Rail Workers Acquitted in Trial on Deadly Lac-Mégantic Oil Train Disaster

Yves here. As this story points out, while a jury determined that the front line rail workers were not guilty in the horrific Lac-Mégantic “bomb train” explosion, the official response had been to scapegoat low level employees. No executives, managers, or public officials were charged.

By Justin Mikulka, a freelance writer, audio and video producer living in Trumansburg, NY. Justin has a degree in Civil and Environmental Engineering from Cornell University. Originally published at DeSmogBlog

The train engineer and two additional rail workers who faced charges for the deadly July 2013 oil train accident in Lac-Mégantic, Quebec, were acquitted on Friday after the jury deliberated for nine days. If convicted of all charges, they potentially faced life in prison.

The end of the trial of these three employees for their role in the Canadian oil train disaster that resulted in 47 deaths and the destruction of much of downtown Lac-Mégantic appears to have brought some closure to residents of the still-recovering town — although most are still waiting for justice.

As the trial began, the BBC reported the sentiments of Lac-Mégantic resident Jean Paradis, who lost three friends in the accident and thought the wrong people were on trial.

It’s clear to me the main shareholder, MMA, are not here. Transport Canada is not here. Transport Canada have let cheap companies run railroads in Canada with less money for more profit…” Paridis told the BBC. Transport Canada is the Canadian regulatory agency with rail oversight.

Another resident, Jean Clusiault, who lost his daughter in the disaster, told the CBC that after the decision, “I felt relieved because these are not the right people who should be there.”

The sentiment that these three men should not have been found guilty was even expressed by the former CEO of the rail company that operated the train that caused the disaster.

“I was happy when I heard the verdict. I think the jury made the right decision,” Edward Burkhardt, former chairman of rail company Montreal, Maine and Atlantic (MMA), told Radio-Canada.

No rail executives, politicians, or regulators were ever charged with any crimes relating to the Lac-Mégantic disaster.

Based on the past four years of reporting on the literal and figurative boom in Bakken oil trains, I have written a book about the story of the bomb trains — from Lac-Mégantic to Trump — which addresses the question of who was to blame for the lethal accident in this small Quebec town and for the many oil train accidents across North America that followed.

The following is the first chapter of that book, detailing what happened in Lac-Mégantic on July 6, 2013.

Chapter 1: Lac-Mégantic

On the evening of July 5, 2013, Thomas Harding finished his shift for the Montreal, Maine & Atlantic (MMA) Railway driving a train full of Bakken crude oil across rural Canada. Harding parked the train on a track siding in Nantes, Quebec, and called to tell the dispatcher that the train was secure.

Harding then called another rail traffic controller in Bangor, Maine, and noted that there had been excessive smoke coming from the locomotive on his trip. He was advised not to worry about it and another engineer was scheduled to take the train in the morning from Nantes to its destination — an oil refinery in Saint John, New Brunswick. Nothing was done about the smoking engine, despite the fact that the train’s cargo was classified as a hazardous flammable material.

And so Harding followed these instructions. The train was left on a track siding in Nantes — running, unlocked, and unattended — as was standard practice and perfectly within regulations. The tracks run right alongside the rural road that connects Nantes to the town of Lac-Mégantic. Harding called a taxi and was taken to a nearby hotel in Lac-Mégantic for the night.

Investigations later revealed that Harding made a critical error that night. After applying manual hand brakes on the locomotives and two tank cars, he was supposed to turn off the air braking system and make sure that the hand brakes would hold the train on their own. He ran that test with the air brakes on, which combined with the hand brakes, provided sufficient braking force to keep the train in place.

At some point that evening after Harding had left, someone driving down the road noticed the locomotive was on fire and called the local fire department — which responded and put out the fire.

According to the accident report, “the firefighters moved the electrical breakers inside the cab to the off position, in keeping with railway instructions. They then met with an MMA employee, a track foreman who had been dispatched to the scene but who did not have a locomotive operations background.” 1

Turning off a locomotive that had been on fire seems like a reasonable thing to do, especially because no one on the scene had expertise in operating a locomotive.

Reasonable except for one fact. The braking system on this oil train was based on technology designed in the late 1800s — the same braking system used on most oil trains in North America — and requires constant air pressure to keep the train braked. Air brakes were revolutionary safety technology when introduced to the rail industry in the 1860s, but now,  understandably, are no longer state of the art.

