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HMCRP Report 1: Hazardous Materials Transportation Incident Data for Root Cause Analysis (2009)
Hazardous Material Cooperative Research Program (HMCRP)

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Transportation Research Board. "2.2.2 Project 5 Overview - Developing Common Data on Accident Circumstances." HMCRP Report 1: Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press, 2009.

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Page
15
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Page
15
Front Matter (R1-R11)
Summary (1-8)
1.1 Project Purpose (9-9)
1.2.1 Literature Review (10-10)
1.2.3 Analysis of Databases (11-11)
1.3 Effective Methods to Ensure High-Quality Data (12-12)
1.4 Potential Measures to Enhance the Ability of Databases to Identify the Root Causes of Hazmat Crashes (13-13)
2.2.1 Rail Equipment - Train Accident Data (14-14)
2.2.2 Project 5 Overview - Developing Common Data on Accident Circumstances (15-15)
2.2.4 Transportation Research Circular 231: Truck Accident Data Systems: State-of-the-Art Report (16-16)
2.2.6 The Human Factors Analysis and Classification System - HFACS (17-17)
2.2.9 Highway Safety: Further Opportunities Exist to Improve Data on Crashes Involving Commercial Motor Vehicles (18-18)
2.2.11 Comprehensive Safety Analysis 2010: 2006 Listening Session (19-19)
2.2.16 Hazardous Materials Serious Crash Analysis: Phase 2 (20-20)
2.3 Summary of Findings and Implications (21-21)
2.3.2 Solutions Being Implemented or Under Consideration (22-22)
3.1 Introduction (23-23)
3.2 Summary of Responses from Carriers (24-24)
3.2.1 Carrier Satisfaction with HMIRS (25-25)
3.3.1 Shipper 1 (26-26)
3.3.2 Shipper 2 (27-27)
3.4.1 Interviews with Agencies Maintaining Databases (PHMSA) (28-28)
3.4.2 Interviews with Agencies Maintaining Databases (FMCSA) (29-29)
3.4.3 Interviews with Agencies Maintaining Databases (FRA) (30-30)
3.5 Summary of Findings from Interviews (31-31)
4.1.1 MCMIS Database Description (32-32)
4.1.3 Database Format (33-33)
4.1.6 Types of Fields Covered (34-34)
4.1.7 Database Purpose and Function (35-35)
4.1.10 Accuracy and Completeness of Data (36-36)
4.1.11 Identification of Hazmat Incidents in MCMIS (37-41)
4.1.12 Quality Control Process (42-42)
4.1.13 Interconnectivity with Other Databases (43-43)
4.1.14 Analyses Using Database (44-44)
4.1.15 Summary and Potential Measures for Improving Root Cause Analysis (45-45)
4.2 Hazardous Materials Incident Reporting System (HMIRS) (46-46)
4.2.1 Database Description (47-48)
4.2.3 Data Collection (49-49)
4.2.5 Accuracy and Completeness of Data (50-53)
4.2.8 Analyses Using Database (54-59)
4.2.9 Summary and Potential Measures for Improving Root Cause Analysis (60-60)
4.3 Fatality Analysis Reporting System (FARS) (61-61)
4.3.4 Types of Hazmat Data Included (62-62)
4.3.6 Data Quality (63-63)
4.3.7 Additional Fields (64-64)
4.3.9 Compatibility with Other Databases (65-65)
4.4.4 Types of Hazmat Data Included (66-66)
4.4.5 Usefulness of the Data for Determining Root Causes (67-70)
4.4.7 Additional Fields (71-71)
4.4.10 Data Uses (72-72)
4.5.1 Database Description (73-73)
4.5.3 Data Collection (74-74)
4.5.7 Interconnectivity with Other Databases (75-75)
4.5.8 Analyses Using Database (76-77)
4.5.9 Summary and Potential Measures to Improve Root Cause Analysis (78-78)
4.6 Railroad Accident/Incident Reporting System (RAIRS) (79-79)
4.6.1 Track, Roadbed, and Structures (80-80)
4.6.3 Mechanical and Electrical Failures (81-81)
4.6.5 Summary of Causes and Impact (82-83)
4.7.3 Data Collection (84-84)
4.7.5 Accuracy and Completeness (85-85)
4.8.1 Scope of Investigations (86-86)
4.8.2 Approach to Identifying Root Causes (87-87)
4.8.4 Data Quality (88-88)
4.8.5 Probable Cause Findings (89-89)
4.8.6 Summary (90-90)
4.9.1 Introduction (91-91)
4.9.4 Populating Records and Improving Data Quality (92-92)
4.9.6 Database Enhancements and Limitations (93-93)
4.9.7 Summary (94-94)
5.2 Information System Development (95-95)
5.2.1 Develop Framework for Identifying Contributing Causes and Root Causes of Hazardous Material Accidents (96-96)
5.2.3 Add or Modify Inventory Data in Databases (97-97)
5.2.5 Develop a System for Each Database That Will Target About 5% of Hazmat Crashes for More Detailed Investigation (98-98)
5.3.2 Complete Values for All Parameters (99-102)
5.4.1 Potential Measures for MCMIS (103-104)
5.4.2 Potential Measures for HMIRS (105-106)
5.4.3 Potential Measures for TIFA (107-107)
5.4.4 Potential Measures for RAIRS (108-108)
5.6 Follow-On Project (109-109)
References (110-111)
Appendices (112-112)
Abbreviations used without definitions in TRB publications (113-113)

