Monday, July 15, 2013

Train Crash: Criminal or Culture?

Train Crash: Criminal or Culture?

Tank car remains after the horrific crash and fire at Lac-Megnatic
The head of the U.S. railway company whose oil train crashed into the Quebec town has blamed the engineer for failing to set the brakes properly. A fire on the train just hours before the crash is also being investigated. Oh it’s the engineer’s fault. That’s the result of the Root Cause Analysis..really. No, obviously this company has a systematic problem. It could be culture, organizational, practices....etc. 
"Under Transport Canada’s Railway SMS Regulations, in force since 2001, all federally regulated railway companies must implement and maintain an SMS. While railways may create an SMS that best suits their organization, needs and operations, it must include documented systems and procedures, which give both Transport Canada and the railways a consistent basis for monitoring safety performance. Railways must also report to Transport Canada on their safety performance, safety goals, and new safety efforts - every year." Transport SMS for Rail.

SMS requires companies to have Standard Operating Procedures in all aspects of their operations. Most companies have procedures but, most do not follow them. It is important to realize the merely having procedures is not enough. Performing routine operation often evolve into "short cut" without an SOP to compare to. This practice is the beginning of a culture problem. 

CEO of Rail World Inc. Edward Burkhardt
"It's very questionable whether the hand brakes were properly applied on this train," said Edward Burkhardt, chief executive officer of Rail World Inc., owner of Montreal, Maine & Atlantic Railway Ltd. "As a matter of fact, I'll say they weren't, otherwise we wouldn't have had this incident."

Burkhardt paid his first visit to Lac-Megantic, four days after an unmanned, 72-car oil train rolled from an overnight parking spot into the town, where it jumped the tracks, incinerated about 30 buildings and killed at least 20 people. Burkhardt laid the blame for the crash on his own engineer for failing to properly apply hand brakes on the rail cars when they were parked in nearby Nantes. He said his company's inspection indicated the brakes were applied on the locomotives, but not on the rail cars. Burkhardt told reporters today that the train's engineer told the company he had applied 11 hand brakes. Procedures require that all handbrakes be applied. 

Fire plumb from the burning tank cars.

"We think he applied some hand brakes, the question is, did he apply enough of them?" Burkhardt said. "He's told us that he applied 11 hand brakes and our general feeling now is that that is not true. Initially we took him at his word."

While leaving locomotives running overnight with no one aboard is standard practice, Montreal Maine won't do so again, Burkhardt said in the interview. "We're going to tighten up our procedures," he said. "I expect there will be a push to tighten up regulation as well. I support that.

"Tightening up regulations? What about the Safety Management System regulation? The SMS already requires procedures be reviewed and analyzed for continuous improvement. 

Asked how he would react if criminal charges are laid, "if that's the case, let the chips fall where they may," he said. "I can't draw the line between carelessness and criminal negligence." Montreal Maine's US accident rates exceed the average for commercial railroads operating in the country for at least the past decade, according to data compiled by the Federal Railroad Administration. 

Just from the reaction of the President of Rail World Inc. It is clear, the SMS is not working in this company. Equally disturbing is the fact Transport Canada Rail should have objective evidence of the break down in the SMS for this company. Unfortunately this tragic accident is additional evidence of the cost of not having a Safety Management System. Your thoughts....

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