Bold decisions needed
Safety expert Najmedin Meshkati on why hauling oil is different from hauling potatoes,
At time of writing, last week’s tragic train derailment and fire in Quebec has killed 38 thus far (with another 12 missing) and devastated the centre of picturesque LacMégantic. However, what has added insult to injury is the apparently defiant demeanour and deflective responses of Edward A. Burkhardt, the chief executive and majority owner of Rail World Inc., whose runaway Montreal, Maine and Atlantic Railway (MM&A) train of oil-tanker cars caused this accident.
Mr. Burkhardt initially attributed this tragedy to “tampering” with the train, then to the “engineer who parked the train,” then to volunteer firefighters — i.e., blaming the “front-line” operators. While doing so, he tried to distance himself and his railroad from this calamity, which is not only woefully disappointing, but also utterly unacceptable.
Drawing on my research and teaching over the past 25 years on complex technological systems’ reliability and transportation safety at the University of Southern California, and my studies of major recent light-rail and train accidents in the United States, such as the Washington Metropolitan Area Transit Authority (WMATA) deadly accident in June 2009, I would like to share the following observations that may have important implications in this context for our Canadian neighbours.
Major anthropogenic accidents are mostly caused by a multitude of factors that compromise barriers to the loss of control or breach defences for safe functioning of intended systems. On many occasions, “human error” is caused by inadequate operators’ response to unfamiliar events. These responses depend very much on the conditioning that takes place during normal work activities. The operators ’ behaviour is conditioned by the conscious decisions made by work planners or managers. Therefore, the error and the resulting accidents are, to a large extent, both the attribute and the effect of a multitude of factors. These include: poor workstation and workplace designs, unbalanced workload, complicated operational processes, unsafe conditions, faulty maintenance, disproportionate attention to production, ineffective training, non-responsive managerial systems, and poor planning. As such, it is a gross oversimplification to attribute accidents to the actions of front-line operators.
The safety culture goes beyond specific rules and rote adherence to standard operating procedures in any organization. In other words, creating safety culture means instilling attitudes and practices in individuals and organizations that ensure safety concerns are proactively addressed and treated as high priority. An organization fostering strong safety culture encourages employees to cultivate a questioning attitude, a prudent approach to all aspects of their jobs, and creates open communication between line workers and management.
In her bold speech, Walking the Walk of Railroad Safety, the impressive chairwoman of our National Transportation Safety Board (NTSB), Deborah A.P. Hersman, reviewed recent major U.S. rail accidents that her agency investigated, including the aforementioned WMATA crash, and said: “When we dug deeper, we found that the transit authority wasn’t minding the store. In our probable cause, we cited the lack of a safety culture — from the top down … You can fix track and alarms, but building a culture of trust and respect doesn’t happen overnight. It takes time. Management must be committed, and employees must be willing.” She concluded, “Yes, when a company has a strong safety culture it manages and values safety just as it manages and values other vital business functions.”
According to the New York Times, MM&A’s “primary business had once been shipping potatoes … The rail business was not great, but the Bakken oilfields in North Dakota changed all that. Just over a year ago, Irving Oil contracted with the MM& A to carry Bakken crude to its refinery in Saint John, N.B. That deal revived the railway … Mr. Burkhardt’s MM&A took it from there.” This small regional railroad hauled potatoes — a harmless material — as cargo. Potato spills would not harm anyone; its damage could be limited and localized, and there is no secondary effect (i.e., fire, heat, force of explosion, and resulting toxic vapour cloud) from such an accident.
The freight train industry will continue to grow, and with it will come the transportation of even more hazardous material. Thus, the Canadian rail safety regulatory agency should come up with a series of bold decisions and take lessons from other countries. The MM&A and other railroads that carry hazardous material should embark on a systematic study of their safety cultures. This industry should also foster an effective safety philosophy through principles of human factors, systems safety and continuous measurement through leading indicators.
Despite the high death toll and devastation of downtown Lac-Mégantic, I believe Canada was lucky because very few tanker cars (four out of 72, each carrying 30,000 gallons of crude oil) caught fire and exploded. We in the U.S. and Canada should always remember what Nobel Prize-winning physicist Richard Feynman said regarding the risk-taking mindset and poor safety culture which led to the Space Shuttle Challenger explosion and technological system failure in 1986, “When playing Russian roulette, the fact that the first shot got off safely is little comfort for the next.”