The Lac-Megantic rail disaster could have been avoided, coroner Martin Clavet concluded in his report on the deaths of the 47 victims.
The coroner's office released its final report Wednesday into the July 6, 2013 disaster, when a runaway train smashed into the heart of the small Quebec town and caught fire, creating a roaring inferno that destroyed buildings.
Search crews and forensic anthropologists spent weeks scouring the wreckage of the town to locate the remains of as many people as they could.
The coroner then set to work identifying the victims.
Clavet's reports are very similar in describing how the Montreal, Maine and Atlantic Railway train parked in nearby Nantes with its engine running and then caught fire, how the motor maintaining pressure on the air brakes was subsequently turned off, and how the train then rolled 11.5 km downhill before multiple tanker cars derailed in Lac-Megantic in front of the Musi-Café bar.
Six million litres of oil spilled from the tankers and caught fire in a series of explosions that engulfed more than a dozen buildings.
The reports then go into specific detail about where each victim was found, who they were with, and the steps taken to identify the remains. In most cases nothing was left except bones and ash.
Clavet also provides the possible causes of death, such as breathing burning hot fumes, succumbing to toxic gases, or fatal shock after being buffeted by an explosion, it being impossible in most cases to determine exactly how each person died.
In each case the reports draw the same conclusion: "It was a violent death. This death could have been avoided."
Clavet then recommends that various levels of government study and implement the recommendations made by the Transportation Safety Board with regards to train safety.
Specifically, he stated there needs to be clear guidelines on how many handbrakes should be applied based on the weight of the trains and slope of the tracks.
The coroner also wanted Transport Canada to ensure trains carrying hazardous materials are not left unattended.
"There have already been notable advances and numerous aspects of rail security have been clarified," Clavet said in a statement.
"However, deficiencies persist and certain measures still have to be clarified."
The teamsters union has launched a publicity campaign on rail security, urging the government to hire more rail inspectors to oversee regulations in order to better protect the public and rail workers.
The Railway Association of Canada commented on the report, saying, "This tragedy never should have happened.... we want the people of Lac-Megantic to know that we remain committed to learning everything we can from this tragedy, and that we're working with all levels of government to make sure that our industry is as safe as possible."
Lac-Megantic Mayor Colette Roy Laroche said the report is a step forward.
"We hope this report will help in the difficult grieving process,” she said in a statement, adding, “Both governments have been warned by the coroner and we hope they take the appropriate measures so this kind of tragedy never happens again."
Transport Canada also responded to the report, stating they have already taken significant action on rail safety, including with brakes and extra supervision for hauling dangerous goods.
"There are a lot of these matters that we've already addressed through our legislation," said Transport Minister Lisa Raitt. We've been working with municipalities and rail on all of these matters. So we've heard this before. It's great to see it again."
Raitt has asked her officials to review this work in light of the coroner's recommendations.
