A Corporate Crime Scene: Lac Mégantic, 2013

[RichardB]

All my previous railway accident stories have concerned British trains in the steam age, since that is my area of interest and expertise, but the Lac Mégantic disaster, which happened in Canada as recently as 2013, is interesting partly because of the contrast in railway practices between here and North America, but mostly because the usual element of bad luck was almost entirely absent. It was the direct result of corporate sacrifice of safety on the altar of cost-cutting and of the governmental negligence that enabled it. One commentator has called Lac Mégantic ‘a corporate crime scene.’

Late in the evening of 5 July 2013, shortly before 2300, a Montreal, Maine and Atlantic Railway (MMA) train drew to a halt near the small town of Nantes, Quebec, only about 15 miles from the border with Maine. This train, while not particularly unusual in North America, was on a scale to beggar the imagination of anyone used to British trains. It consisted of 72 tankers full of crude oil hauled by five diesel-electric locomotives, four of them remotely controlled from the lead engine. It was nearly a mile long and weighed 10,125 tons. MMA had taken the train over from the Canadian Pacific Railway in Montreal, and it was bound for an oil refinery in Saint John, New Brunswick.

This behemoth was in the sole charge of one driver (or engineer, as they are always called in North America), Tom Harding. Transport Canada had only (controversially) allowed single-manning of such trains since the previous year, but it was now standard practice on the MMA, which was a shoestring operation run on the principle of the minimum expenditure it could possibly get away with. The train had stopped because Harding was finishing his shift, and Nantes was a crew changeover point.

But the relieving engineer was not due to take over until the next morning, so the train had to be parked for the night. There were sidings at Nantes, but they were used to store other freight cars, so the train was left on the main line. From my British perspective I find this quite astonishing but, though it is apparently considered unusual, there is no law in Canada forbidding it, and overnight parking on the main line at Nantes was another standard practice on the MMA. It was possible because the number of trains scheduled each way daily over the line could be counted on the fingers of one hand, and none ran during the night.

Harding shut down four of the five locomotives. One engine had to be left running to drive the locomotive’s compressor for the air brakes, to counter the inevitable small leakages in the system. Not unnaturally the engine he left running was that of the lead locomotive, 5017, the one he had been driving.

The need to do this is another thing I find it hard to get my head round, coming from a country where for many years the commonest braking system used on trains was the vacuum brake. It is no longer used in Britain (except on heritage railways), because the air brake can be made much more powerful: vacuum brakes rely on atmospheric pressure (between 14 and 15psi), whereas air brakes routinely operate at a pressure of 60psi or more. But the vacuum brake has one big advantage over the air brake.

A fail-safe factor is inherent in its operation and is thus totally foolproof. Since the vacuum created by pumping air out of the system keeps the brakes off, and letting air in puts them on, any fault, any leakage, will apply the brakes. No train left to its own devices with all power off can possibly move.

Not so with the air brake, at least not in the form in which it has been traditionally used on American railways. The fail-safe factor is provided by a control valve on each vehicle, which will sense a drop in pressure and apply its vehicle’s brakes via the vehicle’s air reservoir, independently of the main system. But that depends on those control valves working properly, and a slow steady drop in pressure may not trigger them.

Actually, none of that should have mattered. Even the slipshod MMA had a rule that the air brakes should not be relied upon to stop a parked train moving, and that some of the handbrakes with which every vehicle in the train is fitted must be applied – at least nine of them on a train of this length – and tested. Harding put on some handbrakes, tested them, and convinced himself that the train was secure. But, tired after his long shift, he’d forgotten to release the air brakes first, and so the test was void and proved nothing. And he’d only applied seven handbrakes. The Transportation Safety Board of Canada (TSB) concluded after its investigations that a bare minimum of seventeen handbrakes should have been applied.

Harding then contacted Richard Labrie in Farnham, Quebec, who was the traffic controller for that stretch of line, to report that the train was secure and to ask for a cab to be called to take him to the hotel he usually stayed in when driving this train, a little over seven miles further down the line in Lac Mégantic, a pretty little town sitting on the shore of the beautiful lake from which it takes its name. Next he contacted the traffic controller for the next stretch of line, located in Bangor, Maine, to report that locomotive 5017 had been running badly all day and had been pumping out excessive amounts of both black and white smoke from its exhaust. He was assured that the engine would settle down once it was left to idle. It would be okay to leave it for the night, and it would be looked at the next day. Harding’s cab arrived and he left for his hotel.

It does seem extraordinary that it should be considered acceptable to leave a train unattended all night with an engine running and the cab unlocked, on a line right beside a public highway – and in North America railways are not fenced off, so there is nothing to prevent anybody from having free access to the track. According to the taxi driver who took him to his hotel, Harding himself was uneasy in his mind about leaving the locomotive unattended while it was voiding oil and black smoke. He had every right to be.

