The 47 victims of last year’s train derailment in Lac-Megantic died "a violent death," the Quebec coroner concludes in his report on the disaster.

Dr. Martin Clavet's report issued Wednesday includes details about each victim: where they were found, who they were with, and the steps made to attempt to identify their remains. Many of the bodies could not be identified, as all that was left was bone and ash.

Clavet lists potential causes of death, including asphyxiation from the intense heat or the release of toxic gases, burns, or trauma.

The victims likely suffered "a quick death," Clavet concludes.

"It was a violent death," he writes, noting the deaths "could have been avoided."

The deadly crash occurred in the early morning hours of July 6, 2013, when a runaway Montreal, Maine and Atlantic Railway train hurtled into the Quebec town, where it derailed and caught fire, spilling six million litres of crude oil.

The explosions and subsequent fires left 47 people dead, destroyed more than a dozen buildings, and spurred tighter federal regulations for the rail transport of dangerous goods.

Clavet also outlines the circumstances from that night, which have been widely chronicled in previous reports, including from the Transportation Safety Board.

At 11:30 p.m. on July 5, the conductor leaves the train parked on a downward slope near the small town of Nantes with one motor running, which is powering the air brakes.

A fire breaks out shortly after. Firefighters that arrive on the scene shut the train's motor and put the fire out. They leave the scene at 12:45 a.m.

With the motor cut, the air brakes begin to lose pressure. Shortly before 1 a.m., the train begins rolling downhill toward Lac-Megantic, which is 11.5 km away. By the time it hits Lac-Megantic, the train is travelling at 105 km/hour.

Among the recommendation in his report, Clavet suggests Transport Canada:

  • revise its rules on how many hand brakes must be applied to immobilize a train according to its weight, the type of material it is carrying, and the slope on which it's parked;
  • ensures that no train transporting dangerous material be left unsupervised, until rail companies can put in place physical defences against runaway trains;
  • study the risks of larger trains and identify routes from which they should be excluded.

Clavet also recommends that Transport Quebec implement the relevant recommendations for rail transport in the province.

With files from CTV Montreal