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OCR for page 86
86 Hazardous Materials Transportation Incident Data for Root Cause Analysis they are filled out with a standard term, such as "not noted" and it is not known if an entry should have been made in the field. 4.7.6 Quality Control No assessment was made as to the use and effectiveness of MISLE quality control procedures. 4.7.7 Interconnectivity with Other Databases There are no common fields that would enable this database to be connected easily to other databases. The MISLE record does contain the date, time, and location of the accident, expressed as the latitude and longitude, so if another database like HMIRS reported the same information, linkages could be made. Since the carrier name is a difficult field to join on (because the name must be identical right down to the spelling of the name, abbreviations, spaces, and periods) automatically connecting database fields would be very difficult. A brief attempt to connect the HMIRS reports listing mode as water, identified no events reported to both databases during a one-year period. 4.7.8 Analyses Using Database Since the MISLE events could not be compared with the hazmat incidents reported in HMIRS with water as the mode, no analyses were performed. 4.7.9 Summary and Potential Measures for Improving Root Cause Analysis Much of the MISLE database is accessible only to Coast Guard staff. Furthermore, the MISLE data become available to the general public only for closed cases and it can take several years to close many of the MISLE-reported incidents. This might be one of the reasons why it was not possible to find common events reported to both HMIRS and MISLE. Lack of timeliness, access, and interconnectivity are considered insurmountable barriers for MISLE use. Any database used for root cause analysis should provide timely accident reports, have unrestricted access, and be able to easily connect reports made to other databases. 4.8 NTSB Accident Investigations and Reports 4.8.1 Scope of Investigations There are numerous NTSB investigations of individual accidents. While all commercial aircraft crashes are included, there are certain rail and truck accidents that are also selected for investiga- tion by NTSB. This section will focus on one particular type of NTSB investigation--passive pri- vate grade-crossing accidents. A study (NTSB 1998) summarized the investigation of 60 passive grade-crossing accidents that occurred between December 1995 and August 1996. The accidents investigated were not selected on the basis of establishing statistical confidence. The criteria were that damage to the motor vehicle had to be serious enough for the vehicle to require towing from the scene and that it had to occur close enough to an NTSB regional office for an investigator to travel to the site before the vehicle was towed from the scene. The NTSB investigator recorded the types of signage present, as well as the characteristics of the grade crossing, and obtained witness statements.