The train had been left on a falling gradient that continued all the way into Lac Mégantic. And the engine on 5017, the locomotive being relied on to keep the air brakes on, did not settle down. It had broken down eight months previously and, to save money and to return the loco to traffic as soon as possible, the repair had been botched with a quick fix using a cheap and insufficiently strong material. That repair had now given way, one of the pistons had collapsed, and oil was building up in the turbocharger. Witnesses who drove along the road beside the railway reported that there was so much smoke drifting across the highway that they could hardly see where they were going, and that sparks were coming from the engine’s exhaust. At 2350 somebody made a 911 call, the American equivalent of 999. The oil in the turbocharger had ignited, and 5017 was on fire.

When the firefighters from Nantes Fire Department arrived, they shut down 5017’s engine to prevent more fuel circulating into the fire. Once they’d put the fire out they called Traffic Controller Richard Labrie to apprise him of the situation, and Labrie in turn phoned Tom Harding at his hotel. Harding offered to go out to check on the train, but Labrie told him that there was already a railway employee on the scene, that the morning would be soon enough to start up another engine, and that he should go to bed – it now being around midnight.

Unfortunately, the MMA employee on the scene was a track maintenance foreman with no training in nor experience of train braking systems. He reported that the train seemed secure and went home, leaving the train unattended once more – but now with no compressor running to maintain pressure in its braking system, which was slowly leaking air. And the leakage was too gradual to trigger the control valves.

It took less than an hour for the air pressure to fall far enough for the weight of the train to overpower the combination of depleted air brakes and inadequate handbrakes. Shortly before 0100 on 6 July, slowly at first, it began to roll down towards Lac Mégantic. A few minutes later one of the firefighters who had helped to put out the fire on 5017 was on his way home when he was astonished to see the train he had attended not long before pass over a level crossing at speed, with no lights showing nor horn sounding.

North Americans are on more intimate terms with their railways than we are in Britain. The absence of fencing mentioned earlier applies even in towns, which is why all North American trains are required by law to carry a bell and to sound it continuously in urban areas. In some places the tracks even run along the streets. A virtual visit to Lac Mégantic via Google Maps Street View shows the railway running beside streets and houses on the level with nothing to separate it from its surroundings. Right in the town centre, near a level crossing, there is a sharp curve limited to 10mph. With the momentum of 10,000-plus tons built up over seven miles of downhill track, the runaway was moving at an estimated 65mph, with sparks and smoke flying from the wheels, by the time it reached that curve, at 0114.

Though all five locomotives stayed on the track, the rest of the train broke away, and 63 of the 72 tanker cars derailed in a huge pile-up. This would have been catastrophic enough in its own right, but two further factors turned the incident into something more like Armageddon.

All the tanker cars were of a design, known as DOT-111, dating back to 1980. Although manufacture had continued until 2012, the standards to which they had been designed had been superseded, and they were known to be insufficiently robust and liable to rupture in accidents. Efforts in the USA, where the train had originated, to legislate for improvements or replacement by more modern designs had run up against ferocious resistance from the oil and railway companies (guess why), and they were still in widespread use. Each of those 63 derailed tankers was carrying 25,000 gallons of crude oil, and nearly every one of them ruptured, spilling unimaginable amounts of the stuff into Lac Mégantic town centre. But even that wasn’t the worst of it.

Crude oil does not normally ignite very readily, but this was not ordinary crude oil. It was shale oil, produced by fracking in North Dakota, and it was considerably more volatile than crude oil usually is. Fire broke out almost immediately, and several explosions followed as more tankers piled into the wreckage. A ball of fire towered two hundred feet into the air. Burning oil ran into the street drains, causing fire to erupt in surrounding streets from drain covers, manholes, and even some cellars and chimneys of nearby buildings, spreading the fire further.

You might suppose that at that time in the small hours the centre of a modestly-sized town like Lac Mégantic would have been almost deserted, but unfortunately there was a popular bar, the Musi-Café, close to the accident site, and it was still open. It had been a lively night in the bar – a warm Friday evening and a couple of highly-regarded local singers – and many patrons were still enjoying themselves and in no mood to go home just yet.

People outside on the terrace saw what was happening and ran for it, but some of those inside interpreted the thunder of the accident and the tremors it was sending through the ground as an earthquake, and took cover under tables. It was their death sentence. And not all of those who did try to flee were able to outrun what one survivor described as ‘a tsunami of fire.’