As the firefighters drove away from the train that night, the air pressure in the braking system began to decrease. When they shut off the locomotive engine, they also unwittingly shut off the power that was maintaining the air pressure in the braking system.

Eventually the brake system’s air pressure decreased to a point where the train began to move down the hill towards Lac-Mégantic. Despite this obvious flaw in rail safety, at the time there were no regulations saying that a train full of flammable liquids parked on a hill above a residential area needed to also have a mechanical device placed on the track to make sure the train could not “run away.” Years later, there still is no such regulation, despite this being a cheap and effective safety measure.

And, so, the train began to roll towards Lac-Mégantic. The rail tracks and road next to it are essentially a straight shot downhill into the center of town. With no curves to navigate, the runaway train remained on the tracks, gaining speed on the six miles of track from Nantes to Lac-Mégantic.

When the train reached town, it was moving over 60 miles per hour. At this point the train passed Gilles Fluet, a local resident who had just left the popular nightspot the Musi-Cafe.

It was moving at a hellish speed … no lights, no signals, nothing at all,” he said. “There was no warning. It was a black blob that came out of nowhere.” 2

Once the train passed Fluet, it quickly arrived at a point where the tracks turned left. Here the train left the tracks and shot straight into the heart of downtown Lac-Mégantic and the Musi-Cafe that Gilles Fluet had just left.

More than half of the people who died that night were in the Musi-Cafe. One lucky survivor described what happened to The Globe and Mail.

The entire bar went pitch black, then turned orange — brighter than the middle of the day, a blinding, lively orange … That was the last time I saw any of them.”3

The sounds of the accident woke Thomas Harding and much of Lac-Mégantic at around 1:15 a.m. At 1:47, Harding called a rail dispatcher and described the scene:4

Everything is on fire — from the church all the way down to the Metro, from the river all the way to the railway tracks. From what I can see, RJ, the box cars have all burnt in the yard — the ties, everything. Whatever is in the yard, rolling stock, is now gone — completely.”

However, neither Harding nor the dispatcher, RJ, were yet aware it was their MMA train involved in the crash and fires.

RJ: What the f*** happened?

TH: I don’t know. I don’t know, but everything, everything … I woke up 20 minutes ago. Evacuate, evacuate, right away.

Harding reportedly helped firefighters move some of the full oil tank cars that were still on the tracks away from the fires. He then called the dispatcher again at 3:29 a.m., at which point he was informed it was his train.

RJ: It’s uh, it’s your train that rolled down.

TH: No!

RJ: Yes, sir.

TH: No, RJ.

RJ: Yes, sir.

TH: Holy f**k. F**k!

TH: She was f***ing secure. F**k!

RJ: That’s what, that’s what I got as news.

Another person awakened in downtown Lac-Mégantic that night was the local fire chief Denis Lauzon. When he opened his front door to see the disaster, his response was simply: “Ok, We’re in hell.” 5

While firefighters worked to evacuate people, they were not equipped to deal with the fire, and as Chief Lauzon noted, there was no way to rescue the 47 people who died.

The 47 people were at the wrong place at the wrong moment. They couldn’t survive that type of fire.”

Around 3:45 a.m., as the explosions stopped, the firefighters attempted to move in to deal with the fire — when another tank car exploded in front of them. The firefighters retreated and the fire would end up burning for three days.

The train was carrying Bakken crude oil in DOT-111 tank cars. For over 20 years, the U.S. National Transportation Safety Board (NTSB) had warned against using the DOT-111 tank cars for moving flammable liquids like oil.6 These tank cars were known to easily puncture at speeds of under 20 miles per hour. At over 60 miles per hour there was no question what would happen. More than 60 of the 72 loaded oil tank cars derailed, spilling over one million gallons of oil.

The spilled oil ignited immediately, creating “rivers of fire” throughout downtown Lac-Mégantic, consuming much of the area and 47 people. Those rivers of fire traveled downhill from the tracks all the way to the river and destroyed almost everything in between.

When the reports of what went wrong were filed, it was clear that the oil and rail industries’ quest for profits over safety was to blame, along with lax regulatory oversight. Long before official accident reports detailed what led to the disaster, a columnist in The Guardian accurately described Lac-Mégantic as “a corporate crime scene.” 7

The Transportation Safety Board of Canada’s accident report for Lac-Mégantic found 18 discrete factors that contributed to the accident. It started with a cheap and improper repair to the locomotive that resulted in the engine fire but extended to lax regulatory oversight and a culture of cost-cutting at the expense of safety at the railroad.

