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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. "3.3.2 Shipper 2." HMCRP Report 1: Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press, 2009.

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27
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Page
27
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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Summary of Interviews with Carriers, Shippers, and Database Managers 27 ing a verification protocol whereby PHMSA/DOT conducts follow-up audits of those accidents meeting a certain severity threshold. From the shipper's perspective, a desirable criterion would be the material hazard, with a focus on TIH (toxic inhalation hazard), flammable, and reactive materials. Although interested in doing so, this shipper has not devoted the time or resources to inves- tigate the merits of using mode-specific hazmat accident data (e.g., MCMIS, RAIRS, MISLE) for performing risk analysis. This interviewee was not willing to provide an opinion regarding the potential value of these databases when investigating root causes of accidents. 3.3.2 Shipper 2 Shipper 2 also is an extremely large corporation. They make approximately 40 million plac- arded shipments annually, of which about 50% are bulk. Several triggers have been defined that warrant the launching of an accident investigation. Examples include whether a spill occurs, a personal injury is involved, an evacuation is ordered, or if the potential existed for a major impact. In such instances, CHEMTREC is to be immedi- ately notified and an internal accident investigation file is opened. When a trigger is met and the shipment is in the custody of the carrier or logistics service provider (LSP), the carrier or LSP is responsible for leading the accident investigation. Shipper 2 may be a part of the carrier's (LSP's) accident investigation team. Regardless, the company expects to be kept apprised of the investigation and updates its internal investigation file accordingly. The updates are entered into the database and tracked through an event-in-action tool (ENAT). Ship- per 2 personnel are highly trained in this aspect of data input and analysis. Moreover, the shipper has established modal experts (warehouse, road, rail, bulk marine, terminal) to assist in collect- ing and evaluating relevant information. This data collection process and repository have proven to be very important and, in many instances, demonstrates that what is reported to CHEMTREC does not align with what really happened. It is important to note that the shipper's philosophy on the need for establishing root cause has evolved over time. Although in the past there may have been an emphasis on establishing an "ultimate" root cause, the company now recognizes that the true root cause may be a combina- tion of factors that collectively lead to accident occurrence and impact severity. This approach also helps in being able to identify a control point (or points) where improvements can be made. Regarding the use of outside databases, Shipper 2 echoed other stakeholder sentiments that HMIRS cannot be relied upon to provide credible information. The company believes that the problem of inaccurate reports that appear in HMIRS is more significant than accidents that go totally unreported. Some fields are notoriously unreliable, but of great analysis interest, such as the type of emergency response. Shipper 2 believes that the inaccuracies and missing elements that appear in HMIRS could be corrected as accident investigations proceed, but that HMIRS records are rarely updated once originally filed. Given these circumstances, the extent to which Shipper 2 utilizes HMIRS is to identify acci- dents that should have been reported to them and were not or, vice versa, to identify accidents that were reported to them but do not appear in HMIRS. The American Chemistry Council aids in this process by providing company-specific HMIRS reporting records to its member compa- nies on an annual basis. Although Shipper 2 does not routinely use modal-specific accident data- bases (e.g., MCMIS, RAIRS, MISLE), its general impression is that inconsistencies exist between accidents reported in these databases and what appears in HMIRS. The company feels that for all rail incidents, RAIRS data is pretty reliable, whereas it prefers to go directly to truck carriers for accident data rather than rely on MCMIS.