Securement of Equipment and Trains Left Unattended
Mr. Luc Bourdon (ASR)
Director General, Rail Safety
14th Floor, Enterprise Building
427 Laurier A venue
Dear Mr. Bourdon:
SUBJECT: RAIL SAFETY ADVISORY LETTER – 09/13
At about 22:45 Eastern Daylight Time (EDT) on 05 July 2013, Montreal Maine & Atlantic (MMA) freight train MMA 2 (the train) was proceeding eastward on the MMA Sherbrooke Subdivision, enroute from Montreal (QC) towards Saint John (NB). The train was 4701 feet long and weighed 10,287 tons. It was comprised of 5 head-end locomotives, a VB car used to house the locotrol equipment necessary for MMA’s single engineer train operation, 1 loaded box car used as a buffer followed by 72 non-pressure dangerous goods tank cars loaded with petroleum crude oil (Class 3, UN 1267).
At approximately 23:00, the train stopped at the designated MMA crew change point at Mile 7.40 near Nantes, Quebec. The single operator secured the train and departed for the evening leaving the lead locomotive unlocked and the train unattended on mainline track with a descending grade of 1.2%.
At about 23:50, a local resident reported a fire on the lead locomotive (MMA 5017) to the 911 emergency call centre. Subsequently the local fire department responded along with another MMA employee. At about midnight, similar with established operating practice, emergency shutdown procedures were initiated on the lead locomotive and the fire was extinguished. After extinguishing the fire, the second MMA employee and the fire department departed the site again leaving the train unattended.
Shortly before 01:00 on 06 July 2013, the train started to move and gathered speed as it rolled uncontrolled down the descending grade into the town of Lac-Mégantic, Quebec, 7.4 miles southeast of Nantes. While travelling at well in excess of the authorized speed, the train derailed near the centre of Lac-Mégantic. The locomotives separated from the train and came to a stop about ½ mile east of the derailment. The derailed equipment included the box car (buffer) and 63 tank cars.
Several derailed tank cars released product resulting in multiple explosions and subsequent fires causing an estimated 42 fatalities and 8 persons still missing, extensive damage to the town centre and precipitated the evacuation of about 2000 people from the surrounding area (TSB Occurrence No. R13D0054).
The ongoing investigation has determined that the braking force applied was insufficient to hold the train on the 1.2% descending slope between Nantes and Lac-Mégantic.
Over the years, the TSB has investigated a number of similar runaway accidents (see Appendix A). Each of these investigations brings into question the effectiveness of the Transport Canada (TC) approved Canadian Rail Operating Rules (CROR) Rule 112 entitled “Securing Equipment” and the standard railway operating procedures and practices utilized for performing that task.
Specifically CROR Rule 112 states:
Trains are required to be secured in accordance with CROR Rule 112 in addition to any related railway company special instructions which vary from company to company. While most railway special instructions specify the minimum number of hand brakes needed in general operating conditions, they do not always provide the number of hand brakes required under specific conditions. In many cases, it is left up to the operating employee to determine the number of hand brakes to apply. The employee must take into consideration the slope or grade of the track and the approximate tonnage of the equipment to be secured at that location.
In addition, TSB investigation R96C0172 previously established that that there was considerable variability in the effectiveness of the hand brake system on railway cars. The variability was associated with the design, condition and maintenance of the hand brake system, as well as with differences among operators with respect to their physical capabilities and personal technique used to apply the hand brakes. Specifically, the torque applied by the operating employee may not be proportional to the effective brake shoe force actually applied. In other words, high torque does not necessarily generate a high braking force. This variability was not widely understood at the time of the investigation and could still present a risk particularly with new employees.
More recently, to add to the complexity, TSB investigation R12E0004 identified that the push –pull test used by railways to satisfy CROR Rule 112 (b) does not always adequately verify if the braking force of the hand brake application was sufficient to hold the cars.
CROR Rule 112 ensures that hand brakes are applied to prevent unwanted movement of the train while providing flexibility for a railway’s operational needs. However, CROR Rule 112 is not specific enough in that it does not indicate the number of hand brakes necessary to hold a given train tonnage on various grades and it continues to be left up to the operating employee to determine the number of hand brakes to apply. Furthermore, it has been demonstrated that the push–pull test is not always a good indicator of whether an adequate number of hand brakes have been applied and not all handbrakes are effective even when properly applied. Considering all these risks, Transport Canada may wish to review CROR Rule 112 and all related railway special instructions to ensure that equipment and trains left unattended are properly secured in order to prevent unintended movements.
Original signed by Robert Johnston
Investigation Operations Rail/Pipeline