Canada's TSB Chair Fox reflects on Lac-Megantic rail tragedy

“From a human perspective, I was devastated.” — TSB Chair Kathy Fox on the Lac-Megantic rail disaster Transportation Safety Board of Canada

By Julie Sneider, Senior Associate Editor 

Kathy Fox was awake and watching television in the early morning hours of July 6, 2013, when she learned of a freight-train derailment that caused explosions and a massive fire in downtown Lac-Megantic, Quebec. 

A Transportation Safety Board of Canada (TSB) member at the time, Fox was horrified at the images she saw on the screen, as news reports unfolded to report what would become the worst freight-train disaster in Canada’s history.  

The accident occurred when an unattended, 72-car train — operated by the now defunct-Montreal, Maine and Atlantic Railway (MMA) — parked for the night at Nantes, Quebec, started to roll uncontrolled downhill, picking up speed to 65 mph. When the train approached the center of the town of Lac-Megantic, 63 tank cars carrying crude oil derailed, causing an explosion and fire. More than 1.5 million gallons of crude oil were spilled by the derailed tank cars. When all was said and done, 47 people died and 40 buildings — about half of the downtown’s structures — were destroyed.  

Fox and the other TSB members were kept informed of the agency’s staff investigation into the accident. The agency is charged with investigating transportation accidents for the purpose of advancing transportation safety. When its report was ready a little more than a year later, Fox met with the families of those who died and briefed them on the report’s findings. Two days later, on Aug. 21, 2014, Fox took over as the TSB’s chair, a position she’s held since. 

Lac-Megantic derailment The Lac-Megantic derailment site following the derailment and subsequent explosions and fire. Transportation Safety Board of Canada

“From a human perspective, I was devastated,” Fox says of her feelings about the disaster’s impact on Lac-Megantic. “But I knew [TSB investigators] would do a good job” in reaching conclusions about what went wrong and the necessary steps for preventing a similar catastrophe in the future. 

On the 10th anniversary of the Lac-Megantic rail tragedy, Fox sat down with RailPrime to discuss the accident’s impact on freight-rail safety in Canada. The agency found 18 causal and contributory findings that led to the disaster.  

“We looked at everything, from the operation of the train to the mechanical issues that resulted in the train rolling away uncontrolled, to the regulatory oversight and safety management,” Fox says. “If you take away any one of the 18 causal and contributing factors, that accident might not have happened because it was fairly complex.” 

A final report and recommended actions 

The TSB ended up recommending five actions to Transport Canada, the government departmtent that regulates transportation. The first three recommendations were issued in January 2014 while the investigation was still underway; the remaining two came out when the TSB released its final report in August 2014. 

The first recommendation called for tougher standards for tank cars used for transporting flammable and hazardous materials by rail. The same day, the National Transportation Safety Board — which Fox says was helpful in TSB’s investigation — also called for tighter tank car standards. 

“That they would issue the recommendation at the same time as us is kind of unprecedented,” she says. “But the NTSB and TSB recognized that those tank cars are going back and forth across the border, so we had to harmonize” the recommendations for improved standards.  

In 2015, Transport Canada proposed upgraded standards for a new series of tank car—the TC-117. The new standard would require all new tank cars built for the transport of flammable liquids to be built using thicker and more impact-resistant steel, and to be equipped with jacketed thermal protection, full height head shields, top fittings protection and improved bottom outlet valves. The regulation rollout included a phasing out of the older tank cars — a “progressive timeline” that Fox at the time suggested would take too long. The current deadline for implementation is 2025.

“The standards are being progressively phased in because it takes time to build or retrofit cars to the new standards,” she says now. “But we’re on track to meet the 2025 deadline, maybe even sooner. ... So, we’ve just assessed the [government’s] response to that recommendation as ‘fully satisfactory.’” 

TSB’s second recommendation — which the board considers satisfactorily addressed and closed — called on railroads to conduct route planning and analysis that assessed risk and risk mitigation when transporting dangerous goods such as crude oil.  

