Findings as to Causes and Contributing Factors
MMA-002 was parked unattended on the main line, on a descending grade, with the securement of the train reliant on a locomotive that was not in proper operating condition.
- The 7 hand brakes that were applied to secure the train were insufficient to hold the train without the additional braking force provided by the locomotive’s independent brakes.
- No proper hand brake effectiveness test was conducted to confirm that there was sufficient retarding force to prevent movement, and no additional physical safety defences were in place to prevent the uncontrolled movement of the train.
- Montreal, Maine & Atlantic Railway did not provide effective training or oversight to ensure that crews understood and complied with rules governing train securement.
- Montreal, Maine & Atlantic Railway’s weak safety culture contributed to the continuation of unsafe conditions and unsafe practices, and compromised Montreal, Maine & Atlantic Railway’s ability to effectively manage safety.
- Despite being aware of significant operational changes at Montreal, Maine & Atlantic Railway, Transport Canada did not provide adequate regulatory oversight to ensure the associated risks were addressed.
- Transport Canada Quebec Region did not follow up to ensure that recurring safety deficiencies at Montreal, Maine & Atlantic Railway were effectively analyzed and corrected, and consequently, unsafe practices persisted.
- The limited number and scope of safety management system audits that were conducted by Transport Canada Quebec Region, and the absence of a follow-up procedure to ensure Montreal, Maine & Atlantic Railway’s corrective action plans had been implemented, contributed to the systemic weaknesses in Montreal, Maine & Atlantic Railway’s safety management system remaining unaddressed.
Findings as to Risk
- If there are no rules and regulations for single-person train operations, nor a requirement for Transport Canada to approve and monitor railways’ plans, then single-person trains may operate without all of the necessary defences in place.
- If systematic testing is not conducted on representative samples of petroleum crude oil at an appropriate frequency, there is an increased risk that these dangerous goods will be improperly classified.
- If not properly classified and documented, dangerous goods may be moved and handled incorrectly, increasing the risk of injury to people, and of damage to property and the environment.
- Without monitoring and effective enforcement of compliance with applicable classification provisions of the Transportation of Dangerous Goods Regulations, there is a risk that improperly classified dangerous goods will enter the transportation system.
- If Class 111 tank cars that do not meet enhanced protection standards transport flammable liquids, there is an ongoing risk of product loss and significant damage to persons, property, and the environment when these cars are involved in accidents.
- It could not be concluded whether single-person train operations contributed to the incorrect securement of the train or to the decision to leave the locomotive running at Nantes, Quebec, despite its abnormal condition.
- The petroleum crude oil being transported by the train was improperly classified; it was assigned packing group III (lowest hazard), despite meeting the criteria for packing group II.