The National Transportation Safety Board issued a report on February 14, 2012, finding a Canadian railroad at fault for a train derailment in 2009 near Rockford, Illinois, that led to a woman’s death.

In the report, the Canadian National Railway was cited for its “inadequate emergency communication procedures,” which prevented it from notifying one of its trains about a track washout. The train derailed, causing 19 of its ethanol-laden tank cars to slide off the tracks and explode. A Rockford woman who was in a car nearby died, and her pregnant daughter lost her unborn child.

The safety board chairwoman said at a hearing in Washington that “there were missteps and miscommunications, procedures not followed and poor decisions made. There were multiple points where this catastrophe could have been averted, but it was not.”

The report noted inadequate Canadian National weather policies and a deficient stormwater drainage system at the site. It issued 15 safety recommendations for the railway, federal agencies, the railroad industry and other groups.

Immediately following the accident on June 19, 2009, residents of 600 homes in Cherry Valley were evacuated. Damages were said to be $7.9 million. In an October 2011 Cook County Court, Canadian National agreed to pay the family impacted by the accident $36.2 million.

The railway company was also faulted for not posting identification information and an emergency contact number at the crossing where the accident occurred. If the information had been posted, “the railroad would likely have been notified of the track washout earlier, and the additional time may have been sufficient for the rail traffic controller to issue instructions to stop the train,” according to the report.

Canadian National was also cited for the inadequate design of its tank cars, which made them subject to damage and catastrophic loss of hazardous materials during the derailment.