An unsafe railway and lax audits from Transport Canada were at the centre of a long-awaited report released by the Transportation Safety Board on Tuesday into the deadliest rail accident in modern Canadian history.
More than a year after an oil train derailed in Lac-Mégantic, the causes of the disaster came into focus with disclosures this week that included recordings between the train's engineer and railway controllers in the first frantic hours of a firestorm that claimed 47 lives in the once-quiet Quebec village.
"It's your train that rolled down," a controller told engineer Tom Harding two hours after Lac-Mégantic's downtown began to burn. "No, RJ," responds a stunned Mr. Harding, slowly beginning to understand the full impact of what was occurring in front of him.
Mr. Harding had only set seven brakes on his train, despite parking 7.7-million litres of volatile crude oil on an incline overlooking the town. The load had been kept secure by air brakes, which were then turned off when a local fire crew responded to an engine fire. Two hours later, the train began to roll unmanned.
The 181-page report from federal investigators found proof of a rail system that has been allowed to operate with few inspections by Transport Canada despite some poor safety practices. While accepting that her department would need to meet "higher expectations," Transport Minister Lisa Raitt deflected much of the blame for the accident on Montreal, Maine & Atlantic Railway.
"It comes down to a fundamental fact: There's 46,000 kilometres of rail track in this country. You can't possibly ever have enough inspectors at every way point," she said after the report's release. "The companies are expected to follow the rules. The company did not follow the rules."
Transport Canada has been given recommendations by the TSB on how to prevent a future disaster. The agency added two new safety recommendations to the three it had previously submitted, calling on Ottawa to conduct more frequent audits of safety plans written by railways and to require physical defences to prevent runaway trains.
While Ms. Raitt's office weighs those recommendations, Mayor Colette Roy-Laroche has pledged to continue advocating loudly for her community's long-running demand that the federal government build a rail bypass around her town.
"The detour is indispensable for the residents of Lac-Mégantic," she said. "We want to be safe at home."
Neither the provincial nor federal governments have yet to pledge money towards the project, expected to cost as much as $175-million. However, due to the dangers of the area's mountainous geography and the fragile state of the town's people and infrastructure as it continues to rebuild, the mayor has taken nearly every public speaking opportunity to hammer for the need to build a bypass.
Her tone represents a change after she spent much of the past year speaking carefully about the disaster's aftermath. Ms. Roy-Laroche said Tuesday that the report's findings and recommendations were "still not enough."
By taking aim at Ottawa's failings and those of the MM&A, she enjoys nearly unanimous local support.
René Simard survived the disaster on July 6, 2013, by leaping from the terrace of a local bar and fleeing moments after the oil train derailed. "We knew that something was wrong and that trains couldn't operate like that without Transport Canada knowing," he said of the railroad's operations before the disaster. "Someone was negligent and everyone I know thought that the federal government was responsible."
Many in Lac-Mégantic had also long been suspicious of the shoestring operation that ran trains through the town. Local contractors complained of poor maintenance on tracks and wondered about the trains pulled by a haphazard assortment of aged locomotives.
Before a surge in profitable shipments of oil on the MM&A's tracks that started in 2012, the railway had been shedding clients and seemed destined for bankruptcy.
The TSB's report showed that while Transport Canada officials in Quebec knew about significant issues with the railway, an audit of the MM&A's safety management system was executed only years after the company wrote the rules. There was a lack of follow-up on identified shortcomings in the company's safety plan.
"This laissez-faire is unacceptable," said Ms. Roy-Laroche, calling for the federal government to enforce zero-tolerance regulations for railroads. "We demand that finances no longer be at the heart of regulations. Transport Canada shouldn't give in to railway blackmail, when they threaten to interrupt service when we don't do everything they want."
While she commended the willingness expressed by regulators and railways after the disaster to increase regulations, she compared the promises to New Year's resolutions and wondered how long they would last.
According to Luc Dion, another local who fled the burning downtown, the report confirms what he had long suspected. "There was just a pack of errors and oversight, and now the victims paid the price," he said.
Raymond Lafontaine said Tuesday that he had lost confidence in the federal government's ability to keep him safe. The patriarch of a prominent local family, Mr. Lafontaine lost a son and several friends in the disaster.
In the past he's suggested that Quebec's provincial police should inspect trains, whether or not Ottawa would allow them to do so. "If they can't keep us safe they should stay at home," he said. "We'll elect politicians who have their hearts in the right place."