Accident Sequence and Risk Management - Paper Example

At around 4: 50PM, a train made a stop at Nantes. It was brought to a halt using the automatic brakes then parked overnight on the main track. The independent brakes were applied by the LE which was then followed by application of handbrakes on the buffer car which was a total of seven cars and also on the locomotive consist. After ensuring the brakes are in place, he then shut down the four trailing locomotives. Consequently, he conducted hand brake effectiveness after releasing the automatic brakes. He did this without releasing the independent brakes of the locomotive. After doing this, the LE established contact with the RTC (Rail Traffic Controller) who had the responsibility of monitoring movement of locomotives between Megantic and Farnham stations .This contact was to communicate about the current security of the locomotive.

Later, the EL contacted the RTC located in Bangor, Maine since they monitored and controlled the movement of the locomotive throughout the United States. While making the conversation, the LE passed information that the locomotive had earlier and was still having mechanical problems all through the trip and that it was by then emitting very dense white and black smoke. The LE expected that this condition would soon be over. They all came to an agreement that the situation be left for the night then it would be fixed in the morning.

The LE was taken to a local hotel by a cab that came to pick him. The taxi driver noticed and informed the LE that the train was faulty and that there were some drops of oil leaking from the tanks. He noticed this after oil droplets from the locomotive landed on his windshield. The taxi driver inquired if the locomotive was in a good condition and if not maybe the LE should communicate with the relevant authorities. The LE informed him that the information has been communicated and that it was to be attended to in the morning. The LE was then taken to the hotel and registered to be off duty. At around 10:40PM, the fire department received a call through the 911 operator. The call reported a fire on a locomotive in Nantes. The fire department within this area responded to the call and within a few minutes they had arrived at the location. On their arrival, they made a call to the RTC offices to inform them about the occurring incident. After getting this information, the MMA attempted to establish contact with the LE and the employees including the mechanical expert but it was in vain. After the failed attempt, the track foreman was sent to the site.

On arrival, he was informed by the fire department that the emergency fuel cut-off switch on the lead locomotive had been used to shut it down. This shut down was done by cutting off the fuel switch which had also been used to shut down the lead train. By doing th9is, they had removed the source of fuel and had therefore put out the fir successfully. In order to remove a potential source of ignition, the firefighters ensured that they have removed the electrical brakes inside the train. Whatever they did was according to the regulations of the safety department. During this event, the fire fighters and the track foreman held a discussion together with the TRC after which they left the scene at the station. Subsequently, the truck foreman also left the scene after the others.

After a while, the air in the brake system of the during the course of this happening, locomotive started to deplete slowly. This made the force that was holding the locomotive to deplete.

At around 1 AM the same night, the locomotive started to gradually roll down the hill heading towards Lac-Megantic which was located 7 miles from the station. Fifteen minutes later, the locomotive got detached from the rail and was derailed at the center of the town. While this happened, an average of 6 million liters of petroleum crude oil was being released. This caused a number of explosions followed by huge infernos. According to information given, the consist of the locomotive separated from the rest of the train. This suggests that the entire train did not derail, however, additional two sections of the locomotive was detached. Footage from the train station showed that the two sections were separated a distance of 104 feet from each other. During the course of these events, the free moving locomotive passed through thirteen separate level crossings.

After approximately 1.5 hours, while emergency and evacuation efforts were under way, the leading section of the locomotive consist rolled backwards toward downtown and contacted the trailing section; both sections travelled backwards an additional 106 feet. The pileup of tank cars, combined with the large volume of burning petroleum crude oil, made the firefighters job extremely difficult. Despite the challenges of a large emergency, the response was well coordinated, and the fire departments effectively protected the site and ensured public safety after the derailment At approximately 0330, MMA officials secured the locomotive consist on the grade by re-tightening the hand brakes. (Genereux et.al 113-120)

Failures/Changes

Braking System

An investigation on the site of the accident including the locomotive that caused or rather was involved in the accident seeks to understand exactly the failures that consecutively led to the occurrence of this tragedy. What precedes this investigations it to look in to exactly what happened and why it happened. Further, it seeks to lay down strategies which should be put in place to prevent such future occurrences. A number of days before this incident occurred, this specific locomotive was sent to one of the MMAs repair center with the purpose of checking its engine which at that time had experienced a minor failure. During the repair, the involved mechanics replaced the part of the engine that was leaking with a material which was substandard. The material used lacked the standard durability and strength. Report suggested that the material used failed while in service and this is what lead to engine surges in turn leading to excessive and dense black and white smoke. In the long run, oil from the locomotives engine started amassing in the turbocharge where they overheated and later caught fire during the night when the incident occurred.

