In sections 7.54, 7.55 and 7.56 of your report, you point out that inspection and audit documentation on the safety management system was missing elements, particularly in terms of follow-up on deficiencies. On that note, let me draw your attention to the fact that, if a company is responsible for the death of about 50 people, one can only conclude that it has never been inspected properly.
The deputy minister said that it is important to ensure that a safety culture is instilled in railway companies. However, in a case where there is no safety culture, the Department of Transport was not even able to review or rectify the situation.
Could you describe the deficiencies and the lack of follow-up observed? We were able to see the consequences for ourselves.