On July 6, 2013, an unmanned, 72-car MM&A train carrying crude oil rolled down a grade and into the town of Lac-Mégantic, Que., where it derailed and exploded, killing 47 people.
Montreal, Maine & Atlantic Railway Ltd. (MM&A) had been the subject of repeated infraction notices for violations of the rules surrounding the securing of trains for years before the tragedy in Lac-Mégantic, but Transport Canada never imposed any sanctions on the company.
Those violations, documented in Transport Canada files obtained by Radio-Canada's investigative program, Enquête, were noted several times in 2004 and 2009, and again in 2011 and 2012.
Just what happened the night in early July when an MM&A train rolled down an incline, derailed and exploded in the core of Lac-Mégantic, killing 47 people, is still under investigation.
CROR Section 112
"When equipment is left at any point a sufficient number of hand brakes must be applied to prevent it from moving. Special instructions will indicate the minimum hand brake requirements for all locations where equipment is left. If equipment is left on a siding, it must be coupled to other equipment if any on such track unless it is necessary to provide separation at a public crossing at grade or elsewhere.
"Before relying on the retarding force of the hand brake(s), whether leaving equipment or riding equipment to rest, the effectiveness of the hand brake(s) must be tested by fully applying the hand brake(s) and moving the cut of cars slightly to ensure sufficient retarding force is present to prevent the equipment from moving. When leaving a cut of cars secured, and after completion of this test, the cut should be observed while pulling away to ensure slack action has settled and that the cars remain in place."
But the use of the handbrakes and how the train was secured are at the heart of the inquiry, and have been since early days.
In the weeks following the disaster, the Transportation Safety Board said its investigation found the braking force applied wasn’t enough to hold the train on the 1.2 per cent descending slope where it had been parked for the night.
The documents obtained by Enquête show at least eight warnings were issued to MM&A by Transport Canada between 2004 and 2012 concerning Section 112 of the Canadian Rail Operating Rules (CROR).
That section requires that a number of handbrakes be applied and a traction test conducted before trains are left parked to ensure they're secure.
Some of those violations were issued for incidents at the Nantes, Que., station, where the train that rolled into Lac-Mégantic had been left for the night.
But the rules do not spell out exactly how many handbrakes must be applied, only that the number must be “sufficient.”
“Special instructions will indicate the minimum hand brake requirements for all locations where equipment is left,” the document states.
In July, Transport Canada confirmed it does not approve or give any specific guidance to Canada's rail companies on how many brakes must be applied for parked freight trains.
In the days following the tragedy, Edward Burkhardt, chairman of MM&A, suspended the locomotive engineer and alleged the driver failed to apply enough handbrakes when he left his train unattended on the main track and headed into Lac-Mégantic to sleep.
“Blaming the conductor, that’s the easiest thing to do,” said Jacques Vandersleyen, a consultant and railway industry expert.
“Those primarily responsible for good management, good ethics and corporate culture are the leaders.”
Vandersleyen said the repeated violations on the books for MM&A show a systemic safety problem within in the company.
He also said Transport Canada failed in its duty by not imposing punitive measures against MM&A.
“There are warnings, reviews, staff retraining . . . but there are no explicit sanctions,” Vandersleyen said.
Several days after the tragedy, MM&A was the subject of another Transport Canada Notice and Order for a new violation of Section 112, only five kilometres from Lac-Mégantic, the documents reveal.
A train of five locomotives and 98 cars was left unattended and without a sufficient number of handbrakes to ensure it would remain immobile.
At the time, the train was located on the main line headed to the station in Vachon.
MM&A filed for bankruptcy protection in August and, in January, the assets of the railway company were sold at auction to Florida Great Lakes Partners, partnered with Fortress Investment Group. The purchase price was not immediately released.
Proceeds from the sale will be used to repay creditors and victims, supplementing $25 million in insurance payouts for wrongful death, personal injury, property damage, fire suppression and environmental impact.