LESSONS LEARNT
HUMAN ASPECTS
The Human aspects that are to be considered in the disaster of La magnetic rail include:
Locomotive engineer
Operators on phone
Supervisors and managers
Trackman (Lacoursière, 2015).
The crew of the rail includes the supervisor who was insufficient to handle the rail and the operator on phone, managers, and Trackman is the other people who are off the board and some of the human factors to be considered in the disaster (McNish, 2013).
PROCESS SAFETY MANAGEMENT ASPECTS
With the amendment of Railway Safety Management (RSM) in 2001, the act has given the organization to design and develop their own Safety Management Systems (SMS) for their products and these laws will constitute by the organization depending on their budget the public safety is considered (Généreux, ET.AL, 2014).
Some of the safety management aspects that include are:
Lead locomotive
Braking systems
Dot-111 tank cars
Crude oil
The failure of these safety aspects are the reasons for the disaster of the Locomotive rail (Campbell, 2013).
COMMUNICATION ASPECTS
There is very less communication made by the transport system and the rail. They are no clear communication channels that will provide the current state of the system. (Winfield, 2015).
There is a huge vacuum in communication among the to headquarters and Quebec. Ineffective communication program is another failure aspect to be considered.
ORGANIZATIONAL ASPECTS
From the organization point of view, it was the failure of the MMS, and the organization CEO has stated that the entire disaster was occurred due to the inability of the safety & rescue service team failure and transport system of Canada.
MMS:
- Weak safety culture
- Not implementing Safety Management system
- Reactive rather than proactive
- Lack of training to employees
- Careless and a step behind rather than a step ahead
- After implementing the SMS, it wasn’t functioning properly
- Cost over safety (repair 2008) (knowing there’s something wrong with lead locomotive yet decided to continue the transportation
- Poor classification of the material transported
- Lack of examination and proper testing to employees
- Significant difference in the operating instructions and the way they act on daily basis
- Company is not able to manage risks
- Sending of Trackman instead of an LE to fire fighters
TRANSPORT CANADA:
- Lack of inspection,
- Knowing that MMA has a weak safety culture yet ignored
- No, follow up
- Checked mma’s SMS after seven years(Late)
- Did not follow up to check if corrective plans took place
- Auditing is not done sufficiently in depth and frequently
- Communication problem between TC headquarters and TC Quebec
- Tc headquarters did not provide requirements regarding auditing
- Tc headquarters did no monitoring
- Ineffective SMS audit program (Généreux, ET.AL, 2014).
PLANT/EQUIPMENT ASPECTS
The equipment that was used in the rail was appropriate in the issues of the people and the government until the disaster has occurred. The breaks that are used to stop the rail are air breaks 101, and a hand break that is mechanical. Air breaks 101 are automatic, and they will slow down and stop the train, they use the air that is injected by the compressor and apply them to the wheels of the train to slow down and stop completely. If these breaks are not working or failed to work Hand break can be applied to stop the train (Lacoursière, 2015).
Lead locomotive
Braking systems
Dot-111 tank cars
Crude oil
EMERGENCY RESPONSE ASPECTS
The emergency response in the disaster occurred are very nominal, and there are no emergency aspects occurred during the incident occurred and after the incident, only certain rescue operations have been performed. One of the major reasons for the disaster is a lack of emergency response plans as per the standards (Campbell,2013).
Lack of equipment’s in town to extinguish the fire
Unattended Train
Failure of automatic braking system
Add more to this
One person operating train
EXTERNAL ASPECTS
Certain external aspects for the disaster include
Leaving the trains unattended
Lack of planning
Analyzing the routes on which the dangerous goods are carried
Lack of systematically testing of the petroleum crude oil and other harmful materials (Mackrael, 2013).
REFERENCES
Campbell, B. (2013). The Lac-Megantic Disaster: Where Does the Buck Stop?.
Généreux, M., Petit, G., Maltais, D., Roy, M., Simard, R., Boivin, S., … & Pinsonneault, L. (2014). The public health response during and after the Lac-Mégantic train derailment tragedy: a case study. Disaster Health, 2(3-4), 113-120.
Lacoursière, J. P., Dastous, P. A., & Lacoursière, S. (2015). Lac‐Mégantic accident: What we learned. Process Safety Progress, 34(1), 2-15.
Mackrael, K., McNish, J., & Robertson, G. (2013). Police Seize Irving Oil Records in Probe of Lac-Mégantic Disaster. The Globe and Mail, 2013-05.
McNish, J., & Robertson, G. (2013). The probe of Lac-Megan tic train disaster turns to the composition of the oil. The Globe and Mail.
Winfield, M. (2015). “Smart Regulation” and Public Safety: Transport Canada’s Safety Management System (SMS) Model and the Lac-M égantic Disaster.