Human, Equipment Error/Failure/Courage

"I was sure it was going to crash. Nobody has ever seen a train come into town so fast. No lights, nothing, just the noise it made."
Patrick Madore, resident of Lac Megantic

"It was like a horror movie."
Joelle Madore

Workers search for victims through rubble in Lac-Megantic, Que., Sunday, July 14, 2013.

Engineer Tom Harding without a doubt was a professional, he knew what he was doing, what he was supposed to do, to secure a 72-car train with a load of crude oil for the night, on the Montreal, Maine & Atlantic Railway's main track at Nantes, a dozen kilometres from Lac Megantic on July 5. He arrived at his destination and the termination of his twelve-hour stint at 11:00 p.m. He set about to "tie down" the train with its 10,000-tonne load.

It is estimated that at some time between 11:15 and 11:30, the taxi arrived to pick him up and drive him to l'Eau Berge, a downtown inn in Lac Megantic; a familiar procedure, one that took place weekly. Fifteen minutes to a half hour -- all that it takes to apply the lead (out of five) locomotive's air brakes, and then go down the line of cars to manually secure another dozen hand brakes which Mr. Harding assured he had done.

A vital but routine measure to ensure that a train parked on an incline on main tracks that, unlike the side track that was already occupied by another freight train, had no restraining device built in to stop a runaway train. To set handbrakes, ladders at the back of each car have to be climbed, and the wheel turned for the brake to be set. Setting the manual brakes on a dozen trains, yes, a routine procedure, taking fifteen minutes to a half-hour?

The length the engineer would have to walk would be roughly a kilometre, then clamber onto the back ladder of each car, turn the wheel securely to ensure the brake was manually locked, then walk back down the line of cars to the point where the taxi would be waiting. Quick work. The taxi driver mentioned he thought it was odd that there were oil droplets in the black smoke from the locomotive left running.

Nothing unusual, said Mr. Harding, and off they drove. A few minutes later an alert was sounded when a fire caused by a broken fuel or oil line required the Nantes volunteer fire department to respond and routinely shut down the lead locomotive, and put out the fire. A Surete du Quebec officer and an MMA employee were on the scene when the firemen left, and at 12:56 the train began rolling with no one to witness it.

Andre Gendron whose trailer is located near the Nantes railyard heard the unmistakable vibration of a moving train after the firetrucks left. "I found it strange its lights weren't on and thought it was an electrical problem on board", he explained. The locomotive crossed the track at the centre of town, and the buffer boxcar jumped the tracks, the tank cars following, because of the excessive speed of the runaway train, at a curve in the track.

Mr. Harding the train engineer, preparing for a restful night after his long shift, heard the explosion. He responded by borrowing a firefighter's suit and began to decouple nine tank cars from the end of the train before they could be consumed by the fire. A railcar mover was brought on the scene by Tafisa Canada particleboard factory workers to pull the cars back and away, out of danger.

A Transportation Safety Board report related to another, earlier incident in 2011 wrote that poor maintenance, like a lack of lubrication or an improper adjustment of components, can result in the handbrakes not properly engaging. That could happen, even if the operator is under the impression he has done everything properly.