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HMCRP HAZARDOUS MATERIALS COOPERATIVE RESEARCH PROGRAM REPORT 1 Sponsored by the Pipeline and Hazardous Materials Safety Hazardous Materials Administration Transportation Incident Data for Root Cause Analysis

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TRANSPORTATION RESEARCH BOARD 2009 EXECUTIVE COMMITTEE* OFFICERS CHAIR: Adib K. Kanafani, Cahill Professor of Civil Engineering, University of California, Berkeley VICE CHAIR: Michael R. Morris, Director of Transportation, North Central Texas Council of Governments, Arlington EXECUTIVE DIRECTOR: Robert E. Skinner, Jr., Transportation Research Board MEMBERS J. Barry Barker, Executive Director, Transit Authority of River City, Louisville, KY Allen D. Biehler, Secretary, Pennsylvania DOT, Harrisburg Larry L. Brown, Sr., Executive Director, Mississippi DOT, Jackson Deborah H. Butler, Executive Vice President, Planning, and CIO, Norfolk Southern Corporation, Norfolk, VA William A.V. Clark, Professor, Department of Geography, University of California, Los Angeles David S. Ekern, Commissioner, Virginia DOT, Richmond Nicholas J. Garber, Henry L. Kinnier Professor, Department of Civil Engineering, University of Virginia, Charlottesville Jeffrey W. Hamiel, Executive Director, Metropolitan Airports Commission, Minneapolis, MN Edward A. (Ned) Helme, President, Center for Clean Air Policy, Washington, DC Randell H. Iwasaki, Director, California DOT, Sacramento Susan Martinovich, Director, Nevada DOT, Carson City Debra L. Miller, Secretary, Kansas DOT, Topeka Neil J. Pedersen, Administrator, Maryland State Highway Administration, Baltimore Pete K. Rahn, Director, Missouri DOT, Jefferson City Sandra Rosenbloom, Professor of Planning, University of Arizona, Tucson Tracy L. Rosser, Vice President, Regional General Manager, Wal-Mart Stores, Inc., Mandeville, LA Rosa Clausell Rountree, CEOGeneral Manager, Transroute International Canada Services, Inc., Pitt Meadows, BC Steven T. Scalzo, Chief Operating Officer, Marine Resources Group, Seattle, WA Henry G. (Gerry) Schwartz, Jr., Chairman (retired), Jacobs/Sverdrup Civil, Inc., St. Louis, MO C. Michael Walton, Ernest H. Cockrell Centennial Chair in Engineering, University of Texas, Austin Linda S. Watson, CEO, LYNXCentral Florida Regional Transportation Authority, Orlando Steve Williams, Chairman and CEO, Maverick Transportation, Inc., Little Rock, AR EX OFFICIO MEMBERS Thad Allen (Adm., U.S. Coast Guard), Commandant, U.S. Coast Guard, Washington, DC Peter H. Appel, Administrator, Research and Innovative Technology Administration, U.S.DOT J. Randolph Babbitt, Administrator, Federal Aviation Administration, U.S.DOT Rebecca M. Brewster, President and COO, American Transportation Research Institute, Smyrna, GA George Bugliarello, President Emeritus and University Professor, Polytechnic Institute of New York University, Brooklyn; Foreign Secretary, National Academy of Engineering, Washington, DC James E. Caponiti, Acting Deputy Administrator, Maritime Administration, U.S.DOT Cynthia Douglass, Acting Deputy Administrator, Pipeline and Hazardous Materials Safety Administration, U.S.DOT LeRoy Gishi, Chief, Division of Transportation, Bureau of Indian Affairs, U.S. Department of the Interior, Washington, DC Edward R. Hamberger, President and CEO, Association of American Railroads, Washington, DC John C. Horsley, Executive Director, American Association of State Highway and Transportation Officials, Washington, DC Rose A. McMurry, Acting Deputy Administrator, Federal Motor Carrier Safety Administration, U.S.DOT Ronald Medford, Acting Deputy Administrator, National Highway Traffic Safety Administration, U.S.DOT Victor M. Mendez, Administrator, Federal Highway Administration, U.S.DOT William W. Millar, President, American Public Transportation Association, Washington, DC Peter M. Rogoff, Administrator, Federal Transit Administration, U.S.DOT Joseph C. Szabo, Administrator, Federal Railroad Administration, U.S.DOT Polly Trottenberg, Assistant Secretary for Transportation Policy, U.S.DOT Robert L. Van Antwerp (Lt. Gen., U.S. Army), Chief of Engineers and Commanding General, U.S. Army Corps of Engineers, Washington, DC *Membership as of October 2009.

