Read the complete report on the Transportation Safety Board website.

  There are more than thirty links failing at the Transportation Safety Board. They have not repaired them even though twice advised of the failures - 5 Feb 2020.

  All thirty or so links have now been repaired - 6 Feb 2020.

Download the .pdf file here.

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Ottawa Ontario - Investigators on Tuesday blamed one of Canada's worst rail disasters that killed 47 people in Lake Megantic last year on the railway's poor safety standards and a lack of regulatory oversight.
 
In a 191-page report, Canada's Transportation Safety Board (TSB) listed 18 causes and contributing factors in the crash, including improper brake tests, a highly flammable cargo in substandard tanker cars, and a curve in the tracks at the bottom of a slope.
 
"Take any one of them out of the equation and this accident may not have happened," TSB chair Wendy Tadros told a news conference.
 
She levelled the strongest criticisms at the shortline Montreal Maine & Atlantic (MMA) railway for "cutting corners" on maintenance and employee training, and on the government for ignoring safety concerns.
 
"This was a company with a weak safety culture," Tadros said.
 
"A company where people did what was needed to get the job done, rather than always following the rules."
 
She described a "booming industry" running "largely unchecked" that saw rail shipments of oil increase dramatically in recent years, from 500 in 2009 to 160,000 last year.
 
"Transport Canada knew about some of the problems at MMA but the follow-up was not always there," Tadros added.
 
The 72-car train carrying 7.7 million liters of crude oil from the US state of North Dakota to a refinery in easternmost Canada derailed in the early morning hours of 6 Jul 2013.
 
It came loose in the middle of the night, rolled downhill unmanned, and derailed in the center of Lake Megantic.
 
Several tanker cars exploded, unleashing an inferno that gutted 2.5 square kilometers of the picturesque lakeside town of 6,000 residents, about 250 kilometers east of Montreal.
 
Firefighters needed two days to put out the raging blaze which also destroyed 40 buildings and 53 vehicles.
 
Seven of the dead were never identified.
 
Three railway workers, including the driver, who was not at the helm at the time of the accident and stands accused of failing to apply the brakes on several cars, have been charged with criminal negligence causing death.
 
Hand brakes alone should have been enough to keep the train halted, but air brakes were wrongly left on during testing.
 
Editor's Note:  "wrongly left on", that's a confusing statement.
 
Firefighters responding to a small locomotive fire later that night shut off power to the locomotive, inadvertantly causing the air brakes to gradually lose pressure.
 
Left unattended overnight, the train started to roll downhill, reaching a top speed of 105 kilometers per hour.
 
The train's owner, American firm MMA declared bankruptcy after the accident, saying it could not face the huge cost of the cleanup or damage payments to victims.
 
Canadian authorities, meanwhile, have announced tougher rail safety rules, including the phasing out or retrofitting of substandard tanker cars used to transport flammable liquids.
 
The Transportation Safety Board urged additional measures so that "trains will always remain secure" and for Transport Canada to beef up its oversight.

Michel Comte.