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96 Hazardous Materials Transportation Incident Data for Root Cause Analysis
same hazmat truck crash may appear in FMCSA's MCMIS database and in PHMSA's HMIRS
database. The information in these databases could be linked to combine information from dif-
ferent sources on the same accident. Similar reasoning could apply for a hazmat rail crash found
in FRA's RAIRS database and HMIRS, or a fatal hazmat truck crash in TIFA and MCMIS.
Beyond the inherent advantage in linking hazmat crashes in different databases, additional
information is needed to more effectively identify root and contributing causes. Current acci-
dent data need to be supplemented by information about the circumstances and conditions that
existed before the accident occurred, factors not presently captured. Since these additional pieces
of information could come from a variety of sources, the term "information system" and not
"database" is used to describe the components and structure of such a system.
An example of the value of this approach is an analysis that NTSB performed on grade-crossing
accidents. Approximately 60 unprotected private grade-crossing accidents were selected for
study, beginning with the information commonly recorded in RAIRS. NTSB gathered additional
information by visiting each site, and collecting information that both supplemented RAIRS data
and validated on-site conditions listed in RAIRS. NTSB also obtained witness statements from
accident sites as soon as possible. None of the information in the witness statements is captured
in RAIRS and it is those data that showed driver distractions to be a frequent contributing cause
of accidents. The data collected by the NTSB showed that driver grade-crossing visibility was
often more limited than documented in RAIRS tables. Had the analysis relied solely on RAIRS
data, poor visibility would not have been cited as a major contributing cause for these passive
grade-crossing accidents. Although field data collection may be too labor intensive and costly on
a recurring basis, this example illustrates the advantages of supplementing data in the databases.
Another approach with considerable potential, which is currently being implemented by FRA,
is more detailed investigation of a representative sample of accidents. FRA conducts approxi-
mately 100 detailed investigations of rail crashes annually. These investigations obtain additional
data that are not captured in RAIRS.
Using the terminology in this report, approaches taken by NTSB and FRA comprise an infor-
mation system for selected accidents. NTSB and FRA investigations illustrate the feasibility of
supplementing information contained in current databases to address a specific class of acci-
dents, improving the ability to identify contributing and root causes for these classes of accidents.
Although site visits and witness statements might be difficult to obtain on a routine basis, clearly,
if the FRA chose to target its 100 detailed investigations on a particular class of accidents, addi-
tional data could be obtained for those targeted accidents. In successive years, the focus of the
detailed investigations could be switched to a different class of accidents. For example, if FRA
targeted private grade-crossing accidents for 60 of the detailed investigations, it could have pro-
duced a report similar to the one produced by NTSB, concluding that the contributing cause,
perhaps even the root cause, of many of the accidents was crossing visibility.
5.2.1 Develop Framework for Identifying Contributing Causes
and Root Causes of Hazardous Material Accidents
This section focuses on developing an information system capable of capturing the data for
thousands of hazmat accidents that occur each year. This information system would not reside
in a single database. Rather, the system would use a number of relatable databases, analysis tools,
and reports that can, in their totality, contain the information in sufficient detail and quality to
identify root and contributing causes of accidents. This would include those databases that are
currently used to collect information on hazmat crashes.
To identify the root and contributing causes of various classes of accidents, an analyst must
be able to relate inventory information to the accident tables. Inventory information character-
