Hazardous Materials Transportation Incident Data for Root Cause Analysis (2009) / Chapter Skim
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From page 32... ...
Once the state reporting agency finds an accident that meets the requirements for reporting the incident to FMCSA, the information for the vehicle from the PAR is coded into the MCMIS Crash file format and 32 C H A P T E R 4 Database Analysis
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Information coded into the MCMIS Crash file and obtainable from the PAR includes the date, time, and location of the accident; a description of the vehicle; the name and address of the carrier; personal information, including driver licensure; parameters that describe the roadway at the accident location; and the accident impacts. Because the database contains driver information -- name, address, sex, and birth date -- the full MCMIS Crash file is publicly available but only after data that can identify individuals have been stripped out.
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From page 34... ...
4.1.4 Threshold for Exclusion or Inclusion The MCMIS Crash file was developed to capture vehicle data on all serious crashes of trucks and buses involved in commerce. A crash is considered serious if there is a fatality, an injury requiring prompt medical attention at a facility away from the accident location, or if one of the vehicles involved in the crash had to be towed from the scene due to disabling damage.
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From page 35... ...
In order to ensure safety, the MCMIS Crash file has been developed to provide data on the number of serious truck and bus crashes that are occurring each year. From such information, FMCSA can monitor trends, evaluate the effectiveness of current regulations, and Database Analysis 35 Table 4-1.
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has been under contract to FMCSA to assess the accuracy and completeness of the MCMIS crash reporting system on a 36 Hazardous Materials Transportation Incident Data for Root Cause Analysis
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Additional analyses reflecting on the accuracy and completeness of the data in the MCMIS Crash file are found in Appendix C (available on the TRB website at www.TRB.org by searching for HMCRP Report 1)
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From page 38... ...
Based on the statistics shown in Table 4-3, the use of one event to define the accident often can be justified. The dominant single-event sequence accident in which a truck is involved is coded as EVENT_ID=13, "collision involving motor vehicle in transit." This is the event code for 82% of the vehicle incidents with a single event listed in the CRASH_EVENT Table.
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From page 39... ...
Crashes described by a single event. Event Description Percentage of Single Events Number of Crash Records Collision involving motor vehicle in transit 82% 73,591 Other 4% 3,358 Collision involving a parked motor vehicle 3% 2,462 Collision involving fixed object 3% 2,424 Non collision overturn (rollover)
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From page 40... ...
Reporting rates of states to MCMIS Crash file compiled from UMTRI reports. State Data Year Overall Reporting Rate Fatal Injury Tow Away Alabama 2005 76.0 91.4 76.4 75.0 Arizona 2005 78.2 93.8 83.4 75.6 Connecticut 2005 Likely <30% California 2003 72.0 84.2 73.9 70.9 Florida 2003 24.0 55.6 26.5 20.0 Georgia 2006 68.1 78.8 68.4 67.4 Idaho 2006 72.9 92.3 90.5 60.7 Illinois 2003 43.0 71.0 42.3 42.6 Indiana 2005 80.5 90.3 81.9 79.6 Iowa 2005 71.6 94.1 86.4 61.4 Louisiana 2005 56.6 79.6 57.0 54.7 Maryland 2005 31.1 84.6 56.0 15.6 Michigan 2003 73.7 92.4 73.1 73.4 Missouri 2000 60.9 76.8 63.7 58.8 Missouri 2005 83.3 94.6 84.9 81.8 Nebraska 2005 86.8 100.0 82.0 82.7 New Jersey 2003 82.5 67.4 81.5 83.2 New Mexico 2003 9.0 27.5 11.0 6.8 North Carolina 2003 48.2 63.3 49.4 47.1 Ohio 2000 38.8 50.7 58.2 28.6 Ohio 2005 42.5 85.4 52.7 32.3 Pennsylvania 2006 77.0 91.7 74.5 77.6 South Dakota 2005 66.4 78.9 64.9 66.4 Tennessee 2004 51.3 93.5 54.8 47.4 Washington 2003 37.6 to 53.7 67.2 About 40
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From page 41... ...
