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The rail industry and the communities it serves are still reeling from the tragedy of  Lac-Megantic. On July 6, 2013, what started as a nighttime fire in a parked locomotive became a flaming runaway train that ultimately derailed in the middle of Nantes, Quebec. Sixty-three of the 72 tank cars were damaged, releasing 6 million liters of crude oil. The explosion that followed killed 47 people and forced another 2,000 from their homes. Following this horrific accident, transportation agencies on both sides of the border have launched investigations, adopted new regulations and have plans for more.

The Transportation Safety Board (TSB) of Canada has now weighed in with its assessment of the accident. It cited 18 distinct causes and contributing factors —indicating that all of the parties involved made critical errors in judgment. These included an inadequate repair of the locomotive, hand brakes that weren’t applied properly to be strong enough to hold the train, a failure of automatic air brakes to engage, tank cars built to an older standard, gaps in the Montreal, Maine & Atlantic’s safety procedures, and the TSB’s failure to effectively monitor the railroad’s safety programs.

The TSB made five recommendations and has vowed to report to the public on the progress—or lack of it—on each of these.

For a summary, as well as the full report, click here.