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Literature Review 15 It is further noted that such errors are less likely to be associated with the more severe accidents since they receive greater investigative scrutiny. The following recommendations are made for conducting verification and validation at various levels of the reporting process: 1. Improvements in the railroad's internal control plan to ensure that missing and corrected data are provided to the railroad safety officer, 2. Review of reports by railroad safety officer prior to submission to FRA, 3. Use of edit checks within FRA's data entry system, and 4. Performance of cross-field and cross-record checks. The information is posted on the FRA Internet site, providing others with an opportunity to review entries and comment on their authenticity. 2.2.2 Project 5 Overview--Developing Common Data on Accident Circumstances Project 5 Overview--Developing Common Data on Accident Circumstances (Bureau of Transportation Statistics) describes a project undertaken to evaluate data currently available from which to identify the factors and circumstances that are present in transportation crashes and incidents. A comparison also is made to what is needed by investigators and researchers to improve analysis effectiveness, leading to recommendations that are made for how to enhance data quality. The overall objective of the activity was to identify those data elements needed for adopting a common framework of factors across a wide variety of events and modes. Included within the scope of the study were crashes or mishaps meeting all of the following conditions: 1. Involving the movement or operation of a vehicle, vessel, aircraft, pipeline, or other con- veyance in the course of moving people or goods, 2. Occurring within a U.S. jurisdiction or involving a U.S. commercial carrier, 3. Being either intentional or unintentional in nature, and 4. Resulting in substantial property damage or injury, or the death of a passenger, crewmember, pedestrian, other worker, or bystander within 30 days of the event. Data reviewed as part of the project included reports filed with U.S.DOT agencies, other fed- eral agencies, and some non-federal agencies (e.g., state medical examiner offices). The basis for performing an evaluation of these data was the Haddon Matrix, a conceptual framework used to analyze risk factors or prevention measures for mishaps and injuries. The Haddon Matrix divides an event into three chronological phases (1) pre-event (contributing to event likelihood), (2) event (influencing likelihood and severity of an injury), and (3) post-event (affecting likeli- hood of survival/recovery). Each of these phases is further divided into four groups of risk fac- tors (1) operator, (2) vehicle, (3) physical environment, and (4) social/cultural/organizational circumstances. Among the data gaps and limitations discovered from applying this methodology were the following: · Some important data elements are rarely collected, such as data on the injury mechanism, operator fatigue, distractions, and alcohol use; · Lack of information on injury type and severity; · Lack of a narrative description in reports, or information contained in narratives is not used; · Lack of detail on human factors;