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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-
