LAC MEGANTIC, Maine (NEWS CENTER) -- The Transportation Safety Board of Canada said that multiple factor led to fiery train accident in its report released Tuesday. The July 6, 2013 train derailment left 47 people dead.
"Accidents never come down to a single individual, a single action or a single factor. You have to look at the whole context," said Wendy Tadros, Chair of the TSB. "In our investigation, we found 18 factors played a role in this accident."
On the evening of July 5, 2013 a Montreal, Maine and Atlantic Railway (MMA) train was parked on a descending grade on the main track in Nantes, Quebec, said the TSB.
When a fire began in the engine, emergency responders shut off the engine - which caused the air holding the brakes to leak and reduce their effectiveness. Without enough force from the hand brakes, the train began rolling downhill toward Lac Megantic.
As it continued down the tracks, the train picked up speed, reaching a top speed of 65 mph.
The train derailed near the enter of town. The TSB says nearly every derailed car was breached, and released closed to six million liters of crude oil - which ignited the fire.
The TSB also found that MMA was a company with a "weak safety culture that did not have a functioning safety management system to manage risks." They also found problems with training, employee monitoring, and maintenance practices at MMA, including industry rules for securing unattended trains, and with the tank cars used to carry crude oil.
The TSB is now calling for additional defenses to prevent runaway trains and for more thorough safety checks to ensure railways are effectively managing safety.