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Hazardous Materials Transportation Incident Data for Root Cause Analysis (2009)

Chapter: Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers

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Suggested Citation:"Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers." National Academies of Sciences, Engineering, and Medicine. 2009. Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press. doi: 10.17226/14336.
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Suggested Citation:"Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers." National Academies of Sciences, Engineering, and Medicine. 2009. Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press. doi: 10.17226/14336.
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Suggested Citation:"Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers." National Academies of Sciences, Engineering, and Medicine. 2009. Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press. doi: 10.17226/14336.
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Suggested Citation:"Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers." National Academies of Sciences, Engineering, and Medicine. 2009. Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press. doi: 10.17226/14336.
×
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Suggested Citation:"Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers." National Academies of Sciences, Engineering, and Medicine. 2009. Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press. doi: 10.17226/14336.
×
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Suggested Citation:"Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers." National Academies of Sciences, Engineering, and Medicine. 2009. Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press. doi: 10.17226/14336.
×
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Suggested Citation:"Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers." National Academies of Sciences, Engineering, and Medicine. 2009. Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press. doi: 10.17226/14336.
×
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Page 30
Suggested Citation:"Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers." National Academies of Sciences, Engineering, and Medicine. 2009. Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press. doi: 10.17226/14336.
×
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Page 31
Suggested Citation:"Chapter 3 - Summary of Interviews with Carriers, Shippers, and Database Managers." National Academies of Sciences, Engineering, and Medicine. 2009. Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press. doi: 10.17226/14336.
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Page 31

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Carriers, shippers, and accident database managers were interviewed to ascertain their knowledge of reporting requirements, learn how they investigate accidents, and gather their suggestions for improving accident databases to support root cause analysis. Database managers were asked to discuss process changes or new initiatives for the databases they are managing. 3.1 Introduction To learn about their internal process for investigating accidents and determining their root causes, carriers and shippers were questioned about their knowledge of accident databases. Rep- resentative examples of the questionnaires are included in Appendix A (available on the TRB website at www.TRB.org by searching for HMCRP Report 1). Appendix B (also available on the TRB website at www.TRB.org by searching for HMCRP Report 1) contains the results of this effort. In several instances, based on the wishes of the interviewee, the questioning became more “free form” and did not precisely follow the questioning order. Nevertheless, the interviews pro- vided the project team with valuable insights into the carrier or shipper’s process for identifying the root causes of hazmat accidents. Table B-1 in Appendix B (available on the TRB website at www.TRB.org by searching for HMCRP Report 1) displays shipment and operator information for the 13 carriers who responded to a request to complete an interview from the National Tank Truck Carriers (NTTC) and the three extremely large carriers that were interviewed via telephone. Table B-2 in Appendix B dis- plays the freight carriers’ responses to questions involving a hypothetical hazmat accident in which the vehicle drove off the road. The names of the carriers have not been included in the table in order to protect the confidentiality of the respondents. Each carrier response is grouped in somewhat arbitrary categories based on the number of power units operated by the company. The following are the categories used for the table: • Small, less than 100 power units; • Medium, 100 to 299 power units; • Large, 300 to 499 power units; • Very large, 500 to 999 power units; and • Extremely large, 1,000 or more power units. The carriers are listed in the order that the questionnaires were received by the researchers. Appendix B also includes the text of an interview with a major water carrier. 23 C H A P T E R 3 Summary of Interviews with Carriers, Shippers, and Database Managers