The TIFA file includes more detailed types of cargo bodies and truck configurations than allowed in the MCMIS Crash file but, for the purpose here, both were aggregated to the levels permitted in MCMIS. Table 4-6 shows the distribution of Database Analysis 41 Table 4-5.
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From page 42... ...
Finally, Table 4-8 shows the percentage of selected variables that are coded the same in TIFA and the MCMIS Crash file. Variables shown in Table 4-8 are drawn from the FARS file and not from the TIFA interview.
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From page 43... ...
Since this is not a serious analysis impediment, improvement in other areas, such as reducing the number of blank entries and ensuring the consistency among current entries, would be more cost effective. 4.1.13 Interconnectivity with Other Databases The MCMIS Crash file could be connected with HMIRS, TIFA, and -- for grade-crossing accidents -- RAIRS.
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From page 44... ...
4.1.14 Analyses Using Database The previous sections have described some of the characteristics of the MCMIS Crash database. Since the focus of this analysis is hazmat accidents, here the focus will be on techniques to identify accidents involving hazmat vehicles and then to show the characteristics of those crashes.
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From page 45... ...
4.1.15 Summary and Potential Measures for Improving Root Cause Analysis The MCMIS Crash file is formed using a complex set of operations that vary from one PAR originator to another, and Crash file preparation that varies from one state to another. Although the managers of the MCMIS Crash file have made great strides in improving the quality of the data, additional improvements are required for this database to be a useful tool in an information system that is capable of identifying contributing and root causes of accidents.
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From page 46... ...
Questions asked about the many situations that occur when filling out the LOCATION field also would be worthwhile given the different formats currently being listed in the MCMIS Crash file. For example, an Interstate route could be designated as I-70, IR70, I070, I70, or some other format.
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From page 47... ...
An examination of the action statements demonstrates that some carriers have prepared thorough accident investigations and probably know the contributing causes and root causes of the incident. This table provides a way of identifying improvements that have been made without providing evidence of negligence that could be used in any litigation arising as a result of the incident, which is a major concern to the accident reporter.
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From page 48... ...
The focus of HMIRS is clearly not the transport accident environment. For the normal transport 48 Hazardous Materials Transportation Incident Data for Root Cause Analysis T_PHASE Air Truck Rail Water En Route 1,049 4,871 1,303 83 Loading 553 4,542 30 6 Unloading 595 19,487 70 24 En Route Storage 1,868 1,709 46 24 Table 4-10.
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From page 49... ...
The other three contained hazardous materials and were not placarded. The new requirement to report damage to cargo tanks having a capacity of 1,000 gallons or greater when they suffer damage to the lading system or its protective system even though there is no release, manifests itself in the recording of 33 additional truck accidents over a two-year period.
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From page 50... ...
The TIFA file provides an opportunity to evaluate the completeness of reporting of a subset of hazmat incidents. The TIFA file includes all trucks that were involved in a traffic crash that included at least one fatality.
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From page 51... ...
TIFA and HMIRS data for 2005, the most recent year when both were available, were used in the comparison. The TIFA file includes all traffic accidents involving a medium or heavy truck and a fatality that occurred as a consequence of the accident, whether from hazmat release or not.
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52 Hazardous Materials Transportation Incident Data for Root Cause Analysis Matched Cargo Spillage No Yes Total None 106 9 115 Spill of hazmat 27 40 67 Unknown 3 1 4 Total 136 50 186 Row Percentages None 92.2 7.8 100.0 Spill of hazmat 40.3 59.7 100.0 Unknown 75.0 25.0 100.0 Total 73.1 26.9 100.0 Table 4-13. TIFA hazmat crash involvements matched with HMIRS TIFA 2005/HMIRS 2005.
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From page 53... ...
However, it is quite unlikely that the overall reporting rate is anywhere near as high as 59%. In the case of the MCMIS crash file, the overall reporting rate is about 75% of the reporting rate for fatal crashes.
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From page 54... ...
