Ottawa Ontario - After last week's acquittal of three men charged with criminal negligence causing the death of 47 in the Lake Megantic rail disaster, some argued the wrong people were on trial.
Certainly, many questions remain about rail safety and accountability, but the answers might lie more with organizational culture than poor judgment of a few individuals.
In the aftermath of the 2013 derailment, Transport Canada (TC) and the Transportation Safety Board (TSB) pointed to Montreal Maine & Atlantic Railway's (MMA) weak safety management as a key cause of the accident.
Following privatization of rail more than 20 years ago, rail regulators have emphasized that each rail company have a strong safety management system in place.
In the academic community, we refer to organizations with such a system as High Reliability Organizations (HRO).
HROs include a culture that learns from mistakes, creates redundancies, and commits itself to transparency.
For a high-risk sector like rail, HRO is the Holy Grail.
Like the Holy Grail, however, no one has ever seen it, and some doubt its very existence.
Critics argue that an HRO is unachievable because accidents are inevitable in complex systems, and safety is only one of a number of competing objectives.
After Lake Megantic, then minister of Transport Lisa Raitt noted rules were in place, but were not being followed.
Collecting information about safety, and creating new standards are comparatively easy in risk regulation, changing the behaviour of those responsible for safety is more expensive, intrusive, and protracted.
In an HRO, the focus is the team, everyone is responsible for ensuring the safety of the organization, no matter where you are in the org chart, transparency is key.
There are, however, strong market and bureaucratic cultures at play that constrain safety culture.
Privatization incentivizes cost-cutting measures.
Prior to Lake Megantic, MMA cut its costs by opting for one-person crews, contrary to the concept of redundancy.
A market orientation is also concerned about over-regulation.
The Railway Association of Canada lobbied public office holders 16 times in the three months following the train disaster, the highest for any three month period between 2010 and 2015.
These market pressures will persist.
Addressing market failures is the principal role of government.
TC is bureaucratic.
Bureaucracies are upwardly accountable, but not outwardly so.
We know almost nothing, for example, about how senior officials were held to account for their failure to enforce rail safety in Quebec, and regarding MMA in particular, which was known to have a poor safety system in the years prior to the derailment.
In a powerful paradox, 25 organizations, including TC, contributed about $450 million to an out-of-court settlement fund for the victims in Lake Megantic, yet accepted no responsibility for the disaster.
We have also learned that many freedom of information requests about rail safety made by the CBC and concerned citizens were denied by TC on the grounds they would violate the financial and commercial interests of the enterprises involved.
Perhaps more importantly, it is hard to see what institutional changes have occurred that would create a culture change.
The department responded in the manner that bureaucracies do, documentation, new standards, auditors, notices, and penalties.
This reinforces a bureaucratic culture, it does not change it.
There is little evidence of a culture change that would increase accountability.
Four and half years after the derailment in Lake Megantic, the transportation of flammable liquids by rail remains on the TSB's Watchlist of principle concerns for the industry.
Increased transparency is crucial for a safety culture, it leads to learning and can support a just process when failures occur.
TC expects an openness that it cannot provide itself, undermining its credibility, and laying bare the inevitable organizational tensions that limit safety practices.