3.2 Summary of Responses from Carriers When carriers experience a hazmat accident, all of the details and events of the accident are recorded thoroughly. Several of the responding companies maintain accident databases that con- tain information that is much more extensive than the information that is required by the feder- ally maintained databases. The carriers that attempt to get to root causes of the accident utilize these more extensive data sets. The investigators record environmental factors and long-term qualita- tive data that would be helpful in understanding how the hazmat accident occurred, and in deter- mining how this type of accident may be prevented (if prevention is possible). In some instances, factors such as driver criminal history, crash history, and cell phone usage would have helped deter- mine whether the accident was due to the driver, which, if true, could result in an action taken to discipline or suspend the driver. In one case, corrective action was taken by a company to make the driver more aware of these external factors, enabling the driver to correct for them and thereby pre- vent future accidents. On the other hand, if factors such as existing traffic/weather conditions and functionality of trucking equipment indicate that the fault of the accident was external to the driver, a change in driving procedures might be made. Carriers would also like to see PHMSA play a more active role in communicating with the companies that reported the accident in order to get complete and accurate information. Most of the companies said they would use training offered by PHMSA to better fill out the crash form. More accurate forms will add to a more thorough database. This will help greatly for those that wish to use the database for research in prevention of serious hazmat accidents and mitigating crash impacts. The questionnaire results provided some insights into how carriers think accident causation analysis should be performed. Although carriers conduct their own investigations of major haz- mat accidents and search for the “root causes” of their crashes, they also believe that the author- ities have a responsibility to do the same. Carriers suggested that the following steps should be taken during an investigation: 1. Obtain vehicle operator statements of evidence for the hazmat accident. – Carriers think that both they and the authorities should collect as much information as possible in order to identify accident causation. This includes collecting witness state- ments, consulting police reports, and reviewing the driver’s log history, license records, and records of violations. Determining when the driver last rested would be especially valuable. – The driver’s cell phone use and satellite tracking records should be accessed to collect addi- tional information. – Driver’s actions should be compiled in order to look for causal events. – Several carriers believe that assigning fault for a crash to a particular driver would be ben- eficial in that often the truck driver is not responsible for causing a crash. – A large water-based carrier contacted by the research team investigates accidents and requires the pilot (or tanker man) to complete a special investigations form they have devised to obtain information that could lead to the identification of the root cause for the accident under investigation. Employees receive training in the proper procedure for completing this form. 2. Search for defects in the vehicle. – As part of this effort, vehicle equipment (such as brakes) should be examined during a post- crash inspection. – Pertinent maintenance records should be reviewed for any insights into the cause of the crash. 3. Examine vehicle operator history in order to identify health problems that could have con- tributed to the accident. 24 Hazardous Materials Transportation Incident Data for Root Cause Analysis

– One extremely large motor carrier looks at a driver’s log book (to try to identify fatigue fac- tors) and checks the driver’s performance history as part of their internal investigation. – Some carriers examine a vehicle operator’s health history for indications of such conditions as sleep apnea, diabetes, or alcoholism. 4. Examine roadway/runway geometry for accident causes. – Road conditions including weather, obstructions, and traffic flow should be part of the investigation. – The infrastructure configuration such as lane width, curves, and slopes can also provide indications of crash causation. 5. Take pictures of the accident scene. – Carriers recommend photographing the crash scene, including images of the roadway, vehi- cle positioning, crash damage, spill location, and any environmental damage. These pictures can be used to assist in assessing crash causation. 3.2.1 Carrier Satisfaction with HMIRS The great majority of the carriers were satisfied with the process of filling out the PHMSA’s HMIRS, although two of these companies actually used a separate spill center to fill out the form. Most companies think that PHMSA’s criteria for filing the hazmat report is clear. One suggestion called for the form to be updated in order to increase clarity. Nevertheless, seven of the carriers currently provide training for completing the 5800.1 report. The great majority of these carriers believe that PHMSA-provided training would be useful for their staff com- pleting the 5800.1 report. For those that would take advantage of such training, if offered, sug- gestions included online training/web conference, by CD-ROM, seminars/classroom setting, and training similar to that given to NTSB inspectors. One carrier believes that PHMSA should consider providing training in identifying root causes of accidents. In this regard, some of the techniques used by the NTSB investigators would be valuable for the carriers as they seek answers to the causes of their own crashes. Most of the companies do not feel that additional data should be added to HMIRS. One excep- tionally large company pointed out that for less-than-truckload cargo, there is often more than one type of hazmat being transported. Consequently, they suggested that there should be provi- sions in the form for listing more than one type of hazmat. Furthermore, the responses indicated that sometimes there are undeclared hazmat shipments found on vehicles and there should be a provision in the 5800.1 report for describing these as hazmat. (Note: provisions for handling both of these situations were added after 2004, and several other carriers take advantage of these pro- visions.) If an undeclared shipment is detected, there is an “Undeclared HM Shipment” box to check when filling out the form. If there are multiple, less-than-truckload shipments, many car- riers check the “Additional Pages” box and complete the form for each of the partial shipments. The responses to include provisions that already exist indicate that there is need for additional training or clarification in the instructions for filling out the form. A medium-sized company said they wanted more detail in Section 6 of the 5800.1 form, including whether other parties and other environmental factors (weather, road conditions, obstructions, fatigue, maintenance history, hazmat training, hazmat experience, age of equip- ment, other human factors) were involved. Those carriers that recommended changes to HMIRS also suggested that it be reworded in terms of carrier industry terminology. Most carriers think that PHMSA has an obligation to contact carriers who do not complete their 5800.1 report properly. They believe that PHMSA should contact the carriers by telephone, letter, or e-mail. Carriers would also like to see PHMSA play a more active role in communicat- ing with the companies involved in the accident in order to get more complete and accurate infor- mation. They believe that improved data in the database will enable them to more effectively use Summary of Interviews with Carriers, Shippers, and Database Managers 25

