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Updated: Tue, 19 Aug 2014 11:48:47 GMT | By CBC News, cbc.ca

Lac-Mégantic: TSB says no one factor to blame

The TSB report will focus on possible human error, the tankers and the brake system used on the train that derailed in Lac-Mégantic in July 2013. Sûreté du Québec

The TSB report will focus on possible human error, the tankers and the brake system used on the train that derailed in Lac-Mégantic in July 2013. Sûreté du Québec

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.

The report 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 in a release.

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.

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.

MMA also did not consistently comply with a Transport Canada requirement that has each railway determine the methods for training and requalification of employees every three years. 

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.

However, Tadros warned that the federal agency's ability to accomplish this task is being made difficult by 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 boarder ran largely unchecked," Tadros said.

But some residents of Lac-Mégantic say they’re not sure the answers in the report will 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.

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.

The TSB report is expected to focus on possible human error, the tankers that were transporting the volatile crude oil and the brake system used on the train. 


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