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HAZARDOUS MATERIALS COOPERATIVE RESEARCH PROGRAM HMCRP REPORT 1 Hazardous Materials Transportation Incident Data for Root Cause Analysis BATTELLE MEMORIAL INSTITUTE Columbus, OH Subject Areas Planning and Administration and Environment Operations and Safety Freight Transportation Research sponsored by the Pipeline and Hazardous Materials Safety Administration TRANSPORTATION RESEARCH BOARD WASHINGTON, D.C. 2009 www.TRB.org

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HAZARDOUS MATERIALS COOPERATIVE HMCRP REPORT 1 RESEARCH PROGRAM The safety, security, and environmental concerns associated with Project HM-02 transportation of hazardous materials are growing in number and ISSN 2150-4849 complexity. Hazardous materials are substances that are flammable, ISBN: 978-0-309-11810-1 explosive, or toxic or that, if released, produce effects that would threaten Library of Congress Control Number 2009940430 human safety, health, the environment, or property. Hazardous materials 2009 National Academy of Sciences. All rights reserved. are moved throughout the country by all modes of freight transportation, including ships, trucks, trains, airplanes, and pipelines. The private sector and a diverse mix of government agencies at all levels are responsible for controlling the transport of hazardous materials and for COPYRIGHT INFORMATION ensuring that hazardous cargoes move without incident. This shared goal Authors herein are responsible for the authenticity of their materials and for obtaining has spurred the creation of several venues for organizations with related written permissions from publishers or persons who own the copyright to any previously interests to work together in preventing and responding to hazardous published or copyrighted material used herein. materials incidents. The freight transportation and chemical industries; Cooperative Research Programs (CRP) grants permission to reproduce material in this government regulatory and enforcement agencies at the federal and state publication for classroom and not-for-profit purposes. Permission is given with the levels; and local emergency planners and responders routinely share understanding that none of the material will be used to imply TRB, AASHTO, FAA, FHWA, FMCSA, FTA, RITA, or PHMSA endorsement of a particular product, method, or practice. information, resources, and expertise. Nevertheless, there has been a long- It is expected that those reproducing the material in this document for educational and not- standing gap in the system for conducting hazardous materials safety and for-profit uses will give appropriate acknowledgment of the source of any reprinted or security research. Industry organizations and government agencies have reproduced material. For other uses of the material, request permission from CRP. their own research programs to support their mission needs. Collaborative research to address shared problems takes place occasionally, but mostly occurs on an ad hoc basis. NOTICE Acknowledging this gap in 2004, the U.S. DOT Office of Hazardous The project that is the subject of this report was a part of the Hazardous Materials Materials Safety, the Federal Motor Carrier Safety Administration, the Cooperative Research Program conducted by the Transportation Research Board with the Federal Railroad Administration, and the U.S. Coast Guard pooled their approval of the Governing Board of the National Research Council. Such approval reflects resources for a study. Under the auspices of the Transportation Research the Governing Board's judgment that the program concerned is of national importance and Board (TRB), the National Research Council of the National Academies appropriate with respect to both the purposes and resources of the National Research Council. appointed a committee to examine the feasibility of creating a cooperative research program for hazardous materials transportation, similar in concept The members of the technical committee selected to monitor this project and to review this to the National Cooperative Highway Research Program (NCHRP) and the report were chosen for recognized scholarly competence and with due consideration for the balance of disciplines appropriate to the project. The opinions and conclusions expressed Transit Cooperative Research Program (TCRP). The committee concluded, or implied are those of the research agency that performed the research, and, while they have in TRB Special Report 283: Cooperative Research for Hazardous Materials been accepted as appropriate by the technical committee, they are not necessarily those of Transportation: Defining the Need, Converging on Solutions, that the need for the Transportation Research Board, the National Research Council, and the Pipeline and cooperative research in this field is significant and growing, and the Hazardous Materials Safety Administration, U.S. Department of Transportation. committee recommended establishing an ongoing program of cooperative Each report is reviewed and accepted for publication by the technical committee according research. In 2005, based in part on the findings of that report, the Safe, to procedures established and monitored by the Transportation Research Board Executive Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Committee and the Governing Board of the National Research Council. Users (SAFETEA-LU) authorized the Pipeline and Hazardous Materials The Transportation Research Board of the National Academies, the National Research Safety Administration (PHMSA) to contract with the National Academy of Council, the Federal Highway Administration, the Research and Innovative Technology Administration, and the Hazardous Materials Cooperative Research Program do not Sciences to conduct the Hazardous Materials Cooperative Research Program endorse products or manufacturers. Trade or manufacturers' names appear herein solely (HMCRP). The HMCRP is intended to complement other U.S. DOT because they are considered essential to the object of this report. research programs as a stakeholder-driven, problem-solving program, researching real-world, day-to-day operational issues with near- to mid- term time frames. Published reports of the HAZARDOUS MATERIALS COOPERATIVE RESEARCH PROGRAM are available from: Transportation Research Board Business Office 500 Fifth Street, NW Washington, DC 20001 and can be ordered through the Internet at: http://www.national-academies.org/trb/bookstore Printed in the United States of America