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- 26 Hazardous Materials Transportation Incident Data for Root Cause Analysis

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. Summary of Interviews with Carriers, Shippers, and Database Managers 27

Regarding ways to improve HMIRS, Shipper 2 believes that the highest priority should be to make the data contained therein more accurate and consistent, only adding more reporting ele- ments if they have a direct connection to establishing root cause. Improved accuracy could per- haps be accomplished by having PHMSA request that the reporting entity update the HMIRS record after a certain amount of time has elapsed since the date of the accident. Techniques to improve data consistency might be to utilize tools that facilitate more automated data entry (e.g., Web-based data entry) and to employ checks and balances in judging whether reported infor- mation makes logical sense. Part of the problem with reporting, the company believes, is a lack of education on the part of shippers/carriers/LSPs in terms of the importance of filing accurately with HMIRS, how best to accomplish this task, and pitfalls to avoid. To that end, PHMSA could provide better training to these stakeholders. Although perhaps a bit removed from the task at hand, the shipper’s vision for HMIRS is that motivation for reporting should be based on industry desire to put improvements in place to mitigate future risk rather than feeling obligated to report in order to achieve regulatory com- pliance. To that end, the company would recommend that the federal government produce data that not only accentuates failures, but successes as well. 3.4 Interviews with Database Managers The research team also conducted interviews with selected agencies that are responsible for managing key databases. The agencies include PHMSA, FMCSA, and FRA. The complete inter- views are found in Appendix B (available on the TRB website at www.TRB.org by searching for HMCRP Report 1). The discussion below presents a summary of findings deemed most significant. 3.4.1 Interviews with Agencies Maintaining Databases (PHMSA) The PHMSA officials indicated that reports go right into the database, which includes high- level quality control processing. They employ character-to-character checks to ensure that their process translated the paper form properly. During this process, they examine the form for personally identifiable information (PII), busi- ness rule inconsistencies, invalid dates, and invalid commodities (by cross-checking with the commodities in the database). To determine if they were caused by the hazardous materials, fatalities and injuries are validated by PHMSA using their own subprocess. Additional checks include cases such as when the report shows that 5.5 gallons were spilled from a 5-gallon con- tainer. PHMSA will go back and ask the filer whether there were multiple packages that failed and request that they file a supplemental report or they will sometimes use an e-mail reply as confirmation to correct the data themselves. They look for city/county inconsistencies. If a ship- per is an individual, they will not put that name in the database. The PHMSA official believes there would be a benefit from more verification, not just form- based validation. Sometimes important information such as costs, injuries, or other important information is left off. Sometimes this is because many big companies hire spill centers to com- plete the forms for them. Rather than checking all submittals, the officials believe that checking the significant or serious incidents would provide the most benefit. With respect to underreporting, PHMSA staff use a Web crawler and look for incidents, which they put in the HMIRS. In addition, they match things up with the telephonics [National Response Center (NRC) record]; if there is no match, it is flagged. They wait 60 days and then marry up the unreported incidents (URIs) to telephonics. 28 Hazardous Materials Transportation Incident Data for Root Cause Analysis

