Railway Investigation R13D0054

The accident

On 5 July 2013, at about 10:50 p.m., after arriving in Nantes, Quebec, a Montreal, Maine & Atlantic Railway (MMA) locomotive engineer parked a train on a descending grade on the main track. The engineer applied hand brakes on all five locomotives, plus two other cars, and shut down all but the lead locomotive. Railway rules require hand brakes alone be capable of holding a train, and this must be verified by a test. That night, the locomotive air brakes were left on during the test, meaning the train was being held by a combination of hand brakes and air brakes, and giving a false impression that the hand brakes alone would hold the train.

When a fire began in the engine of the lead locomotive, in keeping with railway instructions, emergency responders shut off the engine, which subsequently caused the air holding the locomotive air brakes to leak off. Without enough force from the handbrakes, the train began rolling downhill toward Lac-Mégantic, just over seven miles away. As it moved down the grade, the train picked up speed, reaching a top speed of 65 mph. It derailed near the centre of town at about 1:15 a.m.

Almost all of the derailed tank cars were damaged, and many had large breaches. About six million litres of petroleum crude oil was quickly released. The fire began almost immediately, and the ensuing blaze and explosions left 47 people dead. Another 2000 people were forced from their homes, and much of the downtown core was destroyed.

Read the complete Executive summary

Map of the area

Investigation team

Don Ross, Investigator-in-Charge
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Mr. Ross joined the Transportation Safety Board of Canada (TSB) in Hull, Quebec, as a safety analyst in the Accident Prevention Branch. In April 1996, he joined the Investigations Division as a senior investigator. He worked out of the TSB Head Office for seven years. During this time, he led a number of major rail investigations and often relieved the national manager of investigations, Rail/Pipeline. In 2000, he started working in Halifax/Dartmouth as the regional senior investigator, Rail/Pipeline for the Atlantic Region.

Mr. Ross holds a Certified Health and Safety Consultant designation and a Professional Member designation from the Canadian Society of Safety Engineering, and is the national president of Clan Ross Association of Canada. He began his railway career in 1975 at CN Rail's maintenance shops in Sydney, Nova Scotia. After completing a four-year apprenticeship in the trade of carman, he became a permanent supervisor in 1979, and thereafter occupied a variety of supervisory and management positions across Canada, including in Sydney, Halifax, Moncton, Montreal, Winnipeg and Prince George, British Columbia.

His railway experience includes managing car repair shops, locomotive shops, maintenance shops, and a wheel shop. Mr. Ross has also worked in CN district, regional and headquarters offices in positions with responsibilities relating to equipment inspection and maintenance (13 transfers in 6 provinces). He has received extensive training in dangerous goods, and was national coordinator of CN's emergency response network for over three years.

Ed Belkaloul
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Mr. Belkaloul has been with the TSB since 1997. Before joining the TSB, he worked as a consultant engineer with Nicolet, Chartrand, Knoll et Associés in Montreal, followed by 7 years with Canadian National as Maintenance Engineer in the Quebec region, and 8 years at Transport Canada as Infrastructure Engineer in Ottawa. Mr. Belkaloul holds a Diplôme d'ingénieur civil from École Polytechnique de Lausanne, a Master's Degree in Engineering from École Polytechnique de Montreal, and an MBA from the University of Ottawa.

James Carmichael
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Mr. Carmichael has been with the Transportation Board of Canada (TSB) in the Railway/Pipeline Investigations Branch since 2008. During his time at the TSB he has been a key investigator in a number of investigations in Western Canada.

Prior to joining the TSB, Mr. Carmichael held various mechanical positions with four separate railroads. At BCR from 1980 to 2004, Mr. Carmichael gained considerable experience in the mechanical field; he worked as a carman and progressed into a management role as General Supervisor in the Car Department. Over the next 4 years Mr. Carmichael worked for CN Rail and CP Rail as a Mechanical Supervisor. He was also Regional Manager for Mechanical with OmniTRAX's Carlton Trail, Hudson Bay and Okanagan Valley Railroads. He holds certifications as a Hazmat Technician and Tank Car Specialist and was a member of British Columbia Railway's (BCR) Emergency Response Team. Mr. Carmichael lives in Calgary, Alberta.