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COOPERATIVE RESEARCH PROGRAMS CRP STAFF FOR HMCRP REPORT 1 Christopher W. Jenks, Director, Cooperative Research Programs Crawford F. Jencks, Deputy Director, Cooperative Research Programs William C. Rogers, Senior Program Officer Eileen P. Delaney, Director of Publications HMCRP PROJECT 02 PANEL Lori Pavlish, Dow Chemical Company, Scadrift, TX (Chair) John L. Conley, National Tank Truck Carriers, Inc., Arlington, VA Ronald J. Duych, Bureau of Transportation Statistics, Washington, DC Phil Olekszyk, World Wide Rail, Inc., Gloucester, VA William R. Rhyne, Kingston, TN E. Jan Skouby, Missouri Department of Transportation Robert A. Richard, PHMSA Liaison Thomas Palmerlee, TRB Liaison

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FOREWORD By William C. Rogers Staff Officer Transportation Research Board While there has been considerable progress in the development of hazardous materials accident databases, the coverage of incidents reported to the U.S. Department of Transporta- tion is insufficiently comprehensive for identifying root causes or contributors to incidents. This research focused on potential technical improvements to hazardous materials accident databases that are collected and managed by various agencies. The research identified gaps and redundancies in reporting requirements and estimated the extent of the under-reporting of serious incidents. The scope included all transportation modes covered by 49 CFR Parts 100180. The report can be used by public agencies and industry to identify and prioritize measures that could further enhance the usefulness of hazardous materials transportation incident data. The suggested technical improvements are those of the research team and not the Transportation Research Board or the National Research Council. Publicly reported incidents can be used for understanding the root causes of, or major contributors to, events involving a spill or release of hazardous materials during, or inci- dental to, transportation. This understanding can be used by regulators and industry to pri- oritize areas for attention and to develop or improve safety recommendations, regulations, and programs focused on preventing or reducing the likelihood of future incidents. How- ever, complete, detailed, and accurate data are needed for meaningful analyses that reflect actual issues, and there is concern that the coverage of incidents reported to the U.S. Depart- ment of Transportation (under 49 CFR 171.16) is not sufficiently comprehensive. Under HMCRP Project 02, Battelle Memorial Institute, along with the University of Michigan Transportation Research Institute, Calspan, RA-LUX, Mark Abkowitz, and Christopher Barkan, examined the recent literature on hazardous materials transportation incidents; interviewed carriers, shippers, and federal database managers; conducted detailed database analyses; and provided suggested technical changes to the databases that could improve the availability and quality of hazardous materials transportation incident data. The report also describes a pilot program to link the Hazardous Materials Incident Report- ing System (HMIRS) and the Motor Carrier Management Information System (MCMIS) that could show how such an enhancement might more effectively identify root causes.

