No need to force labels on “causes.” A cause, is a cause, is a cause, is a cause…the only question that really needs answering is “Are you going to do something about the identified cause.”


“This report also contains 16 findings as to risk. Although these did not lead directly to the accident, they are related to unsafe acts, unsafe conditions, or safety issues with the potential to degrade rail safety. Some of the risks that need to be addressed are:

  • the continuing risk of leaving trains unattended
  • the risk of implementing single-person train operations
  • the risk of not systematically testing petroleum crude oil
  • the risk of not planning and analyzing routes on which dangerous goods are carried
  • the risk of not having emergency response assistance plans in place
  • the risk of Transport Canada not ensuring that safety management systems work effectively”