Students of major disasters often talk of the concept of ‘disaster incubation’ – a period of cumulating failures on the part of operators and regulators which eventually overwhelm even-multilayered safety systems and lead to tragic outcomes.
No better term could be used to describe the emerging series of failures on the part of railway operators and their safety regulator, Transport Canada that led to the Lac Megantic disaster. Over the past five years there has been an enormous increase in the shipping of petroleum products on Canada’s railways, from 500 car loads in 2009 to a projected 130,000 car loads in 2013. Transport Canada failed to respond to this major change in the kinds of traffic moving over the railway system. Specifically it did not address well-known issues around the safety of the older tank cars being used to carry the bulk of the increased shipments. There were also more general long-term failures to ensure that adequate regulatory controls were in place to make sure that trains carrying dangerous goods were operated safely and parked securely.
The significance of these failures was particularly acute as North American railway operators engaged in cutthroat competition to cut costs and increase profits by any means possible, reducing staffing levels and safety margins in the process. This combination of circumstances made some form of major rail accident in Canada virtually inevitable. Lac-Megantic simply had the misfortune to be where disaster struck first, and in a way and location that caused the loss of 47 innocent lives.
The risk of disaster was far from unknown. There had been a number of near-misses involving trains carrying petroleum over the past few years. Transport Canada had ignored a succession of warnings from the Transportation Safety Board, Auditor-General of Canada, railway unions and safety advocates about declining safety standards and practices in the rail sector.
Transport Canada’s regulatory practices and models for the railway sector pre-date Harper Conservatives, but the current government did nothing to change their course and its budget cutting did much to reinforce their direction. Throughout the federal government there has been a growing emphasis on ‘partnerships’ with regulated entities. The progressively more standardized form of these partnerships in areas where the federal government is the primary safety regulatory, like food and drugs and rail, air and marine transportation, has been to focus on ‘safety management systems.’
Under this model, the federal government is less and less engaged in the direct oversight and first-hand field inspection of the operating practices of the regulated firms. Rather the emphasis is on the review of safety management plans developed by the regulated firms themselves. In effect, federal ‘inspectors’ are reviewing plans and paperwork from their desks in Ottawa, not actual equipment, operations and practices in the field. The approach has the advantage, from the perspective of a federal government focussed on austerity, of being cheaper, as it requires fewer inspectors. From the perspective of operators, it reduces day-to-day regulatory ‘interference’ and government ‘red tape.’
Viewed from a public safety perspective the model is much more problematic. It results in a dramatic reduction in regulators’ first-hand knowledge of what is actually happening among the firms whose practices they are supposed to be overseeing on behalf of the public. This invites serious risks that unsafe operating practices will not be identified and addressed until a major incident occurs. The food contamination episode at the XL Foods plant in Brooks, Alberta last summer and now the Lac-Megantic disaster two weeks ago, stand out as examples these problems.
Although Canada’s Transportation Safety Board has done excellent work in identifying the causes of previous, less serious rail accidents, and in investigating the immediate causes of the Lac-Meganitc accident, its mandate may be too narrow to address the wider questions about the federal government’s approach to public safety regulation raised by the disaster. In light of the already apparent succession of failures that incubated the tragedy, and the scale of the loss of life involved, a fuller judicial inquiry is needed to ensure that the causes of the disaster are fully understood, and that the measures needed to protect the safety of Canadians are taken throughout the federal government. In meantime Canadian governments needs to recognize that regulating on the cheap, or in ways that put the economic interests of the regulated firms ahead of the safety interests of the public, are recipes for further disaster.