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CONTENTS 1 Summary 9 Chapter 1 Introduction 9 1.1 Project Purpose 10 1.2 Research Approach 10 1.2.1 Literature Review 11 1.2.2 Survey of Agencies, Shippers, and Carriers 11 1.2.3 Analysis of Databases 12 1.3 Effective Methods to Ensure High-Quality Data 13 1.4 Potential Measures to Enhance the Ability of Databases to Identify the Root Causes of Hazmat Crashes 14 Chapter 2 Literature Review 14 2.1 Introduction 14 2.2 Synopses of Relevant Studies 14 2.2.1 Rail Equipment--Train Accident Data 15 2.2.2 Project 5 Overview--Developing Common Data on Accident Circumstances 16 2.2.3 "National Crash Data Bases Underestimate Underride Statistics" 16 2.2.4 Transportation Research Circular 231: Truck Accident Data Systems: State-of-the-Art Report 17 2.2.5 Accident Models for Two-Lane Rural Roads: Segments and Intersections 17 2.2.6 The Human Factors Analysis and Classification System--HFACS 18 2.2.7 "Human Factors Root Cause Analysis of Accidents/Incidents Involving Remote Control Locomotive Operations" 18 2.2.8 Large Truck Crash Causation Study (LTCCS) Analysis Series: Using LTCCS Data for Statistical Analyses of Crash Risk 18 2.2.9 Highway Safety: Further Opportunities Exist to Improve Data on Crashes Involving Commercial Motor Vehicles 19 2.2.10 In-Depth Accident Causation Data Study Methodology Development Report (SafetyNet) 19 2.2.11 Comprehensive Safety Analysis 2010: 2006 Listening Session 20 2.2.12 Safety Report: Transportation Safety Databases 20 2.2.13 Illinois Department of Transportation Crash Data Process Audit 20 2.2.14 User's Guide to Federal Accidental Release Databases 20 2.2.15 Comparative Risks of Hazardous Materials and Non-Hazardous Materials Truck Shipment Accidents/Incidents 20 2.2.16 Hazardous Materials Serious Crash Analysis: Phase 2 21 2.2.17 Unified Reporting of Commercial and Non-Commercial Traffic Accidents 21 2.2.18 "Crashes Involving Long Combination Vehicles: Data Quality Problems and Recommendations for Improvement" 21 2.2.19 "Use of Emerging Technologies for Marine Accident Data Analysis Visualization and Quality Control"

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21 2.3 Summary of Findings and Implications 22 2.3.1 Data and Analysis Problems 22 2.3.2 Solutions Being Implemented or Under Consideration 23 Chapter 3 Summary of Interviews with Carriers, Shippers, and Database Managers 23 3.1 Introduction 24 3.2 Summary of Responses from Carriers 25 3.2.1 Carrier Satisfaction with HMIRS 26 3.2.2 Carrier Satisfaction with MCMIS 26 3.3 Shipper Responses 26 3.3.1 Shipper 1 27 3.3.2 Shipper 2 28 3.4 Interviews with Database Managers 28 3.4.1 Interviews with Agencies Maintaining Databases (PHMSA) 29 3.4.2 Interviews with Agencies Maintaining Databases (FMCSA) 30 3.4.3 Interviews with Agencies Maintaining Databases (FRA) 31 3.5 Summary of Findings from Interviews 32 Chapter 4 Database Analysis 32 4.1 Motor Carrier Management Information System (MCMIS) 32 4.1.1 MCMIS Database Description 33 4.1.2 Location and Ownership of Data 33 4.1.3 Database Format 34 4.1.4 Threshold for Exclusion or Inclusion 34 4.1.5 Years of Coverage 34 4.1.6 Types of Fields Covered 35 4.1.7 Database Purpose and Function 36 4.1.8 Data Collection 36 4.1.9 Data Compilation 36 4.1.10 Accuracy and Completeness of Data 37 4.1.11 Identification of Hazmat Incidents in MCMIS 42 4.1.12 Quality Control Process 43 4.1.13 Interconnectivity with Other Databases 44 4.1.14 Analyses Using Database 45 4.1.15 Summary and Potential Measures for Improving Root Cause Analysis 46 4.2 Hazardous Materials Incident Reporting System (HMIRS) 47 4.2.1 Database Description 49 4.2.2 Purpose and Function 49 4.2.3 Data Collection 50 4.2.4 Data Compilation 50 4.2.5 Accuracy and Completeness of Data 54 4.2.6 Quality Control Process 54 4.2.7 Interconnectivity with Other Databases 54 4.2.8 Analyses Using Database 60 4.2.9 Summary and Potential Measures for Improving Root Cause Analysis 61 4.3 Fatality Analysis Reporting System (FARS) 62 4.3.1 Agencies/Organizations Responsible for Data Collection and Entry 62 4.3.2 Database Years of Coverage

