The long-awaited Lac-Megantic Railway Investigation Report from Canada’s Transportation Safety Board reveals that an engine repair made nine months before the deadly July 2013 derailment likely contributed to a fire from the build-up and ignition of engine oil in the body of the engine’s turbocharger.
The Railway Investigation Report released Aug. 19 makes two new recommendations that focus on the need for more safety audits, as well as additional measures for preventing runaway trains, but it’s the revelation of the temporary engine repair that has turned some industry heads.
The report describes the engine block repair as setting a series of unfortunate events into action. The fire occurred in the engine about an hour after the train’s engineer left it idling and retired for the night. When firefighters extinguished the blaze and turned off the engine, it caused the air brakes to stop working. Without a sufficient number of handbrakes engaged, the train rolled downhill toward Lac-Mégantic and derailed.
“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 (see above). 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.”
The report makes two new recommendations in addition to reiterating three earlier recommendations made whilst the Board was preparing the Lac-Megantic report. One of the new recommendations targets the need for more audits.
“In the past, Transport Canada intervened at the operational level,” states the report. “Under the new approach, Transport Canada (or a delegate) will audit and assess organizations at the organizational or system level and be able to verify that day to day operations are compliant. When an operator is found to have a system problem or a day to day problem that is left unresolved or mitigated poorly, Transport Canada will intervene at the appropriate level.”
The report also targets the need for “defence in depth,” an industry concept that uses “layers of defences, or safety redundancy” to avoid catastrophe in the case that one layer of defence should happen to fail, the report states.
The Montreal, Maine and Atlantic (MM&A) railway company is criticized in the Board’s report for its own lack of safety culture.
“If instructions or rules are disregarded, and unsafe conditions and practices are allowed to persist, this leads to an increased acceptance of such situations,” the report states.
Here are some of the highlighted concerns about MM&A:
- MMA management’s acceptance of rail wear on the main track that was well beyond industry norms and their own track standards;
- MMA management’s tolerance of non-standard repairs (for example, to the locomotive engine and the QRB valve), which either subsequently failed, or did not return the parts to their proper operating condition;
- the systemic practice of leaving unattended trains on the main track, and on a descending grade, at Nantes for several hours without in-depth defences to prevent an uncontrolled movement;
- crews and single-person train operators not always correctly applying CROR 112 and MMA’s instructions when securing trains at Nantes;
- inadequate company oversight to ensure the correct securement of trains at Nantes;
- MMA’s inadequate recertification program and SPTO training that did not ensure that operating crews knew and understood the procedures for train securement;
- the giving of extensions for competency cards by MMA management, in some cases for several months beyond the mandatory limit of three years; and
- the fact that only local corrective action resulted from recurring deficiencies identified during TC inspections of MMA track and operations; the systemic issues contributing to these deficiencies were not fully analyzed by MMA, and thus persisted.
MM&A and three of its employees, including the engineer, are charged with criminal negligence in connection with the derailment, which spilled about six million litres of oil over 31 hectares of land. About 740,000 litres were recovered from the derailed tank cars, the report states.