“Weak Safety Culture” And Ineffective Safety Management System Cited In Canadian Train Derailment Investigation Report

Yesterday, the Transportation Safety Board of Canada (TSB) released its investigation report of the July 2013 derailment of a train carrying Bakken crude oil that exploded and killed 47 people in Lac-Mégantic, Quebec.  The TSB report finds that 18 factors played a role in the accident, including that the rail company had a “weak safety culture” that contributed to the continuation of unsafe conditions and practices, and compromised the company’s ability to manage risk.  The TSB report also cites significant gaps between the company’s operating instructions and how work was actually performed day-to-day, deficiencies in employee training and supervision, insufficient audits of risk management processes, and an ineffective safety management system.  As is often the case following a major incident or operational failure, most of the alleged shortcomings relate to the company’s process safety.

The report, which is available here, includes two new recommendations that call for Transport Canada to “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” and for “Canadian railways [to] put in place additional physical [defenses] to prevent runaways.”