A “weak safety culture” at the company that owned the train contributed to the derailment in Lac-Megantic, Quebec, that killed 47 people, the Transportation Safety Board said as it made two more recommendations to improve rail safety in Canada.

Some 18 different factors contributed to the crash, according to TSB chair Wendy Tadros. Take any of them away, she said, and the deadly accident may never have happened.

The chain of causes and contributing factors goes far beyond the actions of any single person, Tadros said. However, she took aim at the train’s owner: Montreal, Maine and Atlantic Railway.

“The context starts with MMA, a short line railway running its operations at the margins, choosing to lower the track speeds rather than investing more in infrastructure, cutting corners on engine maintenance, and training and then relying on employees to follow the rules,” Tadros said in comments Tuesday morning, as the TSB issued its final report into the crash.

According to the TSB, Transport Canada must:

  • Require railways to put in place are more “physical defences” to keep rail cars secure and prevent runaway trains, including wheel chocks
  • Conduct frequent, in-depth audits of all railways’ safety management systems

Transport Minister Lisa Raitt said department officials have the TSB report, which they will review before issuing recommendations for changes to Canada’s railway safety system.

“I’ve asked that they turn it around quickly,” Raitt told reporters early Tuesday afternoon.

The derailment, subsequent explosions, and fire were the result of factors that included “a weak safety culture” at MMA, Tadros said. The company did not have a sufficient safety management system in place and so was unprepared to manage known risks, or identify and address new concerns.

Poor quality rail cars and a weak safety auditing system that failed to catch how MMA was managing, “or not managing,” the risks are also to blame, Tadros said.

The two recommendations come in addition to three that the agency issued in January. At that time, the TSB called for more stringent regulations for the DOT-111 cars that were involved in the crash. The agency also called on railways to conduct route planning and analysis, and prepare emergency response plans when transporting liquid hydrocarbons.

All five recommendations “will move Canada’s railways towards a safer future,” Tadros said. “Because the goal is simple. We must do whatever we can to make sure the events of that night, the events that devastated a town and left 47 people dead, never happen again.”

The TSB launched its investigation after the crash which occurred in the early morning hours of July 6, 2013. That’s when the train carrying more than 7.7 million litres of crude oil was left for the night about 7 kilometres outside Lac-Megantic, having been secured with a combination of hand and air brakes.

A drop in air pressure left the brakes unable to hold the train, which began to roll toward the town. The train left the tracks, caught on fire and began spilling some 6 million litres of oil into Lac-Megantic’s streets. The ensuing blaze and explosions killed 47 people, and left much of the community’s downtown area destroyed.

MMA filed for bankruptcy protection and was sold in January.

In May, the railway company and three of its employees -- engineer Thomas Harding, railway traffic controller Richard Labrie, and manager of train operations Jean Demaitre -- were charged in Quebec with 47 counts of criminal negligence causing death.

In his comments Tuesday, Harding’s lawyer Tom Walsh said the board did “a very good job” on the report.

"They have isolated the 18 factors that contributed to this tragedy," he said in an interview with The Canadian Press. "They made it very clear that this is not a hand brake problem and it's not a problem with just one person. It's a systemic problem that's been going on for years and years and years."

Walsh said he hopes the report plays a factor in the case.

"I'd like the Crown to take a look at that report and wonder if it did the right thing by accusing these three people.”

The accident “prompted strong action” by both Transport Canada and the railways, Tadros said. Weeks after the crash, the federal agency issued new guidelines, requiring that at least two crew members work on trains carrying dangerous goods. As well, locomotives attached to one or more cars carrying dangerous goods can no longer be left unattended.

Earlier this year, Transport Canada also said, over the next few years, it will phase out the DOT-111 cars involved in the crash.

In a statement, Green party Leader Elizabeth May called for a public enquiry into rail safety in Canada.

"We need to bring in a system that can stop or slow a train before certain accidents occur, such as positive train control technology, which is currently being implemented in the U.S.," May said. "A full public inquiry is needed to demonstrate the weak safety culture that exists in Canada today at the expense of Canadians."

With files from The Canadian Press