Searching for Someone to Blame
As the criminal trial wrapped up this month for the Lac Megantic tragedy, it occurred to me that the wrong people were on trial. It seems they just rounded up the 3 people closest to the train - the driver, the traffic controller and the operations manager - and put them on trial to appease public outrage and grief. Thankfully, the men were acquitted. The train driver even rushed to the scene, risking his own life to pull some of the unexploded cars away from the flames, which I would say makes him at least partially a hero. Why is there always this search for someone to "pin" it on? Isn't it possible that this tragedy is a result of a myriad of ill-informed decisions, policies and cost-cutting that can be attributed to many different people? A better approach is to learn from what went wrong, and make changes to prevent another tragedy like this from ever occurring again.
The investigation conducted by Canada's Transportation Safety Board into the derailment uncovered 18 causes and contributing factors. Some particularly shocking ones:
Locomotives and infrastructure were allowed to operate with known defects - the locomotive in the Lac Megantic disaster was requested to be repaired by the engineer just 2 days prior to the derailment, but was told by management that he was "just complaining"
The maximum allowable weight for a train during that time period was 6300 tonnes - the train involved in the tragedy weighed 9100 tonnes
the person in charge of safety and training for all Quebec MMA employees had no budget or resources
MMA had no safety management system in place
MMA had recently implemented one-person train "crews", despite pushback from employees
Now that we know the root causes, how can reparations be made? The $200 million disaster bankrupted the Montreal, Maine & Atlantic (MM&A) railway - there's no point in trying to transform an extinct corporate shell. The assets of the former railway were purchased by the Central Maine & Quebec Railway (CMQ). Should they be responsible for implementing corrective action? Probably not - CMQ has totally different leadership, a different culture, and may not have any of the issues that the MM&A company did. At the time of the derailment, MM&A railway was 72% owned by Railworld Inc, chaired by the infamous Edward Burkhardt. Burkhardt still runs the company, which now operates the San Luis Central Railroad in Colorado, Rail Polska in Poland and Baltic Rail OU in Estonia. Should these railroads be made to follow up on the investigative findings? Again, probably not - these are completely different railway lines, literally continents away from the old MM&A railway.
This is where regulatory agencies play a pivotal role in public safety. In light of the investigation, Transport Canada has imposed the following changes on all rail transport:
banned trains carrying dangerous goods from operating with single-person crews
imposed new tank car design standards
auditing railway safety management systems
mandatory emergency response assistance plans
enhanced train operations for petroleum-carrying trains
The US has mirrored many of the actions, through the National Transportation Safety Board. While it may be cold comfort to many people in Lac Megantic who lost loved ones, these are the systemic changes that needed to happen to ensure public safety. Jailing those 3 MM&A employees would have accomplished nothing. As Don Berwick, American Health Care expert, said: "Every system is perfectly designed to produce the results it achieves". Let's spend more time examining our systems than pointing fingers.