Canada's transportation safety agency is set to release the final results of a year-long investigation into the Lac-Mégantic train disaster, offering the first definitive account of the series of events that led to the worst rail accident in modern Canadian history.
The Transportation Safety Board report, to be released Tuesday morning, is expected to raise questions about safety protocols at Montreal, Maine & Atlantic Railway and the oversight role Transport Canada has played, among other issues. The TSB will also detail what led a parked crude oil train to roll downhill toward Lac-Mégantic, where it jumped the tracks in the early hours of July 6, 2013.
The report will attract significant attention because of the scale of the accident and the broader questions it has raised about moving crude oil by rail. The oil that exploded in Lac-Mégantic was from the Bakken formation in North Dakota and was more volatile and prone to exploding than traditional crude.
When the 1.4-kilometre-long train crashed, its tank cars unleashed a wave of burning oil that destroyed much of the downtown core, levelling dozens of buildings and killing 47 people.
The Globe and Mail reported this week that part of the TSB's investigation has focused on a repair that was completed nine months before the fatal accident.
A source told The Globe that the material used in the repair wasn't strong enough and eventually failed, sparking a series of other problems that ultimately led to a buildup of oil in the engine.
A fire broke out in that engine about an hour after the train's engineer left it idling on the main track in Nantes, Que., and retired for the night. Firefighters extinguished the blaze and turned off the engine, which eventually caused the air brakes to stop working. Forced to rely on an insufficient number of hand brakes, the train rolled downhill toward Lac-Mégantic, reaching a speed of more than 100 kilometres per hour before it derailed.
The TSB has previously said the braking force was inadequate, but the report could provide greater detail on the matter, including how many hand brakes it believes had been set.
MM&A and three of its employees, including engineer Tom Harding, were charged with criminal negligence in connection with the crash earlier this year. Train operations manager Jean Demaitre and railway traffic controller Richard Labrie were also charged.
The TSB investigation, which is not meant to lay blame, placed some focus on the broader regulatory environment, including communications between MM&A and Transport Canada, a source told The Globe. The probe also considered the federal department's oversight of railway safety management systems, another source said.
Transport Canada's handling of railway safety management systems was criticized last fall by the federal Auditor-General, who found the department had conducted just one quarter of planned safety management audits during a recent three-year period.
A source with knowledge of the investigation told The Globe earlier this week that MM&A provided only cursory training to prepare staff for the new single-person operations, and that some of that training occurred within an hour of the first single-operator trains departing from the company's rail yard in Quebec.
During the year since the accident, Transport Canada has announced new rules for railways to undertake risk assessments for routes with a high volume of dangerous goods. In addition, the regulator has imposed new requirements for emergency response plans for crude and ethanol shipments. Transport Canada has also brought in tougher tank-car rules and established new guidelines for securing parked trains.
Mark Winfield, an expert on safety regulations who teaches at York University in Toronto, said he hopes the TSB report includes a look at how Transport Canada could have missed – or failed to act on – the risks associated with the rapid increase in crude-by-rail traffic over recent years. "Everything that's happened has been sort of ex post facto. It's all been after Lac-Mégantic. It's been the right moves, but why did 47 people have to die in order for this to happen?" Prof. Winfield said.
A new report by the Canadian Centre for Policy Alternatives argues that the accident exposed a number of broad regulatory failings, including vague and poorly enforced rail operating rules and a disregard for the risks of Bakken crude oil, which is more volatile than traditional crude.