The third recommendation — also met satisfactorily and closed — addressed emergency response assistance plans for transporting liquid hydrocarbons. This recommendation stemmed from the fact that Lac-Megantic didn’t have the necessary materials to fight and contain the fires and explosions the derailment caused. 

Safety improvement a work in progress 

The board’s final two recommendations — R14-04, which calls for physical defenses such as the handbrakes to be applied to prevent runaway trains; and R14-05, which would require the government to conduct in-depth audits of railroads’ safety management plans — remain open 10 years later, as Transport Canada works with the rail industry to implement changes.  

The MMA train had been secured both with handbrakes and locomotive air brakes. However, a proper handbrake effectiveness test had not been done to ensure that the handbrakes alone would hold the train. When the locomotive supplying air pressure to the train was shut down, the air brake system leaked off in less than an hour and the force from the handbrakes was not enough to secure the train, which then rolled down hill. Both air brake and handbrake systems can fail, as the technology is not fail-proof. 

Regarding R14-04, Fox says the TSB wants the industry to adopt new technology to prevent the uncontrolled movement of trains and rail equipment. Unplanned/uncontrolled movements of rail equipment remains a key safety issue on the TSB’s 2022 safety “watchlist,” and Transport Canada has said it is committed to implementing the recommendation. 

The fifth recommendation calls on Transport Canada to strengthen its oversight of railroads’ safety systems. In its investigation of Lac-Megantic, the TSB found that the government regulator wasn’t effective in its oversight of MMA. Since then, Transport Canada has taken big steps toward implementing that recommendation, Fox says.  

“Transport Canada significantly strengthened and enhanced the safety management system regulations applicable to railways operating in Canada,” she says. “They made them much more explicit and prescriptive about what railways had to do within their safety management systems.” 

Transport Canada also now requires railroads to obtain operating certificates — much like airlines must get — to ensure that they’re operating safely. Additionally, the regulator has strengthened financial penalties for being out of compliance. 

Moreover, Transport Canada strengthened its process of auditing railroads’ safety management systems, increased the number of its rail inspectors and improved their training. 

“So, [Transport Canada] has really done a lot on that recommendation,” Fox says. “But the reason its status is still open is because we want to see results. We want to see that what they’re doing meets the intent of our recommendation.” 

Although the rail industry has been “responsive” to the TSB’s safety recommendations since Lac-Megantic, there’s room for improvement when it comes to safety, Fox believes. 

“The [rail] operators themselves have an interest in never having another Lac-Megantic,” she says. “They’ve taken a lot of actions to reduce the risk, but are we where we want to be 10 years later?” 

Not yet, she says. At times, she’s been frustrated with the “slow pace of change” on certain safety improvement proposals — such as adopting new technology that could prevent uncontrolled movement of rail equipment — that would make a big difference in reducing the risk of accidents that can have catastrophic consequences. 

‘Unfair’ to say nothing’s changed 

At the same time, Fox is concerned when she hears news media reports or members of the public say “nothing has changed” since Lac-Megantic occurred.  

“A lot has changed,” she says. “There are still initiatives that must be done — and that’s why we’re continuing to push for change in those areas where we still see significant risk to people, property and the environment. But it’s unfair to say that nothing has changed.” 

As for change in her own future, Fox indicated a year ago she would retire when her current term as TSB chair expires Aug. 22. But she has agreed to stay on the job for another year. Looking back on her tenure with the board and as chair, Fox says she’s most gratified with the impact the TSB can have in helping people and communities recover from transportation disasters. 

“I look back at some of our key investigations and one of my most memorable moments is when I and the investigator-in-charge can return to the scene of an accident and bring some closure as we produce our report and recommendations,” she says. “Reaching out to the people who've been most affected and trying to reassure them that we're not going to give up, that we’re going to keep pushing for change until these safety issues are resolved — that’s what’s most memorable to me.”