WATCH: We’ve finally learned just how lax safety measures at the railway were, when a runaway train loaded with crude oil exploded in Lac-Megantic. Mike Armstrong reports.

OTTAWA — Eighteen factors led to the shocking and tragic Lac-Megantic disaster, including poor training, mechanical problems and sloppy safety oversight, a Transportation Safety Board (TSB) investigation concluded.

Read the full TSB report here

“All of these factors taken together contributed to the accident,” TSB chief operating officer Jean Laporte said in Lac-Megantic, Que. Tuesday. “If you take any one away, this accident might not have happened that evening.”

WATCH: TSB recreation of Lac-Mégantic train derailment



READ MORE: Public inquiry only way to get to bottom of Lac-Megantic disaster

The findings of the investigation led the independent body to issue two recommendations to Transport Canada: improved monitoring of railways’ safety systems and increased assurance parked trains will never move.

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It was the middle of the night during the first week of July last year when a runaway train carrying 7.7 million litres of crude oil came barrelling into the heart of Lac-Megantic, Que. The sole engineer had left for some rest when the locomotive’s brakes gave out. The tank cars plowed toward the town at speeds reaching more than 104 kilometres per hour. The cars derailed and exploded, killing 47 people, destroying the downtown area and contaminating waterways.

People in the community continue to suffer from the effects of the disaster. Many are being treated for post-traumatic stress disorder as others reconstruct the heart of the town.

WATCH: TSB makes recommendations in Lac-Megantic report

A known danger on Canada’s rails

Hesitant to point the blame for the unprecedented accident squarely in one direction, TSB investigators spread it between Transport Canada for weak leadership and oversight, and the company operating the train, Montreal, Maine & Atlantic Railway (MM&A) for its ongoing dangerous practices.

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Often during these sorts of investigations, TSB focuses solely on facts. But in this case, the context was equally important, TSB chair Wendy Tadros said after releasing the final report.

“The context starts with MM&A, a short-line railway running its operations at the margins,” she said slowly, reading from a prepared statement. “Choosing to lower the track speeds rather than invest more in infrastructure. Cutting corners on engine maintenance and training. And then relying on employees to follow the rules.”

READ MORE: Feds stressed fatigue, workload concerns just before Lac-Megantic disaster

MM&A, now defunct and sold, was a company with a “weak safety culture,” Tadros said. Rather than following rules, people there would sometimes do no more than the minimum necessary to get the job done, she continued.

“For several years, Transport Canada’s regional office in Quebec has identified MM&A as a company with an elevated level of risk that required more frequent inspections,” the report reads. And although the railway normally addressed the problems, the same ones would often pop up on subsequent inspections, according to the report.

Below: Federal government reacts to the Lac-Megantic report.



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Lack of government oversight and action

The problems were exacerbated by the fact the office in Quebec did not always follow up to ensure the underlying problems and issues were fixed.

The question many want answered is why a company with unsafe conditions and practices — poor employee training, risky tank cars and an eye for productivity rather than safety — were allowed to continued.

Transport Minister Lisa Raitt, a half-hour late delivering her response, said she hadn’t yet read the report, but passed it on to her top bureaucrats who are expected to develop “concrete actions.”

“Following this tragedy, our government took decisive action to ensure the safety and integrity of Canada’s rail system,” she said. “We are in the process of implementing each and every recommendation that [TSB] has made.”

Throughout her media availability, however, she skirted questions about any direct role the government may have had in allowing MM&A to continue operating in Canada despite its known safety failings.

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Incomplete pictures of risks to public safety

The TSB report points the finger at Transport Canada for not auditing railways’ safety management systems often or thoroughly enough.

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The result, according to the report, was an incomplete picture of how — or whether — railway companies were mitigating public safety risks.

The disaster has also resulted in numerous charges. MM&A and three of its employees are facing 47 charges of criminal negligence causing death filed by Quebec prosecutors.

Shortly after the accident — long before its investigation was complete — TSB made recommendations for urgent changes to rail safety regulations.

Transport Canada heeded the call and issued a directive two weeks after the accident: two crew members would now be required aboard trains transporting dangerous goods, and trains with even one tank car carrying dangerous goods could never be left unattended on a main track, as was the case in Lac-Megantic.

The federal government also pledged in April to pull certain tank cars off Canada’s rials. Known to pierce easily long before last July’s tragedy, the government moved to prohibit, by 2017, the use of old Dot-111s for transporting dangerous goods unless they are one of the few made to current design standards.

The Transportation Safety Board, however, has warned even those tankers may not be safe enough to transport volatile substances such as crude oil.

It could happen again

Still, there are presently risk factors that could lead to another Lac-Megantic, the TSB’s Laporte said.

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To that end, TSB on Tuesday issued two more recommendations: Transport Canada will have to offer better monitoring of companies’ safety management systems. It is not enough for a company merely to have a system down on paper, TBS said — they must be reliable and effective.

Complex systems require more than relying on employees to follow rules, for even the hardest working and most well-intentioned person can make mistakes, Laporte said.

Secondly, TSB recommended the industry “go back to the basic principle” of ensuring trains can’t move when they are not supposed to. To that effect, Transport Canada must demand “additional physical defences,” the report read.

Brake issues were determined to have played a significant role in the accident.

“The seven hand brakes that were applied to secure the train were insufficient to hold the train without the additional braking force provided by the locomotive’s independent brakes,” the TSB said.

New Democrat transport critic Hoang Mai said the investigation findings point to a symptom of the government’s move to deregulate the industry.

“Conservatives have left companies to monitor themselves. It is an approach that ended in tragedy,” he said. “It’s time for the government to implement more rigorous oversight to prevent accidents like Lac-Megantic from happening again.

TBS officials are not blind to the limitations of their report.

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“For the people of Lac-Megantic, today’s report won’t do anything to bring back their loved ones or to rebuild their town,” Tadros said. “We know that. We do. But we can point the way toward a better future, a safer future. One where the trains that travel through our cities and through our towns are no longer feared.”

Further reaction to the report:

Federation of Canadian Municipalities president Brad Woodside:

“The recommendations announced today by the Transportation Safety Board are critical to improving the safety of Canada’s rail system and the movement of dangerous goods by rail through our cities and communities.

We expect the federal government to respond fully to today’s report and recommendations, to ensure an event like this never happens again.

FCM and the National Municipal Working Group on Rail Safety will provide input directly to Transport Canada on the TSB’s recommendations, and we look forward to continue working together to keep our railways and the communities that surround them safe.”

Greenpeace Canada researcher Keith Stewart:

“This report is a searing indictment of Transport Canada’s failure to protect the public from a company that they knew was cutting corners on safety despite the fact it was carrying increasing amounts of hazardous cargo. This lax approach to safety has allowed the unsafe transport of oil by rail to continue to grow even after the Lac Megantic disaster. It is time for the federal government to finally put community safety ahead of oil and rail company profits or we will see more tragedies.”

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– With files from The Canadian Press