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An Accident Rooted in History

It was Canada’s worst rail disaster in more than a century.  In the early morning hours of July, 6 2013 a 72 car freight train derailed and exploded in Lac-Megantic Quebec.  The train, operated by American company Maine and Atlantic Railway was carrying crude oil form North Dakota to St. John New Brunswick.  At about 1 am the unattended train broke loose and began to roll downhill towards Lac – Megantic and derailed on a sharp curve killing 47 people were spilling or burning 6 million litres of crude oil.  Crude oil landed as far as 120 kilometres away.

We have seen throughout history that all tragic events share a short list of common safety culture and technical shortcomings; we can now add Lac- Magantic to this list.  From the Titanic to Bhopal to Piper Alpha or even the Space Shuttle Challenger the patterns are unfortunately repeated time and time again.  In all these disasters there were warnings signs that should have been heeded, and in hindsight, were obvious.  Fatigue, poor maintenance, production pressures over safety, and lack of training were common in all of these disasters.

Although the Lac-Magantic investigation is still ongoing, the Safety Council of Canada has already stated some initial causes:  improperly labelled cargo, only 1 crew member, unattended train left with engine running, insufficient amount of hand brakes applied during the stop, and a lack of effective regulatory oversight.  Brian Stevens director of the rail division at UNIFOR says “Can you imagine if the aviation industry was run this way….we leave it to the railways themselves and they’ll create a nice report on an annual basis and say ‘hey listen we are doing our job.’”

Safety excellence is rooted in the concept of focusing on exposure rather than injuries.  Focusing on “the accident” fosters inconsistencies in leadership; it is easy to take action when there is blood on the job site but it’s harder to take action when the potential has not yet led to an event. An exposure focus means we are proactively finding the potential for injury on site and examining our systems, procedures, and decision-making that influence the quality and effectiveness of those safety systems.  Let’s hope we can actually learn from this tragedy and companies can start to shift their focus to finding potential incidents before they manifest.  The warning signs are everywhere.

Paul Poscente

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