Both highway and rail show a greater incidence of URIs than expected by the modal distribu- tion of incident reports. For example, 91% of all URIs are highway incidents whereas 86% of all reported incidents are highway incidents. For rail, it is 9% and 4%, respectively. Air has nearly 0% of the URIs (only 1 incident), but 10% of the reported incidents. The official was not sure as to which mode had the most complete incident reports, but indi- cated that many highway incident reports were not completed. The PHMSA official had the following suggestions for improving data collection effectiveness and quality. 1. More companies should report online to reduce errors and 2. More business rules should be used in online tools so a filer could not submit an inaccurate report. Another official indicated that there are two aspects to the reporting requirements, the reg- ulations and the report itself. The rulemaking aspect is an impediment, primarily because it is the rule itself that specifies who has to report. This official said it took 10 years to change the form the last time, making sure all stakeholders were heard, etc. To simply change the form itself, all that is required is to go through Office of Management and Budget’s (OMB) information collection procedures, which include 30-day and 60-day notices and the justifi- cation required by the Paperwork Reduction Act. During the conversation, this interviewee determined that if the specification of who has to report was added to the form itself, PHMSA would no longer have to go through the rulemaking process to make changes in the form and that they could do so more often and more quickly. 3.4.2 Interviews with Agencies Maintaining Databases (FMCSA) The interview below was conducted with a key administrator responsible for the management of the MCMIS database at FMCSA. When accident reports are received, states upload crash reports through SafetyNet. States extract the data, either through an automated system or manually. That is, the data can be extracted using a computer program, or the cases can be keyed in directly. Certain fields are mandatory, such as carrier name and address. All fields are required, although blanks in non-mandatory fields do not result in rejecting the case. FMCSA evaluates the accuracy of the submitted records through the following: 1. Use of a data quality module, 2. UMTRI evaluations of the completeness and accuracy of the MCMIS Crash data, 3. On-site data reviews, 4. NISR (contractor) evaluations of state crash report forms for compliance and accuracy, 5. NISR evaluations of state extraction logic and methods, and 6. Crash data collection training for enforcement personnel. In addition, FMCSA utilizes the State Data Quality Improvement Program to help insure completeness and accuracy. The program includes the following: 1. Independent evaluation of the completeness and accuracy of the MCMIS Crash data, 2. On-site (at the state) reviews of state processes, 3. Evaluation of the accuracy and sufficiency of state crash forms to collect the MCMIS data, 4. On-site (at the state) evaluation of the data extraction logic and methods, 5. On-site (at the state) training for enforcement and other personnel, and 6. Three-day Data Quality and Training Conference in San Antonio for representatives of all the states. Summary of Interviews with Carriers, Shippers, and Database Managers 29

FMCSA has the following suggestions for improving the effectiveness and quality of data collection, and in all cases the administrator believes that suggestions must be tailored to individual states: • Provide continuing funding and technical assistance to the states. • Improve data collection by police officers by providing in-depth training by qualified indi- viduals. • Improve data handling and processing at the state level by developing programs to meet indi- vidual state needs. • Improve data handling and processing at FMCSA by recognizing and correcting system bugs immediately. • Maximize electronic data collection and processing, as well as integrating other databases such as driver history, CDLIS, etc. When asked if additional training was needed for MCMIS, the administrator answered yes but stated that FMCSA already has an extensive training program. They attempt to train personnel at each step of the process of data acquisition, from the officer who collects the data (through direct training, visor cards for police vehicles, and train the trainer) to the state personnel who extract and upload the data, to FMCSA personnel who prepare the file. When asked if improvements should be made to MCMIS to improve data collection for hazardous materials crashes, the FMCSA database administrator responded that it would be unrealistic to collect any additional hazmat data such as quantity and package type than is cur- rently collected. 3.4.3 Interviews with Agencies Maintaining Databases (FRA) The interview was conducted with an FRA official responsible for administering the RAIRS database. When questioned about whether the RAIRS database includes the consideration of root cause analysis and/or root cause releases, the official responded that the RAIRS database and normal accident reports have had limited use for root cause analyses (RCAs) because they are “event” reports rather than detailed investigations of specific incidents. Their principal purpose is to enable accumulation of a statistically valid database on accidents for analysis of historical trends. The official added that about 150 accidents per year are subject to more inten- sive investigation out of a total of about 3,000 annually. Nevertheless, even these more detailed analyses are not fully developed, in-depth RCAs. In 2008, these reports were made available online, in addition to databases which have been available for many years. There are also some concerns about the consistency between railroads in how they interpret primary and secondary causes. Even within a railroad, there can sometimes be problems. Such inconsistencies can interfere with, confound, or complicate analyses. The official pointed out that root cause analysis now falls within the new Risk Analysis Divi- sion. Although the risk analysis initiative is new, it may lead to suggestions for changes. When asked about barriers, either institutional or other, to implementing these changes, the FRA official replied that one barrier relates to regulations. There is a statutory limit to what rail- roads must report so significant changes are not easily implemented. The two paths for significant changes would be via rulemaking process or the Rail Safety Advisory Committee (RSAC). When questioned, the official pointed out that there have been suggestions external to FRA to change or improve the database with respect to root cause analysis. They have received inquiries from labor about more detail regarding operations data such as RCL (remote-controlled loco- motives). NTSB has suggested expanding the cause codes. There is a notice of proposed rule- 30 Hazardous Materials Transportation Incident Data for Root Cause Analysis