Tom Harding was at first incredulous, then appalled, on being told by Richard Labrie that it was his train that had caused the catastrophe he had seen unfolding after being evacuated from his hotel, He went straight to the accident site and helped to pull the nine rearmost tanker cars that were still on the rails away from the fire.

The local hospital went onto high alert, but the expected stream of wounded never materialised. One person, an employee of the Musi-Café, was treated for burns to one arm. Everyone else in the vicinity of the accident either escaped or died.

It took around 150 firefighters, 30 of them from over the border in Maine, until the early afternoon to contain the fire, and nearly two days to put it out. By then the town centre of Lac Mégantic was completely gutted, with at least thirty buildings destroyed. A thousand people were evacuated from their homes during the initial fire fighting, and another thousand later in the day because of the danger from toxic fumes from the chemical foam used to combat the fire.

Forty-seven people perished in the inferno, thirty of them from the Musi-Café. Five of the bodies were never found. In a tight-knit community of about 5,600 people, it was a devastating blow.

Tom Harding’s failure to secure his train properly was only one factor in causing this horrifying disaster. The Transportation Safety Board’s inquiry uncovered a chain of responsibility that stretched deep into corporate territory, and beyond.

Both of the traffic controllers Harding spoke to that night displayed an unwarranted degree of complacency in the instructions they gave him. If only his offer to go out and check on the train hadn’t been declined he would surely have started an engine.

It transpired that another engineer had reported problems with 5017 two days before the accident, but nothing was done and it remained in traffic. The TSB also discovered that a safety control that was supposed to reset the train’s brakes in the event of an engine failure was not wired up to do so on 5017. It was particularly regrettable that this defective locomotive should have been rostered as the lead locomotive on that train.

The inquiry was unable to decide whether single-person operation was a factor in the disaster, but application of those handbrakes took two or three minutes for each one and required quite a lot of physical effort, and it does seem very likely that if the exhausted Tom Harding had had someone to help him more brakes would have been put on. And that someone might well have spotted his mistake in leaving the air brakes on when testing the handbrakes.

The oil in the tanker cars, the TSB found, had been inadequately tested and subsequently classified for shipping as less volatile than it actually was, resulting in fewer precautions being taken in its handling.

But the principal culprit was the penny-pinching Montreal Maine and Atlantic Railway, which neglected the maintenance of its engines and track (though this last wasn’t actually a factor in the disaster), made its staff work exhaustingly long hours, and skimped on staff training and supervision – most significantly, in the securing of parked trains. Its safety culture was, to say the least, problematic. The TSB’s report said:

‘An organization with a strong safety culture is generally proactive when it comes to addressing safety issues. MMA was generally reactive. There were also significant gaps between the company’s operating instructions and how work was done day to day. This and other signs in MMA’s operations were indicative of a weak safety culture—one that contributed to the continuation of unsafe conditions and unsafe practices, and significantly compromised the company’s ability to manage risk.’

The restrained words of an official report give only the palest shadow of an idea of the true state of affairs at MMA. I have found an account written from inside knowledge which paints a devastating picture, in far too much detail to repeat here, of a cash-strapped company on the road to bankruptcy, run with a ruthless determination to milk as much money as possible from the dying undertaking at the expense of all else, including safety and indeed any kind of ethics. Its rate of accidents per miles run was one of the highest in North America. For years it had been not so much a question of whether one of those accidents would be a major one but when.

Transport Canada’s monitoring of MMA also came in for criticism. ‘For several years,’ the report said, ‘Transport Canada’s regional office in Quebec had identified MMA as a company with an elevated level of risk that required more frequent inspections. Although MMA normally took corrective action once problems were identified, it was not uncommon for the same problems to reappear during subsequent inspections… Transport Canada’s regional office in Quebec, however, did not always follow up to ensure that these recurring problems were effectively analyzed and that the underlying conditions were fixed.

‘In addition,’ it continued, ‘although MMA had developed a safety management system in 2002, Transport Canada’s regional office in Quebec did not audit it until 2010—even though this is Transport Canada’s responsibility, and despite clear indications (via inspections) that the company’s safety management system was not effective.’

It was this combination of a cavalier disregard of safety standards by the railway and ineffective or non-existent government enforcement of those standards that engendered a situation where a couple of mistakes by a tired man could trigger a disaster: a train with a hazardous cargo, whose danger had been under-estimated and which was being carried in inadequate vehicles, left unattended on a falling gradient above a town, dependant for its security on a locomotive whose engine had twice been reported as defective, and whose braking safety backup was inoperative.