4.2.8.1 Effect of HMIRS Structural Changes Taking Effect in 2005 The major structural change made to HMIRS at the beginning of 2005 was to break up the three main tables, commonly labeled MAT, CON, and RMK into a series of smaller linked tables titled: IREPORT, IEVENT, IACTION, SHIPPER, MATERIAL, PACKAGE, PKGLAYER, and PKGFAIL. From an overall perspective, the material previously found in MAT is now found in IREPORT and SHIPPER.
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From page 55... ...
Privacy concerns may limit the availability of some personal driver information. To make it publicly available, personal driver information could reside in a separate file that would be kept confidential.
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By successively linking the tables to the IREPORT records it is possible to determine if there are accidents in IREPORT that do not have corresponding records in the linked tables. When SHIPPER is linked, the total number of records increases from 649 to 730.
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From page 57... ...
In MCMIS, if the data fields are fully populated, the vehicle, driver, and road characteristics documented in MCMIS can be coupled with the package information in HMIRS to get a comprehensive picture of the driver, vehicle, package, and route characteristics present at the time of the accident. The restructured HMIRS database provides fields to enter the carrier's DOT number, a parameter not requested prior to the 2005 restructuring.
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From page 58... ...
Information technology is rapidly advancing to the point that it is feasible to require the longitude and latitude of the accident to be included as part of the accident record. Many states already have longitude/latitude as an entry on their police accident reports but few police officers populate the field when filling out the form.
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From page 59... ...
Since MCMIS has more information on the road configuration, environmental parameters, and driver characteristics, it should be possible to perform more analyses that move toward identifying contributing and root causes of hazmat accidents. 4.2.8.6 Inclusion of IACTION Table One of the major changes in the restructuring of the HMIRS database was the addition of an action statement table that can be used by carriers to state the changes they propose to make to prevent or reduce the likelihood that such accidents would occur in the future.
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From page 60... ...
An increase of the carrier reporting rate to at least 90% would be highly desirable. In addition, the action statements given are quite positive 60 Hazardous Materials Transportation Incident Data for Root Cause Analysis
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The TIFA file covers all medium and heavy trucks involved in a fatal crash, and includes virtually all FARS variables for the crash, vehicle, and driver. TIFA survey data supplements FARS data for trucks (hereafter the word "trucks" will be used to refer to medium and heavy trucks, i.e., trucks with a gross vehicle weight rating [GVWR]
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4.3.4 Types of Hazmat Data Included The FARS crash data file includes limited information regarding hazardous materials. Since 2005, the vehicle-related variables (up to two responses allowed)
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In sum, while no doubt there are errors in the TIFA file, it is likely to be more reliable for analyzing truck crashes than FARS. 4.3.5 Usefulness of the Data for Determining Root Causes Because the TIFA file incorporates the relevant data, a discussion of usefulness is deferred to Section 4.4 on the TIFA file.
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From page 64... ...
In the process of compiling the annual TIFA file, each year, a small number of trucks appear on a police report for a fatal crash, but the FARS file contains no record for that vehicle. It is also possible that some fatal crashes are missed because the fatality occurs toward the end of the 30-day window.
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From page 65... ...
(Note that the MCMIS Crash file report number field in the past was supposed to include the PAR number in one of the fields, and it is recommended that MCMIS require that again. Currently, many states use a random report number, rather than using the PAR number.)
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From page 66... ...
4.4.1 Agencies/Organizations Responsible for Collecting and Entering Data into Database The TIFA file is produced by the Center for National Truck and Bus Statistics at the University of Michigan Transportation Research Institute (UMTRI)
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From page 67... ...
Concurrently, more detail about the hazardous material is now recorded, including the hazmat class and UN number. 4.4.5 Usefulness of the Data for Determining Root Causes This section provides a discussion of the variables in the TIFA Crash file that relate to understanding the factors that contributed to the crash or affected the severity of its consequences.
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From page 68... ...
Accordingly, information coded in these factor variables has been explicitly stated by the original crash investigators. The variables for driver-related factors record driver conditions or actions that may have contributed to producing the crash.
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From page 69... ...
The variables for accident-related factors record conditions at the accident level that may have contributed to the crash. These include roadway design problems and roadway defects such as worn or missing pavement markings, inadequate warnings, and roadway washouts.
