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80 Hazardous Materials Transportation Incident Data for Root Cause Analysis Railroads typically operate trains rather than single vehicles; Operation is restricted to a fixed guideway or "single-degree-of-freedom" system; Railroad track age and other infrastructure is generally privately owned and maintained; Much of the operational control is either automated or controlled by individuals other than the train operating crew; Many railcars spend a substantial fraction of the time operating on and under the control of a railroad other than its owner; and These factors all have the effect of reducing certain general types of failure that can lead to a hazmat release, while elevating the importance of certain others. Although human error is an important cause of railroad accidents, failure of infrastructure or vehicle components comprise a much larger percentage of hazmat accidents. Additionally, fail- ures in the traffic control system sometimes cause accidents. These may be mechanical or electri- cal in nature, or they could be caused by human errors committed by personnel other than those operating the train, and who may be located hundreds of miles from the scene of the accident. To support this type of approach, FRA and the railroads have a comprehensive accident reporting system that has roots dating back to 1910 and was implemented in its present form beginning in 1975. FRA regulations require that all accidents in which damage to track and equipment exceeds a specified monetary threshold (adjusted periodically for inflation) must be reported using Form FRA F 6180.54, the Rail Equipment Accident/Incident Report, which records 52 different variables regarding the circumstances and cause of the accident. Beyond this, major railroads maintain their own internal databases. These typically contain all of the infor- mation necessary to comply with FRA reporting requirements, and may contain additional data that individual railroads believe is useful for their own safety analysis purposes. These efforts are significant to root cause analysis in several respects. At the most proximate level, the FRA reporting requirements ensure that all accidents of consequence are subjected to an analysis of the circumstances of the accident, and that both primary (and if applicable, secondary) causes of the accident be determined and reported to FRA. In some cases, these may require fairly intensive analysis of the accident scene if there is some uncertainty about the cause, and major railroads employ specially trained individuals responsible for this func- tion. Understanding all of these aspects is pertinent to root cause analysis of railroad-accident- caused hazmat releases. In the following section, the nature and character of basic elements are described. FRA divides accident causes into five broad categories: Track, roadbed, and structures, Signal and communication, Mechanical and electrical failures, Train operation--human factors, and Miscellaneous causes not otherwise listed. Within each of these categories, there may be sub-categories and then, at the most detailed level, specific cause codes. 4.6.1 Track, Roadbed, and Structures The most frequent cause of railroad accidents, and accidents resulting in a hazmat release are failures of the track system, especially rail failure due to various forms of fatigue-induced frac- ture. Railroads conduct frequent inspection of rails to find and remove defects; however, certain types are difficult or impossible to detect using existing technology. A number of other infra-