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CHAPTER 1 Introduction 1.1 Project Purpose The objective of this project is to develop a set of potential measures that would enable offi- cials to use incident reporting databases more effectively to identify major contributors to haz- ardous materials (hazmat or HM) transport accidents for all modes of transport. The focus of this study is accidents, namely those incidents in which the vehicle was involved in a crash event (as opposed to a stationary release from a loose fitting). In the discussion to follow, the terms "accident" and "crash" are used interchangeably. The goal is to provide the proper data elements, accurately reported, such that root causes of accidents can be determined. For this project, the research team used the following definition of root cause: One or more contributing factors that lead to the occurrence of a transportation accident and/or affect the severity of its consequences. Inherent in this definition is the assumption that if a contributing factor were not present, then the accident would not have occurred and/or the consequences would not have been realized. However, in reality there is seldom one factor, but often there is a series of causal factors or a causal chain that leads to the accident or the impacts. Furthermore, by identifying several contributing factors to an accident, much can be learned when analyses show that one contributing factor is present in a large fraction of a particular type or class of hazmat accident. Table 1-1 provides an example of a sequence of questions associated with investigating the root cause. The research team recognized that in order to effectively determine the root cause of a haz- mat crash or a series of crashes, data on diverse parameters needed to be collected and analyzed. Hazardous Materials Serious Crash Analysis: Phase 2 (Battelle 2005), which is described in more detail in Section 2.2.16, developed a matrix listing the parameters believed to provide a more comprehensive understanding of the accident environment. These parameters are as follows: Vehicle, Driver, Packaging, Infrastructure, and Situational. In some cases, an individual parameter could shed light on root cause but, in many cases, analyses of two or more parameters are needed. In effect, a systems analysis is required. For example, the root cause of a rollover hazmat tank truck crash resulting in a spill could be related to a vehicle problem manifested by faulty brakes, an inexperienced driver with inadequate training, a full load in an obsolete cargo tank with an inadequate inspection history, slick road conditions, and a precipitous lane change by another truck. A matrix showing the 9