making (NPRM) (Docket No. FRA–2006–26173) calling for technical clarifications, expanding the scope of the instructions and improving certain definitions, proposing some new accident cause codes and collection of some additional data. In order to provide information to inspectors in a more timely manner, FRA is constantly monitoring railroad compliance with reporting requirements. When questioned about suggestions for improvement or changes that could be made to the database, the FRA official responded that FRA is especially looking for ways to improve turn- around time. Currently, they use a monthly “batch” process. The vision is for continuous flow of information into the database, enabling rapid detection of trends or evidence of potential prob- lems. Presently, there is about a two-month delay. Another area that FRA would like to see better utilized is reporting of incident location using latitude/longitude (lat/long) coordinates. The record layout permits that, but compliance is voluntary so it is inconsistently reported. The FRA Geographic Information System (GIS) group is developing a linkage between lat/long coordinates and linear locations along rail lines. The official also cited a problem relating to yard-switching miles that are not recorded directly, but estimated based on person-hours worked by the crew. This has a potential impact on the reliability of this parameter for normalization of accidents. 3.5 Summary of Findings from Interviews Many carriers and shippers, particularly the larger ones, have a formal process that triggers a graded response to accident investigation when an employee reports that he or she has been involved in an accident. For the more serious accidents, supplemental information is obtained in an effort to identify the root and contributing causes of accidents. One company collects infor- mation from witnesses, reviews the driver’s log, the driver’s cell phone usage, the driver’s actions during the course of the accident, inspects the vehicle for defects, examines the vehicle operat- ing history, examines the roadway geometry, and takes pictures of the accident scene. Some believe they identify the root causes of accidents for between 70% to 80% of the accidents. In many cases, corrective actions are recommended. Carriers and shippers have a vested interest in preventing accidents, and many of the accident reports recommend corrective actions that will reduce the frequency—and perhaps the severity—of future accidents. Based on interviews with the organizations maintaining federal databases, although there is a commitment to improve both the quality and completeness of the data, there has not been a sig- nificant long-term commitment to capture information that is capable of identifying root and contributing causes of accidents. The most relevant hazmat database, HMIRS, focuses on the adequacy of packaging standards. MCMIS and RAIRS have a broader focus than hazmat acci- dents and would require a major refocusing if they were to begin collecting the information required to identify the root and contributing causes of hazmat accidents. Potential measures for achieving this objective are included in both the discussions of the individual databases in Chap- ter 4 and the potential measures presented in Chapter 5. Summary of Interviews with Carriers, Shippers, and Database Managers 31

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TRB’s Hazardous Materials Cooperative Research Program (HMCRP) Report 1: Hazardous Materials Transportation Incident Data for Root Cause Analysis examines potential technical improvements to hazardous materials accident databases that are collected and managed by various agencies. The report explores gaps and redundancies in reporting requirements and attempts to estimate the extent of the under-reporting of serious incidents.

Appendixes A through E to HMCRP 1 are available online.

Appendix A: Questionnaires

Appendix B: Questionnaire Results for Carriers and Database Administrators

Appendix C: Brief Summary of the 2005 MCMIS Crash Records

Appendix D: The Percent of Missing Data for Variables from TIFA/FARS, 1999–2004

Appendix E: Selected Analyses Performed with the Hazmat Accident Database

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