HFS353: You are tasked to conduct an accident investigation on what caused these losses using evidence that has already been established: Incident and Accident Investigation ECA Assignment,SUSS

Lac-Megantic rail disaster, Canada, 6 July 2013

On 6 July 2013, at about 1.15am, a runaway train, operated by Montreal, Maine and Atlantic Railway (MMA), carrying volatile crude oil in 72 tank cars, derailed and slammed into downtown Lac-Megantic, Quebec, in Canada. The train was unattended and had rolled down from a slope about 11 kilometres away from the town. The train erupted in flames after it derailed in the downtown core, and the explosion and fire killed 47 residents. The disaster also destroyed 40 buildings and caused environmental contamination of the town area.

The freight train was on a 700-kilometer journey from Quebec to its destination in New Brunswick, running on a railway owned by MMA. The train, which was operated by a single train engineer, had stopped at the designated crew change location near LacMegantic. The engineer shut down four of the five locomotives as per company’s standard procedure, leaving the lead locomotive running so that air pressure could be supplied to the train’s air brakes. He also applied hand brakes on the locomotives and some of the train cars before heading off to a hotel in Lac-Megantic for his off-duty
rest.

At around midnight, the local police and fire department responded to a witness’ call that there was fire on one of the train’s locomotives. The firemen shut down the train engine as per protocols to stop any fuel from circulation into the fire and proceeded to put out the fire. The fire service then departed from the scene. As the engine had been shut down, the air supply from the compressor to the air brake system ceased. The locomotives’ air brakes gradually lost their effectiveness due to slow air leakage.

Subsequently, the air brakes and hand brakes were no longer able to hold the train, and it rolled downhill toward Lac-Megantic, where it derailed and resulted in the disaster.

You are tasked to conduct an accident investigation on what caused these losses using evidence that has already been established. You are not expected to uncover new evidence, but should use sources already in existence and discoverable to the public.

Question 1

Evidence and Timeline
(a) Examine the collected evidence for this incident and present this using the structure of the Swiss Cheese Model.

(b) You should present the layers of Organisational Influence, Unsafe Supervision, Preconditions and Unsafe Acts independently and highlight your reasons for placing each item within the layer. Indicate where the shortcomings (if any) are in the evidence, the reasons for these shortcomings, and how they might be overcome (if possible).

(c) For all evidence that you use, you should present actual and/or potential scientific verification, and you should formally cite the source(s).

(d) From this evidence, create a timeline of events that led up to the derailment and fire disaster at Lac-Megantic and the loss of lives. Each element of the timeline should identify the evidences and the layer of the Swiss Cheese Model which they come from.

(e) You are free to use other additional tools to support your analysis, but state your reason(s) for doing so.

Question 2

Root Cause Analysis

(a) From the evidence gathered and your timeline, construct a Root Cause Analysis (RCA) using the Swiss Cheese Model created in Question 1.

(b) Identify the root cause(s) of the incident using a Causal Tree.

(c) From this Causal Tree and using the Hierarchy of Controls, compose your conclusion and recommendations to ensure that this incident does not happen again.

(d) Analyse the likelihood of success for each recommendation, presenting your rationale for this.

(e) You are free to choose the format of the recommendations. However, the format chosen should support the earlier assessment methodologies that you employed.

Question 3

Incident Report
(a) Prepare a detailed report of this incident using the structure studied in this
course:
(i) What happened?
(ii) What caused it to happen?
(iii) What do you recommend should happen next?
(b) Your report should be in a form suitable for submission to the company’s Board using the format shown below:

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