure the city and contain the spill itself.
“I look at it as, you know, depending what it is and where it happens will dictate how quickly” outside resources would have to be pulled in, he said.
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