Daoxing Chen
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Dr. Daoxing Chen, Senior Engineer Specialist, Rail Dynamics, at the TSB Engineering Laboratory in Ottawa, has been with the TSB since 2000. He previously worked at the National Research Council of Canada, the Transportation Technical Center of the Association of American Railroads, and the China Academy of Railway Sciences. He has conducted locomotive event recorder data analysis, train dynamics, vehicle/track dynamics simulation and brake testing for 70 TSB rail investigations. He has published 110 research and engineering reports and academic papers.

John Cottreau
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Mr. Cottreau has been a communicator in the federal government for 23 years, and has been media relations advisor and spokesperson for a number of government departments. He is now manager of media relations at the TSB, where he has worked for 12 years.

Rox-Anne D'Aoust
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Ms. D'Aoust is Manager, Strategic Communications, at the TSB. She has worked in communications in the public and private sectors for over 25 years, and is experienced in marketing, media relations, issues management and strategic communications.

Sylvie Dionne

Sylvie has worked for the TSB Engineering Laboratory since 2006, and currently holds the position of Manager, Materials Analysis and Structures. She has completed over 100 metallurgical examinations in support of TSB investigations since joining TSB. Sylvie holds Bachelor of Applied Science (Metallurgical Engineering, 1985), Master of Applied Science (Metallurgy, 1988) and doctoral (Metallurgy, 1999) degrees from Université Laval in Québec. Before joining the TSB, she had 18 years of experience as a research scientist at Natural Resources Canada where she conducted research projects dealing with the characterization of advanced materials.

Derek Gagné
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Mr. Derek Gagné has been with the TSB since 2003. He holds the position of Electrical-Mechanical Systems Engineer at the TSB Engineering Laboratory in Ottawa, Ontario. He has participated on 180 engineering projects, 20 of which were in the rail mode of transportation. Mr. Gagné holds a Bachelor of Science/Electrical Engineering with a specialty in Radio Frequency Design and Communications.

Tony Gasbarro
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Mr. Tony Gasbarro has been with the TSB since its inception in 1990, having previously worked for the TSB's predecessor, the Canadian Aviation Safety Board. He has participated on 93 engineering projects, 19 of which were in the rail mode of transportation. Mr. Gasbarro holds a Science Technician (Photographic) diploma.

Val Guertsman
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Val Guertsman has been with theTSB Engineering Laboratory since 2008 and currently holds the position of Senior Engineering Specialist – Materials/Physical Sciences. He has over 30 years' experience with several research establishments and educational institutions. Immediately prior to joining the TSB, Val worked for six years at the Materials Technology Laboratory of Natural Resources Canada.

Peter Hickli
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Peter Hickli has been with the Transportation Safety Board of Canada (TSB) since 2006. He holds the position of Senior Regional Investigator Rail/Pipeline in Vancouver, British Columbia. He has been Investigator-In-Charge of several rail accident investigations, and has provided technical expertise on several other investigations as an investigation team member.

Before joining the TSB, Mr. Hickli worked for BC Rail/CN for 30 years, during which time he served a 4-year carman apprenticeship, and worked extensively in the Mechanical Department in unionized and management positions. A hazardous materials technician and advanced tank car specialist, he was also a member of the Derailment investigation team and the Hazmat team.

Xin-Xiang Jiang
Photo of Xin-Xiang Jiang

Dr. Xin-Xiang Jiang, Senior Engineer Specialist, Structures, has been involved in several transportation occurrence investigations since joining the TSB Engineering Laboratory in March 2013. He holds a Ph.D. in Materials Engineering from the University of Leeds as well as M. Eng. and B. Eng. degrees in Materials Engineering from South China University of Technology. Before joining the TSB, he worked 15 years as a senior scientist at the Canadian Space Agency, where he was involved in several Canadian space programs, covering technical aspects of design, prototyping, stress analysis and testing of structures, mechanisms and materials. He holds three patents, and has published 60 papers, 17 of them in internationally refereed journals.

