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An overall view of where a train carrying crude oil derailed in the town of Lac Megantic, Quebec, July 6, 2013.Christinne Muschi/The Globe and Mail

When Don Ross drove his rental car down the steep road toward Lac-Mégantic, the first thing he noticed was the thick blanket of smoke that had gathered just above the small Quebec town.

Nearly 20 hours had passed since residents were awakened by a sudden metallic screech and the wail of fire trucks rushing downtown. The runaway train that had slammed into the centre of town that night sent a flood of burning oil through the streets, incinerating buildings and forcing some 2,000 people from their homes.

Mr. Ross, a veteran railway investigator who'd travelled from Cape Breton, N.S., turned his car into the parking lot of Le Quiet, a motel on the edge of town that would soon become the Transportation Safety Board's temporary headquarters. By the time he arrived, estimates of the missing were running upward of 100, as panicked relatives reported the names of people they hadn't yet heard from. The scene was unlike anything Mr. Ross had experienced.

"You've got a burning town in front of you and you've got that mountain of steel and there could be as many as 100 dead right here in front of you," he later recalled. "It was very sobering. It just affected everybody. The enormity of it was unprecedented."

Forty-seven people were killed in the July 6, 2013, disaster, after a train carrying light crude oil from North Dakota got loose and careered into Lac-Mégantic.

Mr. Ross, the TSB's lead investigator for the crash, and two of his colleagues spoke with The Globe and Mail about what it was like to work in the community and how the agency tackled the sprawling 13-month investigation. The TSB issued its final report in August, 2014, calling for better rules on securing parked trains and tougher oversight by Transport Canada. The report, while not meant to cast blame, uncovered systemic problems with the government's regulation of railways and its failure to address safety issues at Montreal Maine and Atlantic Railway Inc., the railway responsible for the train. Among the largest and most complex in the agency's history, the investigation laid the groundwork for better crude-by-rail safety standards and prompted regulators to develop new rules for a burgeoning industry.

Those conclusions, however, were a long way off as Mr. Ross settled into his motel room on that first night. Peering through the window, he felt the disaster start to weigh on him. "Through that picture window you can see the orange glow, you know, burning there," he said. "And your mind's racing and your heart's racing. And, you know, you're thinking, 'I've got to figure this out.'"

Constructing a timeline

One of the first priorities for TSB investigators is gaining access to what they call "perishable information" – any evidence that could be ruined or compromised over time, whether by heavy rainfall or faulty memory.

In the case of a derailment, investigators are usually thinking of a few key items, such as locomotive event recorders – which are like the black boxes on airplanes – along with another unit at the end of the train that stores data, and signs of heat damage on the brakes. Often, preserving that information means getting a photographer on-site as soon as possible, retrieving recorded data and lining up interviews with everyone involved, from first responders to employees from the company responsible for the train.

"You want to get as much information as you can," said Nathalie Lepage, a TSB investigator who estimates she conducted between 10 and 15 interviews in the week after the accident. "Sometimes, it's repetition – the person you saw right before is telling you exactly the same thing. But you know what? There might be one thing that's new, and you need it."

As information about the crash trickled in, Mr. Ross assigned teams of investigators to pursue different angles of the accident. Glen Pilon, a long-time railroader with extensive industry knowledge, led a team that looked at how the train was operated. Others focused on the role of federal regulations, examined tank-car performance and studied the properties of the crude oil the train had been hauling.

The big picture was all too apparent. "The train had been parked on a hill," Mr. Ross said. "The train ran down a hill. So [there was] no mystery there. … We had a train in front of us, we knew where it started [and] we knew where it ended."

But the details were more complex. What had caused the train to get loose from its brakes? Why had it been left on the main track instead of the siding, where a derailer could have prevented it from sliding downhill? And, perhaps most puzzling of all: How did the crude oil on the train – normally thought of as difficult to light on fire – cause the kind of violent explosions it did?

Investigators met twice daily in Mr. Pilon's motel room to take stock of what they were learning and begin to construct a timeline of the events leading up to the accident. They used Post-it notes and an empty wall. As new details were uncovered, more notes were added.

"Every time we'd find out something, [the timeline] would grow at either end, or you'd need to add space in the middle," Mr. Pilon said. "It kind of puts logic to what you're doing. This happened, then you have to explore why did it happen."

The timeline helped highlight what the TSB refers to as "safety significant events" – possible causes of or contributors to what happened – allowing them to drill down further to determine what role each one might have played in the derailment.

Saying 'merci'

Early that first week, Mr. Ross walked up the line of smashed tank cars, getting as close as he could to the centre of the crash without treading into the pool of water and fuel that had formed on the ground.

"You're looking for physical signs," he said of that visit. "What's the damage to that equipment telling you? What's upright and what's not, what's on the side, which one was sliding [and] which one wasn't, which one banged into the one ahead of it, which one rolled first or second?"

Investigators wanted to understand how the train's braking system had performed. Early reports – later confirmed by the TSB – suggested that too few handbrakes had been set before the engineer left the train parked at the top of a hill in Nantes. Several clues can help determine whether the handbrakes on a train were applied, Mr. Ross said. Those include signs of wear on the brake shoes, which push against the wheels when the brakes are applied, and a "blueing" of the wheels caused by frictional heat.

Within weeks, the TSB issued an advisory calling on regulators to review the rules for securing parked trains. Investigators discovered that the runaway train had been held in place by a combination of handbrakes and air brakes. When the air brakes failed, the handbrakes weren't sufficient to keep it from slipping downhill.

They also raised questions about where the train had been left. Montreal Maine and Atlantic's standard procedure was to leave trains containing crude oil sitting on the main track, investigators found, rather than parking them on a siding where they would be more secure.

During the weeks that followed, Mr. Ross got to know the servers in the Lac-Mégantic restaurants and found he was increasingly recognized around town. In late July, he attended a commemoration service for those who had been killed, standing on the sidewalk as bereaved family members walked by, each clutching a flower.

"I think every family that walked by me, either they made eye contact with me and said 'Merci,' or I can't tell you how many of them walked right over to me to thank me," Mr. Ross said. "And you know, knowing what they were going through would bring tears to your eyes. It was really emotional; it was touching."

Misclassified crude

Over time, the sticky notes on the motel wall were entered into a computer database, and investigators filtered back to headquarters in Ottawa and Gatineau to continue their analysis.

Some turned their focus to the content of the crude oil on the train. The team had watched videos of the fire that were posted online, aired on television news and handed over to them by local residents. They had also collected samples of their own for testing, from the train that had crashed and from another that was behind it, and arranged a visit to the production site in North Dakota.

"It wasn't so much the fire, but the explosions," Mr. Ross said. "Any type of petroleum crude oil, once on fire, can really burn violently. So the enormity of the fire wasn't as surprising as just the report of the explosions."

By September, 2013, the TSB was ready to comment publicly on what they'd discovered about the oil. Investigators found that the crude had been misclassified, playing down how hazardous it really was. Oil from the Bakken formation is now widely understood to be more volatile than traditional crude, so much so that producers in North Dakota must now take additional precautions before they transport it.

Several months later, after a series of fiery derailments in the United States and New Brunswick, the TSB issued a call for tougher standards for the tank cars used to move crude oil, better route planning and analysis and a requirement that emergency response plans be in place for large crude-oil shipments.

Far-reaching legacy

The agency's final, 191-page report on the disaster was released in August, 2014, just more than a year after the disaster. The findings detail a patchwork of failures, from weak government regulation and the company's lax safety record to individual human error in setting the train's brakes.

It said the train had been parked on the main track and only a small number of handbrakes had been engaged – too few to hold it in place on their own. When a fire broke out on the locomotive, firefighters who came to extinguish it in the middle of the night turned off the engine, causing the air brakes to gradually lose pressure and leaving it to rely on the handbrakes alone.

The train drifted downhill, picking up speed until it was moving at more than 115 kilometres an hour. When it reached a sharp turn in the tracks, at the base of the hill, 63 tank cars full of crude oil derailed. The locomotives, which were heaviest, came to a stop more than a kilometre away. The tank cars full of oil crumpled together like an accordion.

Over the past two years, Transport Canada has brought in a series of new regulations in response to the tragedy and the TSB's recommendations, including speed restrictions for trains carrying dangerous goods through urban areas and the requirement that companies develop detailed emergency response plans. Earlier this year, regulators in Ottawa and Washington announced that older-model tank cars would gradually be phased out for crude oil and ethanol shipments and a "next-generation" standard would be introduced.

But municipalities and many safety experts continue to call for further change. Smaller communities would like to see speed restrictions applied to them – not just to larger cities. And the TSB pointed out earlier this year that two derailments in Northern Ontario resulted in serious fires, even though the crude oil was being carried in newer, more crash-resistant tank cars. That, the agency warned, should be cause for concern given the length of the government's timeline for putting next-generation standards in place.

In an interview shortly before the final TSB report was released last August, Mr. Ross said he's hopeful that the lessons of the disaster won't soon be forgotten.

"The legacy of Lac-Mégantic, the lessons learned, I think, are going to be far-reaching and [they] need to be," he said. "So I'm glad to see that. And I'm sure those poor families that are suffering, I'm sure they don't want that to be for nothing. So it's important for them as well that people wake up, take notice and make some change."

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