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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. "4.5.9 Summary and Potential Measures to Improve Root Cause Analysis." HMCRP Report 1: Hazardous Materials Transportation Incident Data for Root Cause Analysis. Washington, DC: The National Academies Press, 2009.

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Page
78
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Page
78
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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78 Hazardous Materials Transportation Incident Data for Root Cause Analysis Table 4-25. Relationship between functional class and interchange in LTCCS. Interchange Functional Class No Yes Rural local 2 Rural minor arterial 4 Rural principal arterial ­ Interstate 1 1 Rural principal arterial ­ other 3 Urban minor arterial 2 Urban principal arterial ­ Interstate 15 10 Urban principal arterial ­ other 2 In a typical data analysis, it is difficult to analyze just a few accidents. Thus, while it is possible to look at the decision factors associated with those 11 interchange accidents, the statistical uncertainty regarding the conclusion will be very high. Clearly, to identify significant differences would require more hazmat truck accidents in the dataset. Just as the LTCCS targeted large truck accidents involving a serious injury or fatality, a com- parable study that focused on hazmat accidents would provide a similar benefit. Rather than doing a two-year study of 1,000 truck accidents, there appears to be merit to doing a continual study of fewer truck accidents, perhaps 100 to 200 per year. To look for differences between haz- mat truck accidents and regular truck accidents, it would be important to have data for both, perhaps a sample of 100 regular truck accidents and 100 hazmat truck accidents. If such a study were performed on an annual basis, it is important to have weighting factors to enable the find- ings from a limited sample of accidents to be related to the universe of accidents occurring annu- ally. These can be developed as part of the sampling methodology or come from other databases such as MCMIS and HMIRS. 4.5.9 Summary and Potential Measures to Improve Root Cause Analysis The analysis of the data from the LTCCS is still ongoing, so the following summary is based on its status as of the time of this report. The potential measures are prepared to focus on the objectives of this project. 4.5.9.1 Summary The LTCCS represents a comprehensive analysis of serious, large truck crashes. The variables captured in the 967 accidents investigated by contributing cause category are shown in Table 4-26. As shown, all of the contributing factors listed under the categories for Vehicle and Situational and most of the contributing factors under the categories for Driver and Infrastructure are covered. The Infrastructure category's factors are actually known by the LTCCS analysts, but have been coded to prevent these data from being known by those outside the LTCCS program. Thus, the training and experience of the driver were the only contributing causes that are not captured under the Driver category. The Packaging category is not well captured, since package behavior was not the focus of the LTCCS. 4.5.9.2 Potential Improvements Based on the LTCCS Experience Comprehensive studies, such as the LTCCS, are needed to obtain contributing and root causes of accidents. Similar to the LTCCS, these detailed analyses can be focused on a sample of all the accidents occurring in the United States, provided that the weighting of the sampling is known.