Bow Tie Analysis of the Lac-Mégantic Rail Disaster
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Oil transportation by rail is one of the most important, yet dangerous means of transportation. The
analysis of transportation incidents is important to determine the faults in the system and the root
causes in order to prevent these incidents from recurring. Bow tie analysis is one of the methods
used to understand the events, consequences, barriers and mitigative controls of incidents, such as
the Lac-Mégantic Rail catastrophe. This disastrous incident occurred on July 6, 2013, and it
destroyed 50 vehicles, 40 buildings, the railway tracks at the west end of the Mégantic Yard and
tragically caused the death of 47 people. There was damage to the environment, 2000 people were
forced to evacuate, almost all 63 tank cars were destroyed and most of downtown Lac-Mégantic
was ruined. By studying relevant case reports, a bow tie diagram was created analyzing the root
causes of this incident. We believe that human factors, organizational safety culture, and
engineering-related factors were key contributors to the incident. The sequence of events was used
to determine underlying causes, possible preventative measures, and mitigative controls. The
analysis of the root causes and sequence of events is important for determining the causes of the
incident, understanding the underlying issues in the safety management system, and ensuring this
type of catastrophe cannot happen in the future.
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http://purl.org/coar/resource_type/c_6670
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en