Cover Image

Not for Sale

View/Hide Left Panel
Click for next page ( 27

The National Academies of Sciences, Engineering, and Medicine
500 Fifth St. N.W. | Washington, D.C. 20001

Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement

Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 26
26 Hazardous Materials Transportation Incident Data for Root Cause Analysis the database to detect contributing factors being experienced by other carriers and thereby address those factors in their own safety training programs. 3.2.2 Carrier Satisfaction with MCMIS Although most carriers do not use the MCMIS crash data, of those that had, the following sug- gestions were made: Add specific information as to which party was responsible for a crash. Distinguish between an accident that was preventable and one that was not preventable. Determine the specific cause, as well as contributing circumstances, as determined by inves- tigators. Designate repeat offenders in the crash reports. 3.3 Shipper Responses Two interviews were conducted with two major shippers of chemicals in the United States. The following summarizes some of the major points and recommendations made by the officials. 3.3.1 Shipper 1 Shipper 1 is an extremely large corporation that conducts formal investigations of accidents involving its hazmat shipments. It is a standardized process that includes an auditing compo- nent. There are several triggers for conducting a formal investigation, including severity and potential consequence (e.g., how much leaked, type of hazard involved, injuries, media atten- tion, and traffic shutdown). When an incident occurs while the shipment is in the custody of a carrier, CHEMTREC is immediately notified. The distribution leader at the shipper's plant site where the shipment orig- inated creates an incident report. Based on the contents of the report, the incident is classified as one of the following: Category A, warranting CEO attention, Category B, investigated within 24 hours with investigation led at the vice president or direc- tor level, or Category C, investigated within 72 hours. Also note that the size of the investigative team increases at each higher level of review. For Category A and B events, the incident investigation may include on-site data collection, but only if deemed necessary for the shipper to have confidence in knowledge of the situation. The results of an investigation are recorded in a database. Among the data elements contained in an incident record are fields for both Surface Cause (e.g., transportation accident due to human error) and Root Cause fields. The interviewee estimated that they identify the correct root cause in 70% to 80% of the cases. When problems arise, it is usually associated with the car- rier's involvement in the process. It was mentioned that bulk carriers tend to provide better reporting than less-than-truckload (LTL) carriers. The outcome of an incident investigation or an analysis performed on multiple incidents in the database is a list of recommended action items to implement in mitigating future risks. Examples of such actions include more targeted training and auditing. It also was suggested that because of recognized issues related to HMIRS data quality, a cred- ible root cause analysis should be performed by PHMSA. This could be achieved by implement-