Railway Investigation R13D0054

Major rail accident in Lac-Mégantic, Quebec

On 6 July 2013, a unit train carrying petroleum crude oil operated by Montreal, Maine & Atlantic Railway (MMA) derailed numerous cars in Lac-Mégantic, Quebec, and a fire and explosions ensued.

Status of the investigation at 23 January 2014

In addition to the four safety advisory letters previously issued, the Transportation Safety Board of Canada (TSB) has issued three recommendations and a news release regarding its ongoing investigation into the MMA train derailment. The TSB is completing its work in Phase II of the investigation (examination and analysis) and will soon move into Phase III (report writing).

What we know

Timeline

  • At about 22:50 on 05 July 2013, the train stopped at Nantes, Quebec.
  • At about 23:50, the fire was reported to the rail traffic controller.
  • Just before midnight, the engine was shut down, and the fire was extinguished.
  • At about 00:30, an MMA employee arrived on site to assist the fire department.
  • At approximately 00:58 on 06 July 2013, the train started to move, after the fire department and MMA employee had left.
  • At approximately 01:15, the train derailled in Lac-Mégantic.

Runaway train

  • The train rolled down the predominantly 1.2% grade into the centre of Lac-Mégantic.
  • The train derailed at approximately 01:15 on 06 July 2013.
  • The locomotives detached from the rest of the train.
  • There were no signals or track circuits, so the rail traffic controller would had no indication of a runaway train.

Progress made in the investigation

The investigation is progressing well. Steps completed by the investigation team so far include:

  • Analysis of the information from the locomotive event recorder (LER) from the lead locomotive and the sense and braking unit (SBU) from the back of the train;
  • Teardown of the lead locomotive engine;
  • Testing of air brakes and hand brakes on locomotives and tank cars;
  • Examination of the track components and wheel set recovered on site;
  • Metallurgical analysis of tank car coupons;
  • Analysis of operational issues.

Next steps in the investigation

We are nearing the end of the examination and analysis phase and we will soon be transitioning to the report writing phase. In the coming weeks, the investigation team and the TSB laboratory will:

  • Conduct further examination of some selected air brake components;
  • Complete theoretical analysis of the retarding forces required to prevent the unintended movement of the train;
  • Develop graphics, animations and other multimedia products to assist in the investigation and to communicate safety messages;
  • Validate and analyze information collected from the railway, Transport Canada and other agencies;
  • Continue to work on several analyses of the crude oil samples;
  • Analyze the results of the locomotive engine teardown to determine the cause of fire; and
  • Complete the analysis of the hand brake and air brake tests.

Completing this work will allow the TSB to determine exactly what happened and why. If at any stage during the investigation the TSB identifies additional safety deficiencies, it will communicate them directly to Transport Canada and industry, and inform the public.

Rail statistics

Map of the area

Photos

Click on the images to see them in full size.

See more high resolution pictures on the TSB Flickr page.

The TSB team

Don Ross, Investigator-in-Charge

Photo of Don Ross

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
Photo of Ed Belkaloul

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
Photo of James Carmichael

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.

John Cottreau
Photo of John Cottreau

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
Photo of Rox-Anne D'Aoust

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
Photo of Derek Gagné

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
Photo of Tony Gasbarro

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.

Peter Hickli
Photo of Peter Hickli

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.

Rob Johnston
Photo of Rob Johnston

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
Photo of Manuel Kotchounian

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.

Claude Lelièvre
Photo of Claude Lelièvre

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
Photo of Nathalie Lepage

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
Photo of Julie Leroux

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
Photo of Ken Miller

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.

Jean Nadeau
Photo of Jean Nadeau

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
Photo of Ted Parisee

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
Photo of Ian Perkins

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
Photo of Glen Pilon

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
Photo of Glen Pilon

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
Photo of Mark Wallis

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.

Transportation Safety Board 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.


Media

News releases

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

Deployment notices

2013-07-06

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

Media advisories

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

Videos and animations

2014-01-23

Class 111 tank car damage in Lac-Mégantic derailment and fire
Watch the animation

Speeches

2013-07-12

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

Safety advisory letters

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 Transport Canada's proposed changes to the Transportation of Dangerous Goods Regulations

Backgrounders

2014-01-23

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

Recommendations

Lab reports

2014-03-06