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62 4.3.3 Criteria for Reporting and Inclusion of Data 62 4.3.4 Types of Hazmat Data Included 63 4.3.5 Usefulness of the Data for Determining Root Causes 63 4.3.6 Data Quality 64 4.3.7 Additional Fields 65 4.3.8 Potential Measures to Improve Data Quality 65 4.3.9 Compatibility with Other Databases 66 4.3.10 Data Uses 66 4.4 Trucks Involved in Fatal Accidents (TIFA) 66 4.4.1 Agencies/Organizations Responsible for Collecting and Entering Data into Database 66 4.4.2 Database Years of Coverage 66 4.4.3 Criteria for Reporting and Inclusion of Data 66 4.4.4 Types of Hazmat Data Included 67 4.4.5 Usefulness of the Data for Determining Root Causes 71 4.4.6 Data Quality 71 4.4.7 Additional Fields 72 4.4.8 Potential Measures to Improve Data Quality 72 4.4.9 Compatibility with Other Databases 72 4.4.10 Data Uses 73 4.5 Large Truck Crash Causation Study (LTCCS) 73 4.5.1 Database Description 74 4.5.2 Purpose and Function 74 4.5.3 Data Collection 75 4.5.4 Data Compilation 75 4.5.5 Accuracy and Completeness of Data 75 4.5.6 Quality Control 75 4.5.7 Interconnectivity with Other Databases 76 4.5.8 Analyses Using Database 78 4.5.9 Summary and Potential Measures to Improve Root Cause Analysis 79 4.6 Railroad Accident/Incident Reporting System (RAIRS) 80 4.6.1 Track, Roadbed, and Structures 81 4.6.2 Signal and Communication 81 4.6.3 Mechanical and Electrical Failures 82 4.6.4 Train Operation--Human Factors 82 4.6.5 Summary of Causes and Impact 84 4.7 Marine Information for Safety and Law Enforcement (MISLE) 84 4.7.1 Database Description 84 4.7.2 Purpose and Function 84 4.7.3 Data Collection 85 4.7.4 Data Compilation 85 4.7.5 Accuracy and Completeness 86 4.7.6 Quality Control 86 4.7.7 Interconnectivity with Other Databases 86 4.7.8 Analyses Using Database 86 4.7.9 Summary and Potential Measures for Improving Root Cause Analysis 86 4.8 NTSB Accident Investigations and Reports 86 4.8.1 Scope of Investigations 87 4.8.2 Approach to Identifying Root Causes 88 4.8.3 Insights for Analyzing Root Cause

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88 4.8.4 Data Quality 89 4.8.5 Probable Cause Findings 90 4.8.6 Summary 91 4.9 The Hazmat Serious Truck Crash Project Database 91 4.9.1 Introduction 92 4.9.2 Adding Explanatory Variables to the Hazmat Accident Database 92 4.9.3 Crash Records Selection 92 4.9.4 Populating Records and Improving Data Quality 93 4.9.5 Quality Control Checks 93 4.9.6 Database Enhancements and Limitations 94 4.9.7 Summary 95 Chapter 5 Potential Measures for Improving the Identification of Root Causes for Hazardous Materials Crashes 95 5.1 Introduction 95 5.2 Information System Development 96 5.2.1 Develop Framework for Identifying Contributing Causes and Root Causes of Hazardous Material Accidents 97 5.2.2 Availability of Carrier Characteristics Inventory Information for Analysis with Accident Data 97 5.2.3 Add or Modify Inventory Data in Databases 98 5.2.4 Link Data from HMIRS, MCMIS, RAIRS, and Other Information Sources 98 5.2.5 Develop a System for Each Database That Will Target About 5% of Hazmat Crashes for More Detailed Investigation 99 5.3 Improving the Effectiveness of All Databases Required to Identify Root Causes 99 5.3.1 Ensure Data Completeness and Accuracy 99 5.3.2 Complete Values for All Parameters 103 5.4 Potential Measures for Improving Capability of Specific Databases to Identify Root Causes 103 5.4.1 Potential Measures for MCMIS 105 5.4.2 Potential Measures for HMIRS 107 5.4.3 Potential Measures for TIFA 108 5.4.4 Potential Measures for RAIRS 109 5.5 Conclusions 109 5.6 Follow-On Project 110 References 112 Appendices