Rail lines in poor condition caused March 2015 Gogama derailment: TSB

The Transportation Safety Board of Canada is recommending that Transport Canada incorporate predictive data on rail surface conditions to help better focus its targeted regulatory track inspections.

The Board's report on the March 2015 Gogama train derailment suggests the incident happened after a recently repaired rail within a joint broke under the train.

Dye test to find defects in track didn't happen

Three days before the derailment, a maintenance employee repaired a broken rail by installing a plug rail. The employee cut the defective rail out of the track, visually inspected the rest of the exposed rail ends, then installed the plug rail.

CN standards require a dye penetrant test to find defects not visible to the naked eye, but the employee didn't perform that before the repair.

That means avertical split head, which is an internal defect, went undetected.

After the repair, the rail head ends within the joint were mismatched. The employee tried to grind theplug rail head end to ease transition,but it wasn't enough. A step between the two rail heads remained.

The TSB's report suggests a "slow order," which would have required trains to reduce speed at this location, should have been issued. But this didn't happen either.

CN testinginformation 'difficult to find'

The employee knew about the dye test, but he had never done it or seen it before during his duties. The report suggestsCN'straining did not highlight the importance of the test, nor did it provide opportunities for practical hands-on training.

The report also states that CN'sprocedures for rail testing and installing a plug rail were located in multiple manuals, making them difficult to find.

The report notes that employees were not given checklists, which could have outlined the steps required to complete the work.

Kathy Fox, chair of the TSB, says railways gather information on leading indicators like localized surface collapse, rail end batter and crushed heads.

"Transport Canada needs to acquire this information," Fox said.

"Without it, the targeted Transport Canada track inspections simply won't be as effective as they otherwise could be."

Training improved since derailment, saysCN

CN spokesperson Patrick Waldron told CBC News that CN has improved safety measures across itsnetwork since the 2015 derailment.

"Nearly 450 track supervisors and track workers have gone through enhanced classroom and hands-on field training to provide them expanded knowledge and tools to better identify track issues and properly complete necessary repairs," Waldronwrote in an email.

"Among those tools are enhanced critical task checklists for various track repairs and maintenance, including dye penetrant tests."

Waldronsays since 2015,CN invested around $400 million in rail infrastructure across northern Ontario, including 200 miles of new rail.

He also notes that CN is committed to the cleanup of the Makami River after the derailment caused extensive environmentaldamage to the surrounding area. This summer, the company continues to clean by flushing residual oil from the track embankment.

"CN...will not leave until that cleanup is complete, and then will continue to monitor conditions for many years," Waldronsays.

Politicians weigh inon report

Nickel Belt MP MarcSerr released a statement on the report, sayingthat the federalgovernment is committed to improving rail safety in Canada.

"A positive aftermath has materialized since the roundtable I facilitated regarding theGogamaderailments in September 2016, which included representatives of all levels of Government, CN,the Mattagami First Nation and Community leaders,"Serr said in a release.

"I am grateful all parties came together andhelped ensure the lines of communication remained open for the residents of Gogama."

Meanwhile, Nickel Belt MPP France Glinas says she's relieved that the TSB finally released its report.

"The people of Gogama and Mattagami First Nation need answers, this report could help. It acknowledges that speed and maintenance were behind this disaster," Glinas said in a release.

"I hope the people of Gogama and Mattagami First Nation can use this report to bring attention to the environmental mess in their community and their water ways."

Transport Canada to review recommendation

A spokesperson for Transport Canada says the department will examine the TSB's recommendations.

"Transport Canada shares theTransportation Safety Board's commitment to advancing the safety of Canada's transportation systemand is committed to working with partners to further enhance the safety of Canada's railway system," the ministry told CBC News in an email.

The ministry has 90 days to respond in accordance with the Canadian Transportation Accident and Investigation Safety Board Act.