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Fire from a train explosion is seen in Lac-Mégantic, July 6, 2013.Reuters

More than a year after the Lac-Mégantic rail disaster, an investigation by Canada's Transportation Safety Board has concluded, to no one's surprise, that there's a lot of blame to go around. The Montreal, Maine & Atlantic Railway that operated the 72-car train cut corners to keep operating costs in line; the train engineer set too few handbrakes; mechanical problems with the lead locomotive weren't fixed; the train was parked on a hill without a physical barrier to prevent it from rolling down. In isolation, each of these errors – and this isn't even an exhaustive list; there were many more – would have likely proved benign. But in the early morning hours of June 6 last year, the mistakes compounded, one after another. The result was the worst rail accident in modern Canadian history, which killed 47 people.

Cataloguing these mistakes is one thing. But the Safety Board's investigation goes a step further to question how these errors – industrial, human and mechanical – were allowed to happen in the first place. There is one federal body that is ultimately responsible for the oversight of Canada's railways: Transport Canada. The Lac-Mégantic disaster falls squarely at its feet. Transport Canada should acknowledge the role its lax oversight played in the railway crash, and take further action to better protect Canadians from the inherent dangers of moving crude oil by rail.

Federal Transport Minister Lisa Raitt has already announced a raft of new rules meant to mitigate those risks. Many certainly hit the right notes: taking the most dangerous rail cars out of service immediately, decreasing the speed limits for trains carrying hazardous materials through populated centres and a requirement that companies conduct risk assessments on all routes travelled by trains carrying hazardous materials. But what's abundantly clear from the Safety Board's investigation is that regulations mean nothing without proper enforcement and oversight. Transport Canada's new regulations around rail safety might look great on paper, but unless the department follows through and enforces them, they are worthless.

Transport Canada's inspection of MMA is a case in point. The investigation report reveals that Transport Canada Quebec Region had been inspecting and monitoring MMA's railway operations, equipment and infrastructure for years. Transport Canada was well aware that MMA had problems. "For several years," notes the report, "MMA had been identified as a railway company with an elevated level of risk requiring more frequent inspections." Those inspections consistently found "ongoing safety deficiencies requiring safety action." What happened next? "TC Quebec Region issued numerous notices, notices and orders, letters of concern, and letters of non-compliance." And then? "Although MMA normally took action after the inspection to address the identified safety deficiency, it was not uncommon for similar deficiencies or risks to be identified in subsequent inspections."

Those deficiences identified at MMA were significant and recurring. For example, the report finds that "problems with train securement were identified on multiple occasions since 2005, and were still present at the time of the accident." Transport Canada repeatedly pointed out staff training deficiencies among "mechanical group, operations and engineering group, and rail traffic control," from 2006 until the time of the accident. And "track condition was noted as an ongoing issue between 2006 and the time of the accident." All of these problems factored into the derailment at Lac-Mégantic.

Transport Canada detected and logged all of these failures – but it failed to get MMA to fix them: "TC Quebec Region did not follow up to ensure that recurring safety deficiencies at MMA were effectively analyzed and corrected; consequently, unsafe practices persisted."

Was the federal regulator asleep at the switch? No. On the contrary, it appears to have watched the litany of regulatory violations passing it by. It took careful note of them. It catalogued their occurrences. And then, eyes wide open, it often declined to pull the switch that could have brought the danger to a halt.

Ms. Raitt has promised "concrete action" within 90 days. This week, she again singled out MMA: "The government puts the rules in place. The companies are expected to follow the rules. The company did not follow the rules," she said at a press conference. It's not that simple. Railway companies don't just need rules, they need oversight, especially when the shipment of crude oil by rail is growing at its current pace. Transport Canada can't just set regulations. It must ensure companies abide by them.

Regulation is about more than just rules. When violations of the rules turn up, there has to be enforcement. Of Lac-Mégantic's many lessons, surely that should be its most lasting.

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