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For all years prior to 2005, quantity shipped was partially captured in the TIFA file as cargo weight, in pounds, for all cargo, but capturing this information was aban70 Hazardous Materials Transportation Incident Data for Root Cause Analysis Level Variable Comment Configuration Captures the exact configuration of the vehicle Cargo Body Distinguishes 16 types of cargo bodies, including liquid, dry bulk, and gaseous tank types Vehicle GVW Prior to 2005, captures both gross vehicle weight and gross combination weight; weight variables dropped for 2005 and later Age Captured Experience Not captured Condition Captured in separate variables that identify alcohol use, drug use, and a set of multiple-response variables that code fatigue, asleep, ill, emotional, distracted, etc. Valid License Captured Driver Citation Issued Captured in a multiple-response variable; up to four citations may be recorded Package Type Captured only to the level of cargo body type Quantity Shipped Weight only, prior to 2005; not captured in 2005 and later Quantity Lost Spill/no spill captured only, not quantity spilled Tank Age Not captured Rollover Protection Not captured Inspection History Not captured Packaging Design Specification Not captured Road Surface Captured, in standard format Road Condition Captured, in standard format Road Type Captured, in standard format Traffic Way Captured, in standard format Access Control Not captured directly; instead, inferred from roadway function class Speed Limit Captured, in standard format Infrastructure No.
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From page 71... ...
That information is taken from PAR and is available for about 75% of the cases. Complete rates of missing data, averaged over five years, are provided for all TIFA variables in Appendix D (available on the TRB website at www.TRB.org by searching for HMCRP Report 1)
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From page 72... ...
The TIFA program could add the following additional information about hazmat cargo: • MC number of the cargo tank, which has been collected in the past as part of a special data collection effort and, therefore, the feasibility of collecting this information has been demonstrated. • Quantity of hazardous material transported, which would entail adding cargo weight data fields back to the survey.
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From page 73... ...
4.5 Large Truck Crash Causation Study (LTCCS) LTCCS was designed as a one-time study to compile a comprehensive set of accident data for approximately 1,000 large truck accidents.
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Most of the database tables are related using two parameters, the case number and the vehicle number. Driver information is collected for all 2,284 vehicles, but it was possible to collect information on driver health for only 1,839 vehicles, about 80% of all vehicles involved in the accidents.
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From page 75... ...
4.5.7 Interconnectivity with Other Databases It is not possible to connect the data in the LTCCS with other databases because the location and day of the month in which the accident occurred has been removed from the public version. The carrier is not named, the DOT number of the carrier is not given, and the vehicle registration number has been shortened.
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From page 76... ...
More than 1,000 would be required to get valid statistics on less common health conditions. This implies that if driver health is a contributing cause, it probably has to be captured in all hazmat truck accident records, as it was a few years ago in MCMIS, and for some reason has been left blank in MCMIS beginning in CY 2002.
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From page 77... ...
Listing of health factors present for vehicles in LTCCS containing hazardous materials. Interchange Junction No Yes Entrance/exit ramp related 1 7 Intersection 2 Intersection related 2 Non-junction 22 Other location in interchange 4 Rail grade crossing 2 Table 4-24.
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From page 78... ...
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.
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From page 79... ...
It is not considered feasible to perform the level of analysis performed in the LTCCS on all hazmat accidents. However, just as the LTCCS looked at injury and fatality accidents involving heavy trucks in a selected area, so it would be possible to perform the LTCCS level of analysis for perhaps 50 to 100 hazmat accidents annually, perhaps those involving a specific type of hazardous material (e.g., TIH [toxic inhalation hazard]
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From page 80... ...
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 fracture.
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From page 81... ...
Railroads use a combination of manual and automated inspection technologies to detect problems before they become critical, but some are not found and derailments can occur as a result. Overall, the FRA has more than 65 different cause codes for railroad-track-caused accidents.
