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The Montreal, Maine & Atlantic Railway (MMA) train derailment that killed 47 people on July 6, 2013, in Lac-Megantic, Quebec, was caused by a multitude of factors, according to a Transportation Safety Board of Canada (TSB) investigation report released yesterday.MMA's train was parked on a descending grade on a main track in Nantes, Quebec, and the engineer applied hand brakes on all five locomotives, plus two other cars, and shut down all but the lead locomotive. Although railway rules require only hand brakes to hold a train if verified by a test, the locomotive air brakes were left on during the test on the MMA train, meaning the train was being held by a combination of hand and air brakes that gave a false impression that the hand brakes alone would hold the train, TSB officials said in a press release.When a fire broke out in the engine, emergency responders shut it off, causing the air holding the independent brakes to leak off, reducing their effectiveness, they said. Without enough force from the hand brakes, the train began rolling downhill toward Lac-Megantic located seven miles away. As it moved down the grade, the train picked up speed, reaching 65 mph, and derailed near the center of town."Accidents never come down to a single individual, a single action or a single factor. You have to look at the whole context," said TSB Chair Wendy Tadros. "In our investigation, we found 18 factors played a role in this accident."The TSB also determined that MMA had a "weak safety culture" without a functioning safety management system to properly manage risks, board officials said. In addition, the TSB learned that Transport Canada did not audit MMA often and thoroughly enough to ensure it was effectively managing risks in its operations; found problems with MMA's training, employee monitoring and maintenance practices; and discovered issues with industry rules for securing unattended trains and tank cars used to carry crude oil.Therefore, the board now is calling for additional "physical defenses" to prevent runaway trains and more thorough audits of safety management systems to ensure railroads are effectively managing safety, TSB officials said."This investigation and its findings are complex, but our goal is simple: We must improve rail safety in Canada,” said Tadros. "That's why, in addition to our three previous recommendations, we are issuing two new recommendations to ensure unattended trains will always be secured and Canada’s railways will have safety management systems that really work to manage safety."Railway Association of Canada (RAC) officials are studying the TSB's report to determine what can be learned to help ensure railroads fulfill their commitment to safety."Since the tragic accident in Lac-Megantic, the Canadian railway industry has introduced new initiatives to improve safety, transparency and emergency preparedness, while accelerating existing efforts," said RAC President and Chief Executive Officer Michael Bourque. "The industry has worked with the federal government to develop new rail safety rules and regulations, and has redoubled its first-responder training efforts. The RAC now also requires companies to make a commitment to safety culture, as a condition of membership in the association."Transport Canada remains committed to working with railroads, all levels of government, the Federation of Canadian Municipalities, international partners and others to continually improve rail safety in Canada, said Canadian Transport Minister Lisa Raitt in statement issued after the TSB released the report.Transport Canada has taken many measures since the accident, such as enhancing inspections, improving the documentation and follow-up for rail safety, and better monitoring the transportation of hazardous materials, including more frequent inspections at sites where petroleum products are transferred from one mode to another, she said."Transport Canada has also proposed or introduced fines, mandatory certificates, and tough new regulations and reporting requirements," said Raitt.Meanwhile, Union of Canadian Transportation Employees officials hailed the TSB for its thoroughness in the report and for making recommendations to improve rail safety and safety management systems.However, the length of time it takes for TSB recommendations to be implemented is "of great concern," union officials said in a prepared statement. Historically, Transport Canada has taken years to implement some TSB recommendations, while others have still haven't been implemented, they said."TSB needs to be given greater powers. They determine the cause of accidents; they determine the faults and they make recommendations," said Union of Canadian Transportation Employees National President Christine Collins. "I believe we need to give TSB the authority to implement these recommendations when other government bodies fail to act."