Lac-Megantic Derailment : Lessons Learned

The adage that you can learn something from everyone has been around for a long time.  The fact of the matter is that what you learn isn’t always what you want to do – it might be something you definitely don’t want to do.  The recent release by the Transportation Safety Board of Canada of the Lac Megantic, Quebec crude oil train derailment investigation report is most certainly the latter.

Living and working in the maritime world, many of the practices and procedures highlighted in the report are disconcerting to say the least.  Leaving a train loaded with close to 70,000 barrels of crude unattended with a locomotive running?  Can anyone imagine the outcry if you tied up a tug with a 70,000 barrel barge, left the engine running and caught a cab to a hotel for the night?  Creating a safety management system for a company in 2003 that has not physically been seen, let alone read and understood, by many employees in 2010?  Having a safety management system that requires annual internal audits that has not been audited in eleven years?

“The Company should carry out internal safety audits on board and ashore at intervals not exceeding twelve months…..” – ISM Code 12.1

Granted, mention the word “audit” and many, if not most, mariners will shudder and wonder when their relief will be onboard.  But, they are familiar with the concept, if not entirely embracing of the process.  There appears to be a world of difference between the ISM(International Safety Management) Code that was implemented in 1998 and the Safety Management Systems that became mandatory for rail carriers in Canada in 2003.  Whereas the system of internal and external checks and balances (audits) are firmly in place in the maritime world, the same cannot be said, using the Lac Megantic disaster as a snapshot, of the rail industry.

There are many similarities between the rail and maritime industries – spills, disasters and the carriage of goods aside.  One that stands out most prominently is the scaling back of crews.  In the case of the Montreal, Maine and Atlantic Railway, the crew on MMA-002 which derailed in Lac Megantic had been reduced to one.

One person to be in charge of five locomotives pulling seventy other train cars.  One person to set the hand brakes required to hold the train on a downhill grade.  One person with no one to watch his back……or check his work.

Within a very short period of time, both Canadian and U.S. authorities required trains transporting dangerous goods – in particular crude oil – to have at least two crew.  This recognition that crews had been reduced too far, contributing to a major disaster should be an eye opener.  The question is, will we see such a breaking point in the maritime industry?  What about the tugs with a crew of five moving 100,000+ barrel barges of crude?  Unfortunately, many safety regulations are “written in blood,” referring to the disasters that brought them about.

Could the maritime industry learn from the rail industry without having its own Lac Megantic?

The SOLAS(Safety Of Life At Sea) convention was brought about by the loss of more than 1,500 passengers and crew on the Titanic.  Carriage of immersion/survival suits was required after the loss of the Marine Electric.  With close to 80% of losses in the maritime industry attributed to the human element, can changes in safe manning be far off?

Fatigue is another common denominator between the rail and maritime industries.  While Transport Canada requires Fatigue Management Plans, the international maritime industry has the STCW(Standards of Training, Certification and Watchkeeping) Code and rest hour regulations.   A looming question with regard to the rail industry in light of the lack of audits required by regulation might be, “Is the same lax oversight being applied to fatigue management?”  If so, there may be future incidents.  On the maritime side, increased emphasis on STCW rest hour implementation by PSC(Port State Control) inspectors is right around the corner.

Recent reports by the International Maritime Organization (IMO) have publicized the fact that crewmember fatigue is increasingly being recognized as a major factor in maritime accidents… – American Bureau of Shipping, 2002.

The Lac Megantic disaster is certainly an example of an SMS being viewed as a “system of documents” instead of a “documented system of safety management.”  While the recriminations abound, there are some very serious lessons to be learned – both in the rail industry and outside it.