Additionally, regulations allowed these oil trains to operate with only one person on board — another cost-saving measure. That meant Harding did not have anyone to double-check his work braking the train.

After reviewing all of the accident’s details, Wendy Tadros, head of the Transportation Safety Board of Canada, had the following question.8

Who was the guardian of public safety? That is the role of the government to provide checks and balances and oversight, yet this booming industry where unit trains were shipping more and more oil across Canada and across the border ran largely unchecked.”

So who was held accountable for this disaster? MMA only had a small amount of insurance and quickly declared bankruptcy. The owner of MMA was not charged. And later, as part of the bankruptcy hearing, one of the largest hedge funds in the world bought the rail company and resumed moving trains through Lac-Mégantic — something strongly opposed by the residents.

While there were no immediate answers to why the fires and explosions in Lac-Mégantic were so intense, oil companies continued to load the same Bakken oil into the same DOT-111 tank cars and ship it across North America through towns and cities as if nothing had happened.

Less than six months later, in November 2013, a Bakken oil train derailed in the wetlands of rural Alabama where it exploded like the train in Lac-Mégantic and spilled over 500,000 gallons of oil.

A month later, a Bakken train derailed in Casselton, North Dakota, resulting in more mushroom clouds of fire, an oil spill of 400,000 gallons, and the evacuation of the local town. And then another Bakken oil train derailed and exploded in Canada. As the evidence piled up about the dangers of these new Bakken oil trains, rail workers began calling them “bomb trains.”9

And people in Lac-Mégantic and across North America began demanding change.

In May of 2014, a tactical unit of the Quebec provincial police force, La Sûreté du Québec, the equivalent of a U.S. SWAT unit, arrived at Thomas Harding’s house where they found him in his backyard with his son and a friend. The three were thrown to the ground, and Harding was handcuffed, despite being cooperative throughout the investigation.

The official response to what was described as a “corporate crime scene” was to blame the lowest level employee involved and send in a SWAT team to arrest him at his home. Two other employees were arrested as well. Was Thomas Harding the one who had let the growth of these oil trains go “largely unchecked”?

A columnist for Canada’s National Post called the event “embarrassing” and a “politically motivated stunt.”10

There is one more fact about this accident that makes the arrest of Harding all that more outrageous. There were three braking systems on the train parked at Nantes. There are the hand brakes, as well as two air-brake systems: the independent brake on the locomotives, and the automatic brake, which holds the rest of the rail cars in place.

Harding set the independent brake and hand brakes but did not set the automatic brake, because he was following MMA’s corporate policy.

The brakes he did apply were sufficient to hold the train. But then the locomotive caught fire that night and the fire department cut power to the engine, which led to the loss of pressure in the independent brake and the train “running away” down the hill towards Lac-Mégantic.

It would have taken Harding 10 seconds to engage the automatic brake. If this had been done, the train most likely would have remained in place until it was scheduled to continue the next morning — even with the locomotive powered down. But company policy was to not engage the automatic brake even when parking a loaded train of explosive Bakken oil on a hill above a town. Why not?

Because while it takes only 10 seconds to engage the braking system, it takes between 15 minutes and an hour to disengage the system when the train is restarted the next day. And in the rail industry, time is money. So, in order to save that time, the company simply chose not to instruct its engineers to engage the automatic brakes and enshrined this in corporate policy, as was noted in the Transportation Safety Canada report on the accident, where it states:

While MMA instructions did not allow the automatic brakes to be set following a proper hand brake effectiveness test, doing so would have acted as a temporary secondary defence, one that likely would have kept the train secured, even after the eventual release of the independent brakes.11

Harding was simply following the rules.

The Globe and Mail first reported this situation in March of 2016 in an article titled, “Ten-second procedure might have averted Lac-Mégantic disaster.”