It is not surprising that MMA’s CEO, Edward Burkhardt, was heckled when he visited Lac Mégantic a few days after the disaster. Nor that many of the residents were by no means convinced that justice was being served when Engineer Tom Harding, Traffic Controller Richard Labrie, and Jean Demaître, who was manager of train operations on the night of the disaster, were each charged with forty-seven counts of criminal negligence causing death and put on trial, with the possibility of life sentences if they were convicted.

On the day the three men first appeared in court a local man who’d lost a daughter in the disaster called out, ‘It’s not them we want!’ During and after the trial itself (during which several witnesses gave evidence about the responsibility of the company’s executives for the dodgy practices at MMA) other residents expressed similar views. ‘Transport Canada have let cheap companies run railroads in Canada with less money for more profit instead of acting on security,’ said one, who’d lost three friends. Another said that the railway’s executives rather than the three employees ‘should have sat in the bench of the accused.’

After a protracted trial culminating in nine days of deliberation by the jury all three men were acquitted. The Canadian government decided not to proceed with prosecuting MMA, Burkhardt and other executives of the company.

MMA went bankrupt the following year, thus enabling Burkhardt and his company to escape most of the fines and litigation arising from the disaster, not to mention paying compensation to the families of the victims and the huge costs of rehabilitating Lac Mégantic. Fortunately a consortium of companies involved in the shipping of the oil, led by Canadian Pacific, raised a fund of over $460 million, which was used for compensation and reconstruction.

Lac Mégantic’s recovery has been slow. Rebuilding was impossible until the area had been decontaminated, and the process has been difficult, taking years of work. Many more buildings in addition to those destroyed in the fire have had to be demolished because the soil they stood on was so badly contaminated that the only solution was to remove it and replace it. To this day there are wide areas of open space around the railway in the town centre.

Recovery has come no more quickly for the community of Lac Mégantic, where nearly everybody knew at least one person who died in the disaster. Those open spaces serve as a constant reminder of the tragic events of a decade ago, as does the continued passage through the town of oil and other freight trains. Although some of the recommendations the TSB made in its report have been acted upon – the DOT-111 tankers have been phased out, and all trains transporting hazardous loads must now have a crew of at least two – the railway industry’s response to others has been slow or non-existent. Most notably, to the one urging that such trains should be routed to avoid towns and cities.

The line is now once again owned and operated (rather more responsibly) by the mighty CPR, which had sold it off in the 1990s. It has taken years of campaigning, but Canadian Pacific has finally agreed to build a new line by-passing the town, and work is under way. It can’t come soon enough for the people of Lac Mégantic.

The Musi-Café re-opened, on a different site, the year after the disaster. It is still there.

The dead and the bereaved have not been the only victims of the disaster. It has weighed heavily on Tom Harding, who has suffered from PTSD and depression. I have not heard the same said of Edward Burkhardt, former CEO of the Montreal Maine and Atlantic Railway.

 

Marginally relevant footnote:
A by-product of my researches for this was the unexpected pleasure of discovering the idiosyncratic and richly colourful world of French-Canadian swearing. There’s a whole page on Wikipedia about it. Possibly of interest on what is, after all, a writers’ forum.

[Athelstone]

Mr Burkhardt is an interesting character who has, it seems, been profoundly interested in trains his entire life. Your blog inspired me to research the man a bit and it does seem that he knows best in matters of running a railroad. Of course, he had “previous” for being the manager of a railroad that allowed a train to run down a sloap while loaded with combustible and toxic materials causing millions of dollars worth of damage and requiring thousands people to be evacuated. That was the 1996 Wisconsin derailment https://en.wikipedia.org/wiki/Weyauwega,_Wisconsin,_derailment .

By some miracle there was no loss of life and only minor injuries. Subsequent investigation highlighted poor maintenance (broken rail parts, and a part missing for over a year) and inadequate training of track inspectors.

He was a man well-liked by the incumbent government who awarded him an honorary consul post, and it seems he avoided any personal comeback for that incident as well.

Yet another great blog, Richard. These really are superb.

[RichardB]

Burkhardt’s first reaction to the disaster was to lay the blame on Harding (now there’s a surprise…). This, after Harding had expressed concerns about the locomotive, which were dismissed, and made his offer to go and check on the train, which was also dismissed. The transcript of the phone call makes his anxiety plain. After he’s told he’s not needed at the train he begs Labrie to call him back. ‘Call me back, RJ.’ ‘No, no. Go to bed.’

To me at least, Harding comes across as a conscientious man who made a mistake, and Burkhardt as an unprincipled rat.

It’s still going on. Only last February a train carrying an assortment of hazardous chemicals derailed in Ohio, resulting in a fire that burned for two days, mass evacuations, and vast environmental damage – though fortunately no casualties. And these trains are still running through rowns.

[Author]

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