Lac- Mégantic deaths avoidable, coroner says
Reports argue those who perished would be alive if not for a series of preventable errors
“This was a violent death. This death was avoidable.”
That line — straightforward and unembellished — appears in every one of the 47 individual reports made public by the provincial coroner’s office on Wednesday morning. Dr. Martin Clavet, the physician assigned the grim task of determining the cause of death for the dozens of victims of the LacMégantic, Que., train derailment and explosion in July 2013, makes it abundantly clear that the men, women and children who perished that night would still be alive had it not been for a series of catastrophic and preventable errors.
“The events that unfolded in Lac- Mégantic must serve as a lesson for both ( the provincial and federal) governments,” Clavet writes.
The victims were identified mainly through DNA analysis and dental records. In some cases, however, the remains could not be matched to a specific person. In other cases, the reports indicate that searchers found no remains at all.
Determining the exact causes of death was nearly impossible. Those in the Musi- Cafe bar likely died of asphyxiation or from injuries caused by the shock wave and falling debris, Clavet speculates, but their bodies were badly burned and sometimes reduced to charred bone. Those who died further from the explosion’s centre likely succumbed to asphyxiation, he notes.
While the coroner’s descriptions and findings are grim, his reports may still provide some solace to the families of the dead, all of whom received a copy of the report linked to their family member ahead of the public release Wednesday, and are being encouraged to contact the coroner’s office with any questions. Each document states that the victim would have lost consciousness moments after the train hit the downtown core and exploded, filling the air with toxic smoke.
“Considering the dynamic nature of the events and the environment, it is likely that the ( deaths) were rapid — without being able to determine an exact duration — and were preceded by a loss of consciousness,” Clavet writes.
While nearly identical, the 47 documents do offer a few unexpected glimpses into the lives of individual victims. David Lacroix Beaudin, 27, was a resident of Switzerland at the time of his death, for example, but had come to Lac- Mégantic for a visit. He planned to return to Switzerland later in the day on July 6, the report into his death states. Kathy Clusiault, 24, had gone to bed early on July 5 in anticipation of an early morning trip with family. Her remains were found halfway between the building where she lived and the Musi- Cafe.
Lac- Mégantic Mayor Colette Roy Laroche responded to the coroner’s findings Wednesday afternoon, saying that she hopes the reports will “provide satisfactory answers to questions that have lingered since the tragedy” and “help with the difficult, but necessary, grieving process.”
Roy Laroche also thanked Clavet and his team for carrying out their work with “respect and sensitivity.”
Given that three people face criminal charges in connection with the accident, Clavet was not allowed, by law, to assign
The events that unfolded in Lac- Mégantic must serve as a lesson for both ( the provincial and federal) governments. DR. MARTIN CLAVET PHYSICIAN WITH THE QUEBEC CORONER’S OFFICE
blame. He did not grant any interviews on Wednesday.
The coroner’s recommendations, based on evidence collected at the scene and recent discussions with various agencies, mirror those issued by the Transportation Safety Board earlier this year. They include updating regulations to ensure no trains carrying hazardous materials are left unattended until additional physical defences are set up along tracks to prevent runaway vehicles.
Clavet also notes that while the TSB mandated rail companies transporting dangerous goods conduct detailed risk assessments along key routes in April, that order only applies to routes that see more than 10,000 wagons of dangerous materials pass through each year.
“It’s therefore possible that this minimum of 10,000 wagons per year limits the number of itineraries that must be subject to the reinforced security measures,” he writes.