According to the CRO rules, it was required that any unattended locomotive should be left only after a sufficient number of handbrakes are applied. But before the handbrakes are applied, their effectiveness should be inspected to make sure they are in a good condition. According to these rules, the EL should not by any means fully depend on the brakes system in order to prevent unnecessary movement of the locomotive. Even more crucial is the requirement to test the effectiveness of the hand brakes. That night, the engineer carried out the hand brake effectiveness test with the locomotive air brakes still applied. As a result, the test did not identify that an insufficient amount of hand brake force had been applied to secure the train. The TSB concluded that, without the extra force provided by the air brakes, a minimum of 17 and possibly as many as 26 hand brakes would have been needed to secure the train, depending on the amount of force with which they had been applied. (Genereux et.al 164-052)

Class 111 tank cars: Damage and construction

Investigations suggested that all the 72 tank cars from the locomotive were made between the years of 1980 and 2012. Even though the locomotive was designed to meet the then standards, it was old and unfit to be used presently. Its design was short of thermal protection, full head shield and the jacket. Because of these shortcomings, the derailed cars from the locomotive breached in almost every part including the top, bottom and head fittings including the shell. These damages are what led to the spilling of the petroleum oil which later led to the fire breakout. However, if the safety of the tank cars were enhanced it could have largely prevented the occurrence of this incidence.

Safety culture at MMA

When it comes to addressing the safety issues, an organization such as the MMA should be proactive in their implementation. However, the MMA was unreactive in the implementation of the latter. Moreover, the manner in which work was done in the company and also its operating instructions had a major gap. When the investigation looked carefully at MMAs operations, it found that employee training, testing, and supervision were not sufficient, particularly when it came to the operation of hand brakes and the securement of trains. Although MMA had some safety processes in place and had developed a safety management system in 2002, the company did not begin to implement this safety management system until 2010and by 2013, it was still not functioning effectively. (Therrien et.al 260-277)

Dangerous goods: Inadequate testing, monitoring, and transport

Unlike how the petroleum product was described on the shipping document, it was dangerous than thought. Crude oil is often improperly classified in case it is not tested and analyzed systematically. In the event that they are improperly classified, such goods can pose risk to people, property and the environment. This is one of the main reasons behind TSB issuing a safety advisory letter that was calling for charges. To reduce or rather curb such situations from ever happening again, MMA removed train operations that were carried out by a single person and increased the rules guiding operations in the company.

Moreover, this company ensured that they have cut off the process of moving unit trains filled with petroleum and petroleum products. Canada as a country decided to introduce route planning and recommendations in case of hazardous products are transported by means of rail. The Canadian Rail Operating Rules (CROR) were then were rewritten and there was the introduction of new tank cars that were standard.

Errors Committed According to My Findings

There are a number of errors that the MMA committed based on my findings after carrying out a thorough research on the Lac-Megantic locomotive disaster. Some of the errors can be blamed on human error due to ignorance while part of the same problem was unavoidable due to mechanical problems.

Ineffective risk management strategies

While the MMA was making significant changes in their network, they failed to identify the risk and manage it thoroughly to ensure safety of the operations. The safety management operations were therefore not fully implemented. A view through its safety management system showed that they failed to incorporate the key processes. More so, some of these processes were not used in an effective manner. Therefore, there safety management system was not fully functional to be able to manage the risks effectively.

Ineffective training and oversight on train securement

According to my own views, MMA failed to provide effective oversight and training with the purpose of ensuring that its crew and EL understood or rather complied with the regulations and rules that governed the company. Moreover, MMA did not have safety defenses that would help in the controlling of the locomotive. Based on my research, I would suggest that the company put the latter in place and in fact set rules that would ensure that the above is followed to the latter. Ensuring this will not only curb such tragic incidences from happening, but will also ensure safety transportation of goods.

Safety of the locomotive

According to the reports provided, the safety of the locomotion was not wired with the ability to activate the penalty breaks just in case the rare penalty breaks were opened. I concluded that there was no air pressure that was provided to the brakes when the locomotive was brought to a halt. Moreover, there was a shut down on th...