What can we learn from Lac Mégantic
In July of 2013, the deadliest Canadian rail accident since 1867 occurred in Lac Megantic, Quebec. A series of errors resulted in a train carrying crude oil to roll downhill before derailing in the town of Lac Megantic. The accident resulted in:
- 63 derailed rail cars
- 47 deaths
- 2000 people forced from their homes
- 4200 people impacted
- 30 buildings destroyed
- multiple criminal charges
- $460 million dollars in settlements (and ongoing legal battles)
While it might be tempting to assume an accident of this magnitude is the result of a single large error or mechanical failure, this was not the case. Investigators identified 18 causes and contributing factors that led to the disaster. Here are a few common, but potentially dangerous assumptions, that were made by the rail company and are often heard in the emergency response and business continuity arena:
- We’ve trained our staff in all safety procedures. The rail engineer in the Lac Megantic disaster received training. Despite this, he did not conduct a proper brake test to ensure the locomotive was secure. The engineer applied 7 handbrakes, yet investigators estimate that the operator should have applied at least 17 brakes to secure the train. Investigations revealed that training, testing and supervision were insufficient. Safety training is important, but regular reviews and testing are just as critical. Management needs to be sure that staff are always following procedures accurately and consistently.
- We have written procedures for our staff to follow. In the rail disaster, personnel mislabeled the oil cars with the wrong type of crude oil and did not follow brake procedures. Just because procedures are written down doesn’t mean staff will always follow them. We can learn from the checklist approach used in the airline industry and now adopted in operating rooms as well. Mandatory checklists require the pilot/surgeon to physically check off that required procedures are followed, every time.
- We’ve evaluated the situation and decided it’s too costly to fix so we’re going to accept the risk. Eight months before the Lac Mégantic rail disaster the lead locomotive was in for repair. Due to the costs associated with a standard repair and the pressure to return the locomotive to service as quickly as possible, the company took short cuts using an epoxy-like material instead of performing the standard repair. This material caught fire the night of the disaster and was a significant contributing factor to the events that led to the derailment. Businesses make cost-benefit decisions everyday but we need to be sure we’re fully recognizing all the costs. The railway is now in bankruptcy protection because of the event.
- We are regulated and regularly inspected so we’re confident that we’re following all required procedures. Prior to the rail disaster, reports documented a pattern of repeat problems. Despite these reports, Transport Canada did not always follow up to ensure the company was addressing the underlying conditions that led to these recurring problems. Lack of oversight left gaps that contributed to the disaster. While many regulations exist, regulators often do not have sufficient resources to verify that companies are following the rules. Do not confuse compliance with safety. Companies need to do their own due diligence.
These are just a few of the excuses we hear companies use to make themselves feel comfortable that they’re meeting safety and business continuity obligations. These are also some of the same issues that led to the Lac Megantic disaster. Don’t assume you are meeting your obligations. Test, retest, and ensure you have tools and plans in place to ensure the safety of your operations.
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