Rob Johnston
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Mr. Johnston has been with the Transportation Safety Board of Canada (TSB) since 2001. He was Senior Regional Investigator in Winnipeg until 2004, when he assumed the position of Senior Investigator, Standards and Training Officer at TSB Head Office in Gatineau, Quebec. He became Manager of Central Regional Operations in November 2009, and served as Acting Director of Investigations - Rail/Pipeline for 9 months in 2010– 2011. He now manages a staff of 6 rail/pipeline investigators in Winnipeg, Toronto, and Ottawa, and is responsible for all activities related to rail investigations in TSB's Central Region, which extends from Cornwall, Ontario, to near the Alberta–Saskatchewan border. During his time at the TSB, Mr. Johnston has been Investigator-in-Charge of 20 rail accident investigations, and has provided technical expertise on a number of other investigations. Before joining the TSB, Mr. Johnston worked for Canadian Pacific Railway in Winnipeg from 1984 until 2001, where, as a member of the Train Accident Prevention group, he acquired an extensive background in mechanical operations, failure analysis, and dangerous goods.

Manuel Kotchounian
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Before joining the TSB in 2011, Mr. Kotchounian worked nearly 10 years at Transport Canada, where he held various positions including remedial measures specialist and means of containment specialist. Prior to that, Mr. Kotchounian also worked at the National Energy Board as a senior pipeline engineer, where he provided technical expertise in public hearings, inquiries, and investigations related to pipelines and public safety matters. Throughout his career, Mr. Kotchounian has acquired extensive experience in regulatory affairs and technical matters pertaining to pipelines, pressure vessels, tank cars, and dangerous goods. Mr. Kotchounian holds a Bachelor of Engineering and a Master of Applied Sciences from l'École Polytechnique de Montréal, and is a registered professional engineer in Ontario.

Louis Landriault
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Mr. Landriault, Senior Engineering Technologist, joined the TSB in 1990, having worked in both the Canadian Aviation Safety Board (1984–1990) and the Aviation Safety Bureau (1983–1984). With over 30 years of experience in accident investigation, he has worked on countless major rail, air and marine occurrences.

Claude Lelièvre
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Mr. Lelièvre, Senior Engineer, Materials, at the TSB Laboratory in Ottawa, has been with the TSB since 2009. He previously worked at the Department of National Defense for 19 years. He is an avid outdoorsman and loves fishing.

Nathalie Lepage
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Nathalie Lepage has been with the Transportation Safety Board of Canada (TSB) for over 20 years. She was appointed to her current position in 2011. Ms. Lepage is a certified train conductor and brings on board extensive experience in TSB investigation processes and communications. She graduated with a bachelor's degree from the University of Ottawa in 1992.

Julie Leroux
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A member of the TSB media relations team since 2007, Ms. Leroux has organized countless press events and also worked on-site at several investigations. She has a bachelor's degree in Communications and a diploma in marketing.

Ken Miller
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Mr. Miller joined the Transportation Safety Board of Canada (TSB) in 2002 and has been a senior investigator with the Rail and Pipeline Investigations Branch since 2004. During that time he has participated in over 40 investigations while also performing the duties of standards and performance specialist.

Before joining the TSB, Mr. Miller worked for consulting companies in the resource sector providing geological expertise. In this capacity, he was responsible for the development, management and successful completion of exploration projects.

Mr. Miller's education credentials include a Bachelor of Science degree in Geological Sciences from Queen's University in Kingston, Ontario, and a Masters of Business Administration degree from the University of Toronto, Ontario.

Joel Morley
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Joel Morley is a Senior Human Performance Analyst at the Transportation Safety Board of Canada, a role he filled from 2001 to 2007 and returned to in 2012. While at the TSB, Joel has participated in numerous investigations in the air, rail and marine modes and trained a large number of investigators in the theory and practice of investigating for human performance factors. In addition to the TSB, Joel has experience applying safety management and human factors for a large air navigation service provider and has worked as a researcher and consultant. Joel holds a PhD in Applied Psychology from Cranfield University.

Jean Nadeau
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Mr. Nadeau has been with the TSB since 2008. He holds the position of Senior Human Factors Investigator in TSB Head Office in Gatineau, Quebec. Since his arrival at the TSB, he has been the lead Human Factors investigator for 23 investigations, of which 13 were of rail accidents. Before joining the TSB, Mr. Nadeau worked for 6 years as a senior consultant in Human Factors following a 22-year career in the Canadian Armed Forces.

Ted Parisee
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Mr. Ted Parisee has been with the TSB since 2000. He holds the position of Senior System Technologist—Geospatial at the TSB Engineering Laboratory in Ottawa, Ontario. He has participated in 79 engineering projects; 16 of them were in the rail mode of transportation. Mr. Parisee holds a bachelor's degree in Computer Science with background in electrical engineering. He has provided geospatial analysis and 3D computer-aided design (CAD) reconstruction and animations to numerous TSB investigations.