The publication asked the Canadian regulatory agency how this could be possible:

Asked why the railway was able to issue such an instruction to its staff, Transport Canada told The Globe that its role is “to monitor railway companies for compliance with rules, regulations and standards through audits and safety inspections.” However, the department added, “Transport Canada does not approve or enforce company instructions.”12

No SWAT teams have been sent to the offices of oil or rail company executives. And yet they knowingly still ship trains full of oil in unsafe tank cars throughout North America. In 2016 — three years after the Lac-Mégantic disaster — the head of the U.S. National Transportation Safety Board warned that a “Lac-Mégantic” type accident could happen in an American city at any time.13

When Harding and two other rail employees were frog marched into court by the police after their arrest, Ghislain Champagne, the father of a woman who died in the Lac-Mégantic accident, yelled out, “It’s not them we want.”

This book is about the people Ghislain Champagne and many others would like to see held responsible for these corporate crimes. The ones who are responsible for the disaster in Lac-Mégantic and the rise of bomb trains in North America. The ones who make corporate policies that put profits over safety. And how the rise of the Bakken bomb trains in America illustrates just how badly broken the American regulatory and political system is — where corporate profits always trump the safety of citizens and the environment.

  1. Transportation Safety Board of Canada, “Lac-Mégantic runaway train and derailment investigation summary,” October 28, 2014
  2. David Crary and Sean Farrell, “In Lac-Mégantic, ‘the train from hell’”, Associated Press, July 14, 2013
  3. Justin Giovannetti,”Last moments of Lac-Mégantic: Survivors share their stories,” The Globe and Mail, November 28, 2013
  4. Alex Finnis, “Audio emerges of the panicked moment driver realised his train had derailed, killing 47 people,” DailyMail.com, August 22, 2014
  5. Erik Atkins, “‘Okay, we’re in hell’: Lac-Mégantic fire chief recounts night of train explosion”, The Globe and Mail, October 16, 2014
  6. Curtis Tate, “Railroad tank-car safety woes date decades before crude oil concerns,” McClatchy, January 27, 2014
  7. Martin Lukacs, “Quebec’s Lac-Mégantic oil train disaster not just tragedy, but corporate crime,” The Guardian, July 11, 2013
  8. Rob Gillies, “Investigators release Quebec train disaster report,” Associated Press, August 19, 2014
  9. James MacPherson and Matthew Brown, “Safety questions after ND oil train derailment,” Associated Press, December 3, 2013
  10. Matt Gurney, “Arrest of Lac Mégantic engineer an embarrassing sideshow,” National Post, May 14, 2014
  11. Transportation Safety Board of Canada, “Railway Investigation Report – R13D0054,” TSB.ca
  12. Grant Robertson, “Ten-second procedure might have averted Lac-Mégantic disaster,” The Globe and Mail, March 7, 2016
  13. Ashley Halsey III, “NTSB’s ‘10 Most Wanted’ list for 2016 underscores need for rail safety,” Washington Post, January 13, 2016
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24 comments

  1. Fiery Hunt

    Great and important post.
    I had no idea about the circumstances around the accident…more evidence of the corruption of this neoliberal corporate system.

    Infuriating.

  2. Lambert Strether

    > Harding was simply following the rules.

    This story is even more outrageous than I thought, and it was pretty outrageous to begin with.

    But executives have impunity, so move along, people, move along. There’s no story here.

    1. visitor

      My feelings, exactly.

      Whenever a railway accident occurs, one quickly hears about “human error” and individual operators being investigated. What one almost never hears is about those hidden company policies — like explicitly instructing drivers not to engage specific security mechanisms — that result in catastrophes.

  3. A

    The braking system on this oil train was based on technology designed in the late 1800s — the same braking system used on most oil trains in North America — and requires constant air pressure to keep the train braked.

    Astounding, if true. I’ve trained as a locomotive engineer, but not in North America. All air brakes I’ve seen have worked in the opposite manner: constant air pressure is required to keep the brakes open. This kind of fail-safe air brake was invented in the 1860s.

    1. marku52

      The air brakes on 18 wheel OTR trucks do operate in the fashion you describe. Air pressure is required to release the brakes. It’s a safety feature. Why locomotives operate in the reverse, I would suspect it is due to the technology being applied first there.

      To change it now would require reworking every single rail car. Probably not going to happen.

      I happened to talk to a guy who escaped the Santa Rosa fires. He had an old greyhound bus he was trying to save, but the air compressor was weak and it took about 30 minute of operation for the air pressure to come up and free the brakes.

