Eighteen errors lines up to cause last summer 's catastrophic derailment of a runaway train in the Quebec town of Lac-Mégantic , Canadian accident investigators said Tuesday , concluding an investigation that has revealed serious safety lapses in the transport of crude oil through Canada and the United States . Among the factors : a `` weak safety culture '' in the railroad that transported the oil ; a government agency that required safety plans from industry but did little to check them ; and a train that consisted almost entirely of substandard tanker cars . Those tanker cars -- known as DOT 111s -- still carry the bulk of the oil from the Bakken oil fields of North Dakota to ports on the east coast of the United States and Canada , although both countries -- spurred by the Lac-Mégantic tragedy -- are taking steps to phase them out . The Lac-Mégantic derailment was among the most disastrous in modern North America . Forty-seven people died , some 40 buildings were destroyed and 53 vehicles were demolished when the 63 tank cars and two boxcars derailed and erupted in flames . About 2,000 residents of the community were evacuated . The Transportation Safety Board of Canada ( TSB ) listed 18 factors contributing to the disaster , but declined to say whether any were more serious than the others . The accident may have been avoided if any one of the 18 factors were not present , the TSB 's Jean Laporte told reporters . `` 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 . Crude oil shipments by rail have increased dramatically in the past decade as oil companies have perfected technologies to extract oil from shale . The increase took a number of people by surprise , including government regulators , Tadros said . Police : Evidence criminal act may have led to crash . In Canada , rail shipments of oil have increased from a mere 500 carloads in 2009 to 160,000 in 2013 . In the U.S. , shipments have increased from 10,800 carloads to 400,000 in the same period . Tadros and Laporte said Transport Canada has taken measures of phase out the use of DOT-111 tankers -- one of three recommendations made in January in an unprecedented joint recommendation by the safety boards of both countries . But they sidestepped questions about whether newer , stronger tankers would have remained intact in the Lac-Mégantic derailment . TSB investigator Don Ross said there are `` not enough data points '' to determine whether newer tankers would have survived the incident . The incident occurred July 6 , 2013 , when an engineer for the Montreal , Maine & Atlantic Railway ( MMA ) parked the train for the night on a descending grade . Runaway train devastates Canadian town : The route , the damage , the aftermath . Investigators said the engineer set seven of the train 's hand brakes , far fewer than the 17 to 26 needed to prevent the train from rolling . The additional holding power of the train 's air brakes kept the train secure at first . But when a fire broke out in the lead locomotive because of a mechanical problem , the locomotive was shut down , an no additional air was provided to the air brakes . A slow air leak led to the failure of the air brakes , and the unattended train rolled down the incline , reaching a top speed of 65 miles per hour before derailing seven miles away at a curve in Lac-Mégantic . Many of the cars were split open , releasing large amounts of crude oil , which ignited , causing large fireballs and a pool fire . The TSB said the railroad cut corners on engine maintenance and training , and that crude oil trains `` ran largely unchecked '' by Transport Canada , the Canadian equivalent of the U.S. Department of Transportation . Opinion : Stop shipping volatile oil by rail . MMA filed for bankruptcy after the disaster . The railroad 's Canadian assets have been sold . Investigators also discovered that the oil was improperly described in shipping documents . It was labeled as a `` Packing Group II '' product , but was shipped as a less volatile Group III product . Following the Lac-Mégantic disaster , the U.S. Federal Railroad Administration and the Pipeline and Hazardous Materials Safety Administration ( PHMSA ) issued a safety advisory and announced an operation to conduct unannounced inspections and testing of the crude oil that is being shipped by rail . Tadros , the TSB chair , said governments and the rail industry have made improvements , but more needs to be done . Canada `` still allows trains to be left unattended on a descending grade , '' she said . The government needs to do more than rubber-stamp companies ' Safety Management Systems , which are intended to detect and address safety issues . `` It 's not enough for a Safety Management Systems on paper ; that SMS has to work , to do what it was designed to do , '' she said . Loss , now anger , fuel a town forever changed .
The Lac - Mégantic rail disaster of August 2013 killed 47 people , . Canadian safety agency report faults railroad , government and train itself . Note : Accident may have been prevented if any one of 18 factors were not present . Recent increases in Canadian shipments of coal surprised even government officials , says TSB chair .