Ian Perkins
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Mr. Perkins worked with Canadian Pacific Railways for 10 years as conductor and engineer. More recently, he was involved in training and recertifying of locomotive engineers and conductors. He recently joined the TSB as Investigator in the Quebec Region.

Glen Pilon
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Mr. Pilon has been with the TSB since 2008 as Technical Coordinator and investigator at the TSB Head Office in Gatineau, Quebec. He has been the Investigator-in-Charge on 3 rail accident investigations and and had acted as train operations expert on many others. Mr. Pilon worked for the Ottawa Valley Railway (OVR) from 1996 until 2008 as locomotive engineer and safety officer and with the Canadian Pacific Railway (CPR) from 1987 until 1996 in operations as trainman and conductor.

Jacqueline Roy
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Jacqueline Roy joined the Transportation Safety Board of Canada in September 2011 as the Director of Communications. Ms. Roy has held several senior communications positions during her 22-year federal public service career in departments such as the Privy Council Office, Transport Canada, the Canadian Air Transport Security Authority, Public Safety Canada, and Environment Canada. Ms. Roy has a Bachelor of Arts degree in Political Science from McGill University and has a diploma in Public Relations and Communications Management from McGill University.

Jon Stuart
Photo of Jon Stuart

A human factors specialist for over 20 years, Dr. Stuart has published in the fields of Artificial Intelligence, Sports Science, Industrial Psychology and Systems Safety. Since obtaining his doctorate in applied psychology from Loughborough University in England, he has worked in the roles of systems designer, customer researcher, and accident investigator.

After building Nortel's approach to incorporating human factors into accident investigation, he joined Transport Canada's Civil Aviation, where he developed the System Safety Branch's methodology for collating safety information. In 2003, he joined the TSB as a Senior Human Performance Analyst. He has participated in air, marine and rail investigations, including the 2012 derailment of a VIA Rail passenger train in Burlington, Ontario.

Mark Wallis
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Mr. Mark Wallis has been with the TSB since 1990. He holds the position of Senior Engineering Specialist—Mechanical at the TSB Engineering Laboratory in Ottawa, Ontario. He has participated on 163 engineering projects; 58 of them were in the rail mode of transportation. Mr. Wallis holds a bachelor's degree in Science/Mechanical Engineering and is a licensed professional engineer.

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TSB investigation process

There are 3 phases to a TSB investigation
  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

Report

Executive summary
Final report
2014-08-19

Railway Investigation Report R13D0054
Runaway and Main-Track Derailment
Montreal, Maine & Atlantic Railway
Freight Train MMA-002
Mile 0.23, Sherbrooke Subdivision
Lac-Mégantic, Quebec
06 July 2013

TSB Laboratory Reports

Safety communications

Recommendations
2014-08-19

TSB Recommendation R14-05: Transport Canada must take a more hands-on role when it comes to railways' safety management systems—making sure not just that they exist, but that they are working and that they are effective.
Not yet assessed

2014-08-19

TSB Recommendation R14-04: Canadian railways must put in place additional physical defences to prevent runaways.
Not yet assessed

2014-06-18

TSB Recommendation R14-03: Requirements for emergency response assistance plans
See the TSB's assessment of the response to the recommendation.

2014-06-18

TSB Recommendation R14-02: Route planning and analysis for trains carrying dangerous goods
See the TSB's assessment of the response to the recommendation.

2014-06-18

TSB Recommendation R14-01: Vulnerability of Class 111 tank cars to sustain damage
See the TSB's assessment of the response to the recommendation.

2014-01-23

Letter from the TSB to the Honourable Lisa Raitt, P.C., M.P., Minister of Transport, and Ms. Cynthia L. Quarterman, Administrator, U.S. Pipeline and Hazardous Materials Safety Administration, dated 23 January 2014 making TSB recommendations R14-01, R14-02, and 14-03.

Safety advisories
2014-08-15

Letter to Transport Canada on adequacy of short line railway training

2014-08-15

Letter to Transport Canada on monitoring program for the classification of mined gases and liquids

2013-09-11

Letter to Transport Canada on the determination of petroleum crude oil properties for safe transportation

2013-09-11

Letter to the Pipeline and Hazardous Materials Safety Administration on the determination of petroleum crude oil properties for safe transportation

2013-07-19

Letter to Transport Canada on the securement of unattended locomotives

2013-07-19

Letter to Transport Canada on the securement of equipment and trains left unattended

(See also the safety advisory letter to Transport Canada arising from Railway Investigation R13T0060 on the operating lever design for tank car bottom outlet valves on Class 111 tank cars. The letter was sent to Transport Canada on 26 November 2013.)