      So he’s in this bus revving the engine, yelling “Come on, Come on”. But it was too late. the fire got to the bus before the air came up. He barely got out with his life.

    2. DW

      The brakes on the cargo cars worked as you expected: they require actively supplied pressure in the brake pipe from the compressor in the locomotive consist. I assume the quote above is an attempt to describe the brake system in the locomotive consist, which does in fact require active pressure from a running locomotive. Those brakes are typically used to slow the train, not as parking brakes. Actually, that’s what’s suppose to happen by regulation, but what happened in Lac-Megantic, and was a common practice, was that the locomotive’s brakes were still active when the hamd brake test was performed.

      FYI this info is all from the Transportation Safety Board of Canada’s report. I’ll add a link in a few.

      http://www.tsb.gc.ca/eng/rapports-reports/rail/2013/r13d0054/r13d0054-r-es.asp

      (sorry for the formatting, I’m on mobile)

  4. The Rev Kev

    Having spent some time of my misguided youth as a railway shunter, I can say now that when I read that they left the train running, unlocked, and unattended overnight and that was standard procedure I knew that they were playing fast and loose with the rules. Ideally you want to bleed the air out of the lines which can be initiated in seconds followed by putting the manual bakes on. That is something that you can turn your back on. How about if someone called it a terrorism thing and asked what if a terrorist simple jumped aboard an unattended oil train and set it in motion anywhere else in Canada or the USA. Then a locking mechanism would have to be installed ‘on the grounds of national security’ but it seems that anything connected with the oil industry gets a free pass.
    I was reading up on the DOT-111 tank car (https://en.wikipedia.org/wiki/DOT-111_tank_car) and that was just trouble in a handbag. Not only are they prone to rupture but the oil from the Bakken is considered both corrosive and volatile which may be a result of the hydraulic fracturing process. There have been other accidents involving this type of tanker and currently they want to upgrade them to what they call the DOT-117 model before 20025. In other words, they are still going to run these Bakken oil trains.
    As for that Mickey Mouse SWAT arrest, you would think that the Canadians would be embarrassed. The New Zealanders certainly were when anti-terrorism Special Tactics Group were used to raid Kim Dotcom with helicopters. In an interview after the SWAT-like arrest, the officer who issued the warrant against Thomas Harding and the others, Inspector Jacques Clouseau jnr., said that he was just following normal police protocol and did not see a problem with it.

  5. Chauncey Gardiner

    Timely post as corporations, large Wall Street banks, and wealthy families continue to use the Supreme Court’s Orwellian-named Citizens United decision to corrupt legislators, write laws that effectively grant them immunity from criminal negligence or worse, and avoid regulations and taxation that would reduce their personal incomes and individual wealth in the interest of public health and safety. That these oil trains and pipelines carrying corrosive, explosive and toxic liquids are allowed to operate without strict liability for losses and prosecution for reckless negligence or willful disregard is an abdication of the primary responsibility of government, which is the health and safety of its citizens.

    In this particular instance 47 people died, mostly children and young adults, and a small town was destroyed. Part of a broader increasing pattern of damaging and deadly behavior that is obfuscated by the corporate-owned media.

  6. JEHR

    A person can be even more specific about the reasons that rules are changed (and employees’ incomes reduced) in order to increase profits from railways: when hedge funds and private equity firms “invest” in railways, then profits become the main focus. At least four railroads in Canada are “owned” by foreign companies and all the owners have made changes that increased profits without taking due consideration for environmental and public safety. In my opinion, these railroads should be owned and run by the Canadian government as public utilities.

    1. lyman alpha blob

      My recollection is that shortly after the Lac-Megantic explosion, the railroad companies still fought any attempt at increased safety regulations which is unconscionable considering the circumstances. IIRC one proposal was simply to have two human beings per train instead of just the one that was required at the time and even that was too much for management to bear. I can’t find the article from a few years ago but this one touches on the subject: http://earthfirstjournal.org/newswire/2017/07/15/we-got-lucky-four-years-after-lac-megantic-another-oil-train-accident/

      Its the railroad execs who should be on trial here, not the engineers.

  7. Light-a-Candle

    Thanks NC for posting this excellent well-written article and its thoughtful analysis and insights.

    Canadian mainstream media almost ignored this trial and even supported the establishment’s attempt to scapegoat the workers.

