WINNIPEG -- The Transportation Safety Board of Canada has finished its investigation regarding a train derailment in Ponton Man. in September 2018, which killed one person and injured another.

The TSB said it "identified a number of factors" that caused the track to washout in the area.

On Sept. 15, 2018, a Hudson Bay Railway train was travelling north on the Wekusko Subdivision when the three head-end train and the first four cars derailed around 4:30 p.m. Police said they weren't told about the crash until 5:45 p.m. and officers didn't arrive until around 7 p.m.

The crew was trapped and the conductor died from his injuries, while the train engineer was rescued and taken to hospital in critical condition.

The conductor was identified as 38-year-old Kevin Anderson and the medical examiner determined he died from several blunt force injuries.

The TSB said the train's fuel tanks ruptured and released 6,800 litres of diesel fuel.

Police had also said the train was carrying liquid petroleum gas which was a significant hazard for all first responders.

The TSB said it identified gaps in the emergency response.

"HBR’s emergency response plan had not been reviewed by the regulator and did not set forth any processes or procedures for responding to a train derailment, particularly one that involved dangerous goods and employee injuries/fatalities, occurring in a remote location," the report said.

The TSB also found that although track inspections had been done and water was flowing through the culverts at the time of the inspection, rising water levels and uneven ponding against the embankment led to the track failure.

"The area had experienced heavy precipitation throughout the summer which contributed to the high water conditions. Furthermore, the reduction of HBR’s beaver control program left the track infrastructure vulnerable to a washout, particularly in situations when a beaver dam is breached."

The TSB said the railway company has made several changes since the incident, including a more comprehensive beaver control program, an updated security and emergency response plan and safety management system, and its communication policy and requirements were changed as crews are now required to check in every hour when operating in "dark territory."

ANDERSON'S FAMILY RESPONDS

Reached by phone in The Pas, Man., Anderson’s mom, Debbie Leeper, told CTV News she’s read the report from the TSB and wasn’t surprised by the agency’s findings. She said her family was already well aware of the factors that led to the crash before the report was released, adding the issues raised don’t change the outcome.

“It doesn’t change the fact it happened,” said Leeper, during a brief telephone call. “After it did happen, it doesn’t change the fact these men suffered and my son died.”

Leeper said she’s hopeful an inquest called by Manitoba’s Chief Medical Examiner will help shed more light on the circumstances surrounding his death.

In addition to reviewing the circumstances of Anderson’s death, the Chief Medical Examiner’s office has previously said the inquest will review the coordination of a multi-agency response to a serious incident in a remote setting, and examine policies and protocols used by police, paramedics, and other first responders in a potentially dangerous setting.

No date for the inquest has been announced.

TEAMSTERS CANADA REVIEWING REPORT

Teamsters Canada, which represents 125,000 members in all industries across the country, said it is reviewing the TSB's report.

"Shedding light on the circumstances surrounding the fatal Ponton derailment is essential to the ongoing healing process. Teamsters are currently reviewing this report and gathering feedback from front-line union representatives," said Christopher Monette, director of Public Affairs for Teamster Canada.

Monette said because they are gathering feedback they will not be able to provide comment on the specific content in the report at this time.

- With files from CTV's Stephanie Tsicos and Beth Macdonell