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From page 82... ...
to root cause analysis, it is worth reviewing a few of the categories that railroads are required to provide: Item 38 -- Primary Cause Code, Item 39 -- Contributing Cause Code, and Item 52 -- Narrative Description. Item 38 -- Primary Cause Code Proper entry of the correct primary cause code is of critical importance, not only for the accident being reported, but also for FRA's analyses conducted for accident prevention 82 Hazardous Materials Transportation Incident Data for Root Cause Analysis
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From page 83... ...
There are several additional paragraphs providing more detail about the factors railroads should consider when identifying and possibly updating the Primary Cause Code as more information becomes available. Item 39 -- Contributing Cause Code If there were one or more contributing causes, enter the code for the foremost contributing cause.
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From page 84... ...
In addition, MISLE manages the information flow involving the administration of all of these activities, from the initial triggering event, to incident management and response, and the resulting follow-on actions. Its development was initiated in 1992 and it became fully operational in January 2002 when the Coast Guard transitioned from the Marine Safety Information Reporting System.
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From page 85... ...
4.7.5 Accuracy and Completeness Assessing the accuracy of the entries in the MISLE database is difficult for outside investigators. Since the majority of the events entered into MISLE involve legal action taken on the part of the Coast Guard, the accuracy of the entered data is likely to be very high.
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From page 86... ...
While all commercial aircraft crashes are included, there are certain rail and truck accidents that are also selected for investigation by NTSB. This section will focus on one particular type of NTSB investigation -- passive private grade-crossing accidents.
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From page 87... ...
• NTSB listed the closest town to the grade crossing whereas FRA reports the nearest timetable station, county, and city (if the accident occurred within city boundaries)
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. As shown in Table 4-27, NTSB separated its assessment of obstructed view into two parameters, the view as the motor vehicle approached the crossing and the view of the oncoming train 88 Hazardous Materials Transportation Incident Data for Root Cause Analysis NTSB Findings Sight Distance Limited on Approach Sight Distance Limited at Stop Line FRA Database View Parameter Number of Cases Yes Yes Topography 1 Yes Yes Vegetation 1 5Yes Yes No Obstruction Yes No Permanent Structure Yes No Vegetation 1 1 Yes No No Obstruction 24 No Yes No Obstruction No No Passing Train 1 1 No No No Obstruction 22 Table 4-27.
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From page 89... ...
In 4 of the 57 cases, the FRA database shows there was a stop sign when the NTSB investigator reported none was present. Being inaccurate in 25% of the cases makes it difficult to draw conclusions regarding the effectiveness of stop signs at passive grade crossings.
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From page 90... ...
This means that if the same person fills out both forms, he or she is already trained in determining accident causation. 4.8.6 Summary The following potential measures apply to capturing root causes routinely in grade-crossing accidents: 1.
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From page 91... ...
The Hazmat Serious Truck Crash Project used the MCMIS Crash file for serious crashes occurring in 2002, extracted the crashes that involved hazardous materials and, for a sample of 1,000 hazmat crashes, supplemented the data in MCMIS with information from other sources. These sources included HMIRS, PARs filed by police from individual states, and direct correspondence with the involved carriers.
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From page 92... ...
of Lanes Weather Condition Table 4-28. Explanatory variables used in the Hazmat Accident Database.
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From page 93... ...
Nevertheless, significant Database Analysis 93 Analyzed Crashes Estimated 2002 Totals Hazmat Group Description Crashes Spills Crashes Spills 1.1 – 1.6 Explosives 19 2 21 2 2.1 Flammable gases 148 14 256 21 2.2 Non-flammable gases 60 8 102 12 2.3 Gaseous poisons 11 1 18 2 3.0 Flammable liquids 544 125 914 182 4.1 – 4.3 Flammable and reactive solids 7 2 8 2 5.1 – 5.2 Oxidizing materials 31 9 36 10 6.1 – 6.2 Poisonous and infectious substances 14 2 16 2 7.0 Radioactive materials 4 2 4 2 8.0 Corrosive liquids 75 16 139 23 9.0 Miscellaneous hazardous materials 57 23 86 27 Unknown Hazmat group could not be determined 17 5 28 9 Table 4-29. