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Crews search through the debris near the area where the Musi-Café once stood in downtown Lac Mégantic, Que.

Peter Power/The Globe and Mai

A Quebec coroner says the 47 victims of the Lac-Mégantic train disaster died violent and avoidable deaths and governments have to step in to bolster rail safety.

Martin Clavet outlines the circumstances of each loss of life in the 2013 crash, telling the personal stories behind the calamity before calling on federal officials to upgrade regulations and create specific braking rules for trains to prevent another such rail disaster.

"It seems essential to me to make the … recommendations for a better protection of human life," Dr. Clavet writes.

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In 47 individual reports, based on the painstaking work of search crews and forensic investigators, Dr. Clavet lays out the scope of the human tragedy that unfolded when a train carrying volatile crude oil derailed and exploded in the heart of a small Quebec town. Investigators had to sift through mounds of ash and dust to find the human remains and try to identify them, sometimes with little more than microscopic bone fragments.

Dr. Clavet does not assign blame for the disaster, but says both provincial and federal officials need to improve rail safety regulations. He calls on the federal Department of Transport to issue clear rules for the number of handbrakes that must be applied on unattended trains, depending on the weight of the cargo and incline of the tracks. He also calls for explicit rules for verifying that a train's handbrakes are sufficient to keep it from moving.

Dr. Clavet's recommendations reflect those issued by the Transportation Safety Board in August, which found more than a dozen factors contributed to the crash, including a failure to apply enough handbrakes and lax federal regulation. He urges Ottawa to prevent trains carrying hazardous loads from being left unattended on main rail lines until Canadian rail companies put up extra physical barriers for the trains.

Beyond policies, his account sheds a light on the personal toll of the railway disaster. His reports, released to the public on Wednesday, indicate that investigators used dental remains and DNA in most cases to identify victims. One, 93-year-old Eliane Parenteau, was identified by her metal hip.

Each study is a painful glimpse of a life that was wiped out.

Four-year-old Alyssa Charest Bégnoche was at home with her mother and sister when she died, the coroner wrote. "The father of the two children was not far away downtown, and saw their building go up in flames, without them being able to get out."

Richard Veilleux, 63, who lived near the centre of the explosion, spoke to his son at about 9 p.m. and told him he was going to bed; he was never heard from again. Kathy Clusiault, 24, texted a friend at about 9:30 p.m. saying she was going to sleep because she was getting up early the next morning. Her body was found on the street between her home and the popular Musi-Café nightclub; she was probably trying to flee her home when the explosion engulfed the town, the coroner writes.

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In many cases, the cause of death is given as probable asphyxiation or trauma caused by the explosion.

In each case, the coroner issues the same somber, cautionary refrain: "This was a violent death. This death was avoidable."

As much as a scientific accomplishment, the coroner's findings are another difficult chapter for families who lost loved ones in the July, 2013, disaster. The reports, presented to family members in Lac-Mégantic this week before they were made public, spell out the cold details of how brothers, sisters, parents and children died. Relatives were invited to the presbytery of the Sainte-Agnès Church to discuss the findings; the Red Cross and health professionals were on hand.

The report had to be read to a woman whose daughter died at the Musi-Café because she was in no shape to read it herself. "It was cruel to hear," the mother, sobbing, said by phone on Wednesday. She asked not to be named.

Richard Custeau quietly read the details of how his brother, Réal, died in his apartment near the Musi-Café. "That's where he was when the explosions detonated and the flaming oil spread from the derailment site toward the lake, engulfing the downtown on its way," the coroner writes. Réal's body was found in the debris.

"Frankly, I didn't think that reading such a complete summary would hurt so much," Richard Custeau said in an interview. "It's not like we didn't know the results. But this confirms it. It's still an open wound."

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