Aug 19 (Reuters) - Canada's Transportation Safety Board on Tuesday released its final report on last year's Lac-Mégantic crude train disaster, including a list of 18 "causes and contributing factors" to the catastrophic derailment that killed 47 people.
Most of the independent agency's findings focused on what happened the night of the accident, the state of the train, actions taken by employees of the Montreal, Maine and Atlantic Railway Ltd and the company's overall safety culture. For the most part, they have been previously reported.
But the last three findings singled out Transport Canada, the federal transportation ministry, for criticism:
1. The agency found that Transport Canada knew about major operational changes at Montreal, Maine and Atlantic (MMA) but "did not provide adequate regulatory oversight" to make sure the railway addressed new risks.
The agency noted in its full report that MMA's dangerous goods shipments rose 280 percent between 2011 and 2012, largely because of an increase in crude oil shipments.
2. Transport Canada's Quebec office found "recurring safety deficiencies" at MMA but did not follow up to ensure they were fixed, the agency found.
In the full report, the agency wrote that "for several years, MMA had been identified as a railway company with an elevated level of risk requiring more frequent inspections." Among other things, problems with "train securement" came up multiple times between 2005 and the accident.
Train securement proved a key factor in the disaster. The train was left unattended on a slanted track, with an insufficient number of hand brakes set to hold its full weight after a locomotive fire disabled another type of brake. The runaway train hurtled into Lac-Mégantic, derailed and exploded on July 6, 2013, leveling the town center.
3. Transport Canada's Quebec office did only a "limited number" of audits of MMA's safety management system, the agency found, noting the audits had limited scope. The department had no procedure to ensure problems were corrected, it added.
It wrote that this "contributed to the systemic weaknesses in Montreal, Maine & Atlantic Railway's safety management system remaining unaddressed."
(Reporting by Allison Martell; Editing by Paul Simao)