MONTREAL — Blame a rule-breaking rail company, blame ineffective train inspectors, but don’t blame the federal government for the deadly Lac-Mégantic train disaster, says Federal Transport Minister Lisa Raitt.

In the wake of a scathing report into the July 2013 derailment that killed 47 people in the Quebec town, Raitt pointed the finger at three employees of the Montreal, Maine & Atlantic railway now charged with criminal negligence, and referred questions about lapses leading to the accident to bureaucrats under her command.

“We need to remember that in terms of safety, the government puts the rules in place. The companies are expected to follow the rules,” Raitt said in Ottawa. “The company did not follow the rules and that’s a very important fact here too.”

The Transportation Safety Board’s definitive account of the incident said the crash was caused by a marginal rail company that put profits before safety during more than a decade in business.

The TSB identified 18 distinct factors that led to the crash, including mechanical problems, unsuitable tank cars carrying crude oil, the cost-conscious rail firm and human error. If any of them had been avoided, the crash may have been averted.

The safety watchdog said an engine repair in October 2012 led to a locomotive fire on the night of July 5, 2013. After fire crews extinguished the blaze in Nantes, Que., about 10 km from Lac-Mégantic, they cut power to the unattended train’s lead locomotive, which caused the air brakes to bleed off.

The seven hand brakes applied earlier that night by the train’s engineer, Tom Harding, were not sufficient to prevent the 72-car train carrying highly flammable crude oil from rolling along a sloping track and into Lac-Mégantic, where it derailed and exploded.

But the TSB noted it was ultimately the federal government that allowed MMA to operate with minimal hindrance for more than a decade despite what was identified as “an elevated level of risk” caused by repeated issues over how it secured its trains, trained its employees and maintained its tracks.

Transport Canada’s regional office in Quebec never undertook a safety audit of the company until 2010 and those in Ottawa charged with supervising the regional office did not intervene because they were largely in the dark about any oversight weaknesses with its Quebec rail inspectors.

“Who then was in a position to check on this company, to make sure safety standards were being met? Who was the guardian of public safety?” asked TSB chair Wendy Tadros.

“That is the role of the government, to provide checks, balances and oversight. And yet this booming industry where unit trains were shipping more and more oil across Canada and across the border ran largely unchecked.”

Lac-Mégantic Mayor Colette Roy-Laroche said the release of the long-awaited report won’t erase what happened last summer, but she hopes it will bring her town some peace of mind and lead to a greater level of rail safety.

“It’s what I wish for the families, but also for all the residents who have seen their lives transformed and lost their bearings since the tragedy,” she said.

In the nearly 14 months since the incident that demolished 32 buildings and so many families in the town of 6,000 people there have been a number of changes to the rules around rail transport.

They include mandatory two-person crews on trains carrying dangerous goods, more stringent rules around how unattended trains are secured and parked, and a 2017 phase-out of older, weaker models of the DOT-111 tanker cars whose steel hulls are vulnerable in a derailment.

The TSB added to those rule changes two more recommendations in its report:

That Transport Canada force rail companies to use additional physical defences to prevent runaway trains;

That Transport Canada take a more aggressive approach to ensuring railways follow the safety plans they are mandated by law to put in place — “making sure not just that they exist, but that they are working and that they are effective,” Tadros said.

To do that, there will have to be a vast cultural change within Transport Canada, said Brian Stevens, who represents some 9,000 workers in the railway sector for the Unifor union.

Bureaucrats used to shuffling papers at desks and attending meetings in board rooms should be shifted into the field, he said.

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“That’s what we do with our highways. We have inspectors who run around pulling over trucks and having blitzes. Most of the truck drivers are safe, most of the operators are safe, but there’s some out there that aren’t,” he said.

Stevens, a vocal advocate for greater safety since the Lac-Mégantic disaster, said he was disappointed in the TSB recommendations that, he said, appeared deferential to the rail industry’s desire to avoid the delays and lost revenues that would be involved in a complete shut-down each time a train is left unattended, or require any train to be parked in a secure rail yard when not in use.

“Since Lac-Mégantic we’ve had 10 runaways in this country. Thankfully, they’re not of the magnitude of Lac-Mégantic, but they’re continuing to happen,” he said.

Raitt insisted Tuesday that the inspection and disciplinary regime for errant rail firms has been beefed up in recent years, particularly for trains carrying dangerous goods. A spokesperson Raitt said there are 110 rail inspectors working across the country, which is up 10 percent from 2013.

But with 46,000 km of track in the country Raitt said it is impossible and unrealistic to have “continuous oversight” of rail company operations. Instead, she emphasized the need for companies to work in lockstep with her department so that “whether you be an executive or you be a train conductor, everybody is thinking of safety at all times.”

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