    Really disgusting establishment actions, including the completely excessive and unnecessary SWAT team arrests and FOUR government lawyers trying to manufacture a case for three years. Glad to see the jury doing the right thing. Seems like the judge was rightfully skeptical of government’s motivations too.

    (And TPTB have done nothing to protect other towns from this same type of rolling disaster).

  8. Altandmain

    As a Canadian, I am disgusted that of MLA’s executives, along with senior members of the Harper administration who approved of this mess are not in jail.

    They created a culture of prioritizing greed over safety. That is why this whole tragedy occurred.

  9. Altandmain

    As a Canadian, I am disgusted that of MLA’s executives, along with senior members of the Harper administration who approved of this mess are not in jail.

    They created a culture of prioritizing greed over safety. That is why this whole tragedy occurred.

    Our media has been a disgrace too. They are like the American media. The media’s job it seems is to force the views of its owners on the public.

  10. Ken

    “Investigations later revealed that Harding made a critical error that night. After applying manual hand brakes on the locomotives and two tank cars, he was supposed to turn off the air braking system and make sure that the hand brakes would hold the train on their own. He ran that test with the air brakes on, which combined with the hand brakes, provided sufficient braking force to keep the train in place.”

    Train engineer Harding was clearly at fault. He did not do his job correctly. There is plenty of blame to go around, but operating within the rules and instructions from the company (insufficient or defective as they might be), Harding failed to take all reasonable safety precautions.

    1. Paul Jurczak

      Agreed. There is plenty of corporate and regulatory malfeasance to write about, but the key contributing factor to this awful accident was an error made by Harding. It doesn’t justify sending a SWAT team to arrest him. It does justify a complete review of safety procedures. For example, the supervisor who allowed excessive smoke generating locomotive to run unattended coupled to the train with highly flammable cargo, should not have done so. Fire department intervention to extinguish locomotive fire should be followed by immediate on-site inspection by MMA supervisor to verify the train is safe. It should go all the way to the top where corporate profit versus public safety ratio is determined.

  11. witters

    “Harding failed to take all reasonable safety precautions.” …failed to take all reasonable safety precautions… Now apply this criterion carfully and comprehensively…

  12. VietnamVet

    This is the essence of deregulation. Make a profit, get rich, and place all the risks and costs on society. Just like the Talgo Train crash in Washington State, cost cutting enabled the engineer’s error that then turned into a deadly disaster.

    No different than FDA’s approval of Oxycontin for the Sackler family. Opioids are killing more Americans than AIDS at its peak.

  13. Jean

    ONE engineer running the train, no brakeman, no one in the caboose because they stopped using those a long time ago. Just think of all the money the railroad saved by having ONE guy running the train.

    The directors of this railroad should go to prison for murder, the shareholders should be held liable and all railroad property seized and sold off for damages.

    Something stinks and is bass ackwards about the brake story. Did this train not use Westinghouse safety brakes that have been standard and required technology since the 1800s?

    In this braking system, found on all railroad equipment in North America, AFAIK, the brakes shoes are held away from the wheels, that is the brakes are off, as long as there is sufficient air pressure generated from the locomotive. In an accident, or the locomotive’s air compressor shutting off for any reason, the air pressure drops and the brake shoes on each car are pushed into the wheels by powerful springs.

    Those hoses connecting each car under the coupler are air hoses. Should a car or a train break in the middle, the air hoses separate and the brakes all along that line of cars go on.
    The valves at the end of each car can be shut, holding enough air in the car’s air reservoir to allow it to be moved, but the valves would all be open in a line of cars.

    1. Igor

      It works that way if pressure is removed suddenly, like when a train coupling breaks. If the train line gradually loses pressure over a period of hours, the accumulators will slowly leak out as well, and there will be no pressure differential to activate the brakes. This is what happened in this case. The air brakes are there to stop moving trains; they aren’t designed to operate when the train is shut down. The manual brakes are the primary safety device for parked trains; the other brakes are there mostly as additional redundancy (just like leaving a car in gear when parking is a good idea, but not a substitute for the parking brake).

      The critical errors that Harding committed that directly caused this accident was (1) not setting manual brakes on enough cars to hold the train stationary and (2) not following the proper procedure for testing the effectiveness of manual brakes, thus failing to detect the problem. The fact that his employer
      and Canadian regulators were also negligent in many ways is not an excuse for his own failings.

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