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10 Hazardous Materials Transportation Incident Data for Root Cause Analysis
Table 1-1. Root cause questioning.
Question Response
Why did the truck run off the road? The driver fell asleep.
Why did the driver fall asleep? Driver has sleep apnea.
Why were you not aware of this disease? We did not have an up-to-date medical record.
Our written procedure did not require us to check if
Why did no one check that he had an outdated
employees had not updated their medical records
medical record?
in the last year.
five major parameters with key variables under each is presented in Table 1-2, where the con-
ditions described in this example are shaded.
Note that, in addition to these major parameters, institutional characteristics, such as com-
pany financial condition, organizational structure, and safety culture, can play an important role
in contributing to accident potential. For the purposes of this study, it is assumed that these con-
siderations are embedded in the likelihood that the major parameter variables emerge as causal
factors. For example, an organization with a poor safety culture is more likely to utilize a young
driver with little experience and an invalid license. Unfortunately, the science on the relation-
ship of "company organization" or "safety culture" to safety is still sufficiently new that there is
no well-defined set of variables capturing the salient characteristics of "company organization"
and "safety culture" that could be implemented feasibly.
1.2 Research Approach
For the project, the following research approach was used.
1.2.1 Literature Review
The research team examined the literature related to hazmat crash databases, including those
that may be dominated by non-hazmat crashes, to determine how the problem of identifying
root causes had been addressed in the past. Part of the literature review was aimed at gaining
insight into how root cause analysis should be conducted and lessons learned in other research
Table 1-2. Accident parameters.
Vehicle Driver Packaging Infrastructure Situational
Pre-Crash
Configuration Age Package Type Road Surface
Condition
Cargo Body Experience Quantity Shipped Road Condition Dangerous Event
GVW Condition Quantity Lost Road Type Vehicle Speed
Vehicle Defect Valid License Age (Cargo Tank) Traffic Way Impact Location
Rollover
Vehicle Response Citation Issued Access Control Primary Reason
Protection
Driver Response Inspection History Speed Limit Accident Type
Design
Training No. of Lanes Weather Condition
Specification
Location Light Condition
Time of Day
Health
Consequences
Note: Shading reflects contributing factors to root cause of the hypothetical hazmat tank truck crash described in Section 1.1.