Other correspondence
2014-02-10

Letter addressing TC's proposed changes to the Transportation of Dangerous Goods Regulations

Media materials

News releases
2014-08-19

TSB identifies systemic problems leading to Lac-Mégantic train accident and calls for additional safety defences to improve rail safety
Read the news release

2014-07-06

Statement by Wendy A. Tadros, Chair, Transportation Safety Board of Canada, on the anniversary of the Lac-Mégantic train accident
Read the news release

2014-06-18

Strong first steps taken on TSB recommendations in Lac-Mégantic investigation
Read the news release

2014-03-06

TSB releases analysis of petroleum crude oil samples from train accident in Lac-Mégantic, Quebec
Read the news release

2014-01-23

TSB and NTSB call on Canadian and U.S. regulators to improve the safe transportation of crude oil by rail
Read the news release

2013-09-11

TSB calls on Canadian and U.S. regulators to ensure properties of dangerous goods are accurately determined and documented for safe transportation
Read the news release

2013-08-01

Lac-Mégantic update: On-site operations wrapping up, ongoing investigation remains a top priority
Read the news release

2013-07-19

Lac-Mégantic update: Immediate safety issues identified
Read the news release

2013-07-12

Lac-Mégantic update
Read the news release

Backgrounders
2014-08-19

Investigation findings in the July 2013 rail accident in Lac-Mégantic, Quebec

2014-08-19

Recommendations ensuing from the rail accident in Lac-Mégantic, Quebec

Speeches and presentations
2014-08-19

Release of the Railway Investigation Report R13D0054
TSB Chair, Wendy Tadros
Read the speech

2013-07-12

The major rail accident in Lac-Mégantic, Quebec, on 6 July 2013
TSB Chair, Wendy Tadros
Read the speech

Media advisories
2014-08-11

TSB releases its final report into the July 2013 Montreal, Maine & Atlantic Railway train derailment in Lac-Mégantic, Quebec
Read the media advisory

2014-08-05

TSB will release its final report into the July 2013 Montreal, Maine & Atlantic Railway train derailment in Lac-Mégantic, Quebec, on 19 August 2014
Read the media advisory

2014-01-21

Transportation Safety Board of Canada to release three recommendations related to ongoing investigation into train accident in Lac-Mégantic, Quebec
Read the media advisory

2013-09-10

Transportation Safety Board of Canada to release a third Safety Advisory Letter related to the ongoing investigation into the train derailment and fire in Lac-Mégantic, Quebec
Read the media advisory

2013-07-31

TSB to provide information on next steps of the investigation into the train derailment and fire in Lac-Mégantic, Quebec
Read the media advisory

2013-07-18

Update on TSB investigation into Lac-Mégantic, Québec Train Accident
Read the media advisory

2013-07-11

TSB Chair and Chief Operating Officer to hold news briefing on the investigation into the train derailment and fire in Lac-Mégantic, Quebec
Read the media advisory

2013-07-08

News briefing on the investigation into the train derailment and fire in Lac-Mégantic, Quebec
Read the media advisory

2013-07-07

News briefing on the investigation into the train derailment and fire in Lac-Mégantic, Quebec
Read the media advisory

2013-07-06

News briefing on train derailment and fire in Lac-Mégantic, Quebec
Read the media advisory

Deployment notice
2013-07-06

Transportation Safety Board of Canada deploys investigators to rail accident in Lac-Meéantic, Quebec
Read the deployment notice

Video and audio materials

Audio clips
2014-08-19

TSB Chair, Wendy Tadros, speaks about the TSB investigation into the accident in Lac-Mégantic
Download and listen to the audio clips

Video clips

News conference, Tuesday, 19 August 2014, 10:30 AM EDT, Lac-Mégantic, Quebec
Watch the news conference

Animations
2014-08-19

Sequence of events in the Lac-Mégantic derailment and fire
Watch the animation

2014-01-23

Damage to a Class 111 tank car in the Lac-Mégantic derailment and fire
Watch the animation

Other resources

Rails statistics