The inquiry concluded that no one individual was to blame, instead it condemned what Foisy described as a "railroader culture" that prized loyalty and productivity at the expense of safety. As an example of lax attitudes to safety, Foisy noted that engineering crews that took over trains at Edson did so "on the fly". While the locomotive was moving slowly through the yard, the new crew would jump on and the previous crew would jump off. While this method saved time and fuel, it was a flagrant violation of safety regulations which required stationary brake tests after a crew change. Management claimed to be unaware of this practice, even though it was quite common. In regards to engineer John Hudson, the Foisy Commission concluded it was a possibility that the collision happened because he had either fallen asleep at the controls or had suffered a heart attack or stroke due his extremely poor health.