The Transportation Safety Board's report into the deadly train derailment in Lac-Mégantic, Que., in 2013 is calling for additional safety measures to prevent runaway trains, as well as more thorough audits of safety management systems.

While the report said "no one individual, a single action or a single factor" caused the derailment, it left no doubt about problems with the train's owner — Montreal, Maine and Atlantic (MMA). 

"The TSB found MMA was a company with a weak safety culture that did not have a functioning safety management system to manage risks," the agency said.

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The core of Lac-Mégantic, Que., was devastated by the derailment and tanker car explosions in 2013. (CBC)

The report says railway rules require hand brakes alone to be capable of holding a train, yet air brakes were left on during the hand brake test the night of the disaster.

"Without enough force from hand brakes, the train began rolling forward downhill toward Lac-Mégantic, just over seven miles [about 11 km] away."

Among the problems identified at MMA were gaps in training, employee monitoring and maintenance practices.

The report also found that Transport Canada did not audit MMA often and thoroughly enough to ensure safety procedures were being followed.

Rail industry’s “laxity” unacceptable: Lac-Mégantic mayor

Lac-Mégantic Mayor Colette Roy Laroche said she hopes today’s findings will make rail transport safer.

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Lac-Mégantic Mayor Colette Roy Laroche says the safety culture in the rail industry needs to change. (CBC)

​ “The publication of today’s report won’t erase the horrors of the tragedy. I hope that all the elements of this report will bring us some peace but also help us to look forward to a safer future,” she said.

Roy Laroche called on the government to take swift action and instill tighter rules.

“We believe that the [government’s response] is not enough yet. We are calling for adequate regulations on the transportation of dangerous goods, including better supervision and monitoring, and a thorough review of safety measures so all residents of Lac-Mégantic and the region – and all Quebecers and Canadians – can feel safe.”

The TSB’s report highlighted that Transport Canada didn’t monitor the railway often and thoroughly enough -- something Roy Laroche said she’d like to see change immediately.

“We’re … asking for significant changes in the safety culture at Transport Canada and the rail industry. Both on the side of Transport Canada and the rail companies, we should enforce zero tolerance. The laxity we have noticed is unacceptable,” she said.

The rail line between Nantes and Lac-Mégantic – along which the train sped before derailing and exploding in the town’s downtown core last summer – is the steepest slope in Quebec and the second steepest in Canada.

Roy Laroche said lowering the speed limit is not the answer.

"Reducing speed – rather than repairing [the track] – shouldn’t be tolerated. That cannot be the only rule that will ensure our safety. Imagine if our roads were regulated the same way? It would be unacceptable,” the mayor of Lac-Mégantic said.

“We are spending millions to repair roads when a stretch of road is deemed dangerous. Why does it not apply to the railroads?”

Roy Laroche added she and other officials will be keeping a close eye on Transport Canada.

“There is an urgent need for action because rail transportation is still a reality.  It is necessary for our economy, but this economic need shouldn’t be to the detriment of people’s safety.”

18 factors contributed to disaster

In all, the TSB found 18 factors that contributed to the accident.

"Take any one of them out of the equation, and this accident might have not happened," said Jean Laporte, TSB chief operating officer.

Among the 18 factors is the finding that MMA did not effectively manage risk and it cut corners when it came to safety.

"This was a company with a weak safety culture, a company where people did what was needed to get the job done rather than always following the rules. A company where unsafe practices were allowed to continue," Wendy Tadros, chair of the TSB, told reporters.

While MMA had certain safety processes in place and had developed a safety management system in 2002, 
the company did not begin implementing it until 2010.

That program, however, did little to identify hazards and mitigate risks, the report says.

Transport Canada oversight lacking

MMA's many deficiencies were allowed to continue in part because Transport Canada did not audit the railway often enough and thoroughly enough to know if it was managing risks properly.

Accordingly, the report recommended that Transport Canada audit the safety management systems of railways in sufficient depth and frequency to confirm that the required safety management systems are effective and that corrective actions are implemented to improve safety.

Tadros warned that the federal agency's shortcomings when it comes to enforcing railway safety regulations are all the more worrisome in light of the increasing volume of oil being shipped by rail across Canada and the United States.

"Who was the guardian of public safety? That is the role of the government...and yet this booming industry where trains were shipping more and more oil across Canada and across the border ran largely unchecked," Tadros said.

Federal government responds

Lisa Raitt, Canada's minister of transport, said the federal government is taking the report seriously and working to implement all of the recommendations.

However, her response to the report focused mainly on the questions it raised about MMA's operations.

"The TSB report indicates that insufficient hand brakes were applied to the train and that the hand brakes were not tested appropriately. As you know, criminal charges have been laid by the Sûreté du Québec, and this is now before the courts," she said.

As to the report's criticism of Transport Canada, Raitt said she has asked her ministry to come up with concrete solutions to the issues and concerns raised.

"After that, we will look at implementation of the actions," she said.

Raitt also said Transport Canada has hired additional auditors and inspectors to ensure rail safety after an earlier report by Canada's auditor general into shortcomings at the agency.

Raitt would not say how many more auditors and inspectors have been hired since that report, but added that Transport Canada has the resources it needs to implement the recommendations.

NDP MP Hoang Mai, transport critic for the Official Opposition, said the government has to focus more on regulation instead of deregulation. 

"This report is really clear, and reminds us of the consequences of a hands-off approach to safety," he told reporters. 

He also questioned Raitt's claim that more auditors and inspectors have been hired, saying there were no extra funds outlined in the Conservative government's last budget.

"We need stronger regulations and more rigorous enforcement," he said.

Action needed 'immediately'

Peter Flowers, the lawyer for victims of the disaster and their families, said the report's recommendations need to be implemented without delay.

"You see how frequently crude oil is transported every day, and you know action is needed immediately," he told CBC News. 

Flowers said the problem "starts the minute oil is extracted from the ground," and risks run across the petroleum and transportation industries.

"Every player in this whole operation was negligent," he said.

Before the report's release, some Lac-Mégantic residents were already doubting that the report would satisfy people in the community who are still grieving, many of whom want to see Transport Canada found responsible.

Marilaine Savard, who helped create a Lac-Mégantic group for citizens, said there's a sense that the government is partly to blame for the disaster.

"We feel that these people are never going to admit their share of responsibility," she said. 

The aim of the TSB report is not to assign blame for the disaster. The agency’s mandate is to look for ways to prevent a similar accident.

Report follows earlier recommendations

In January, the TSB made urgent recommendations to revise the way materials such as crude oil are carried by rail, including tougher standards for the DOT-111 rail cars — the tankers involved in the Lac-Mégantic derailment— that are widely used in the oil-by-rail industry.

The recommendations were announced in response to "three critical weaknesses" the agency said it discovered in the rail system during its investigation.

Transport Canada has already made changes based on the TSB findings, including a new requirement that emergency response plans be prepared for all crude oil, gasoline, diesel, aviation fuel, and ethanol rail transportation. 

Transportation Safety Board recommendations