Lac-Mgantic derailment: Anatomy of a disaster

The Transportation Safety Board examined the complex series of events leading to last years derailment in Lac-Mgantic that killed 47 people. The events included a faulty repair on the lead locomotives engine, a lack of sufficient handbrakes, weak safety training for Montreal, Maine & Atlantic staff and a failure of federal oversight. Heres a timeline based on details in the 191-page report.

Engine Repair: About nine months before the accident, MM&A performed a low-cost non-standard repair on the engine in the trains lead locomotive. The repair used a material that wasnt strong enough for the job and eventually failed, leading to a series of other problems in the engine and an accumulation of oil in the turbocharger and exhaust manifold.

Engine Troubles: Two days before the crash in Lac-Mgantic, an engineer reported trouble with the locomotives engine on a separate trip. Despite that concern, the locomotive was put at the head of the train bound for Nantes on July 5, 2013. Engineer Tom Harding noticed that the engine was surging, making it difficult to keep up a consistent pace. By the time he arrived in Nantes, it was spewing smoke and oil droplets his taxi driver noticed them landing on the cabs window. Mr. Harding discussed the issue with a rail traffic controller in Bangor, Me., but both agreed to deal with the matter the next morning. The locomotive was left running.

Insufficient Brakes: Mr. Harding set just seven hand brakes far fewer than the number that would have been required to keep the 1.4-kilometre train in place on the hill where it was parked if the main air brakes failed. TSB testing found that the minimum number of hand brakes set out by a company chart nine wouldnt have been enough on their own either. Instead, investigators say between 18 and 26 hand brakes on cars and locomotives would have been needed to hold the train if the air brakes failed. Other locomotives, with systems that could automatically restart in a brake failure, were also shut down. The TSB said the railway didnt give staff enough training.

The Main Track: The engineer left the train idling on the main track, rather than pulling it into the siding that ran parallel . The TSB found that this had been MM&As standard practice for several months because it kept the siding free for storing other rail cars that werent in use. The practice was not prohibited or questioned by government. Had the train been parked on the siding when it began rolling forward, it would have hit a derail device that should have prevented it from continuing downhill to Lac-Mgantic.

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Lac-Mgantic derailment: Anatomy of a disaster