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Wendy Tadros, TSB chair, responds to questions as Jean Laporte, chief operating officer, listens during a news conference following the release of the Transportation Safety Board report on the deadly train derailment Tuesday, August 19, 2014 in Lac-Megantic, Que.

Paul Chiasson/The Canadian Press

More than a year after the worst rail disaster in Canadian history, Ottawa has been called to account for its role in allowing a culture of lax safety practices to flourish on the country's railways.

A long-awaited report into the rail disaster in Lac-Mégantic, Que. – which killed 47 people and destroyed dozens of buildings when a train loaded with crude oil derailed and exploded in the centre of town last summer – places considerable blame on the railway involved, Montreal, Maine & Atlantic, for failing to operate safely on the night of the deadly accident.

But the findings contained in the 181-page document by the federal Transportation Safety Board also take blunt aim at Transport Canada for failing to enforce its own safety requirements, and for neglecting to act on safety concerns at MM&A that the department was aware of before the disaster on July 6, 2013.

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The transportation watchdog, which independently investigates accidents, accused Transport Canada of lacking sufficient oversight of the safety regime it designed. Amid a period of extensive deregulation of the railway sector over the past decade, the federal government handed over responsibility for many safety and operating procedures to the industry. Railways were required to file details of their operating procedures with Ottawa. Transport Canada would then approve these plans – known as Safety Management Systems (SMS) – if it felt satisfied by the promises the companies were making on safety.

However, the TSB said the government did not adequately investigate whether MM&A was actually following those procedures. Away from Transport Canada's eyes, the railway was conducting itself with insufficient federal oversight.

"MM&A really only had a safety management system on paper," TSB chair Wendy Tadros said Tuesday after the report was made public in Lac-Mégantic, which is still struggling to rebuild 13 months after the core of the town was destroyed. In addition to failing to keep consistent tabs on the railway, Ms. Tadros said the watchdog is concerned that Transport Canada failed to act on concerns that arose when they were found when checks were carried out.

"The problem is not just about the frequency of Transport Canada's audits, but also extended to a failure to follow up on issues that came up during the regulator's routine inspections," Ms. Tadros said.

It is a troubling indictment of the way the federal government has managed rail safety for the past several years, culminating in the Lac-Mégantic disaster, which came at a time when railways have been moving record amounts of crude oil by rail to make up for a shortage of pipelines. The train that exploded was carrying 7.7-million litres of volatile crude oil from fields in North Dakota, and was destined for a refinery in Saint John, N.B. "This booming industry where oil trains were shipping more and more oil across Canada and across the border ran largely unchecked," Ms. Tadros said.

The investigation found that too few brakes were set on the train by the conductor when the train was parked for the night, at the top of a slope near Nantes, Que. The conductor set just seven hand brakes – which are manually set on each car – and relied on the train's air-brake system to also hold the train in place for the night. But when the train caught fire, forcing emergency crews to shut down the engines, the air-brake system eventually failed.

The TSB report said MM&A failed to follow safety procedures by not setting enough brakes, and criticized the railway for operating under "a weak safety culture." The report issued several recommendations that the TSB believes need to be introduced by Transport Canada, including better methods for securing trains, such as new brake systems and putting chocks under the wheels. The report also recommends the government step up its enforcement of railway safety procedures.

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Responding to the report, Transport Minister Lisa Raitt said her department will look at the recommendations, but would not immediately commit to implementing them. "The fact is there are rules in this country when it comes to Transport Canada and the transport of dangerous goods. And in this case, the rules were not followed," Ms. Raitt said. "Transport Canada will take a look at the TSB recommendations regarding its own practices, and I'll get advice from the deputy [minister] as to what to proceed with."

Ms. Tadros acknowledged criticism that Transport Canada is too close with the railways, but said the investigation reached no conclusions on that point. However, she expressed frustration with industry attempts to water down Transport Canada's response to previous TSB recommendations.

Lac-Mégantic Mayor Colette Roy-Laroche said the government should not be subject to pressure from the railway industry, which has argued in the past that tougher regulations could hurt their business and impact service, which she called blackmail. "We demand that finances no longer be at the heart of regulations," she said. "Transport Canada shouldn't give in to railway blackmail, when they threaten to interrupt service when we don't do everything they want."

While the TSB report spread the blame for the situation between MM&A and Transport Canada, the railway's chairman said the disaster was due to the failing of the conductor in charge that night.

"If you have a situation where the engineer violates the rules – the man in charge of the train violates the rules – it creates a situation, a tragic situation," MM&A chairman Ed Burkhardt said. "The fact is this is a failure of one individual."

However, Thomas Walsh, a lawyer for engineer Tom Harding, said the report may not change the way his client's criminal case proceeds, but it goes a long way toward showing the public that Mr. Harding was not the only one at fault in the crash. "I think what it means for him and the other people that are accused right now – the only people that are accused – is that the public is aware now that their role in that thing was a partial role."

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With reports from Justin Giovannetti and Josh Wingrove

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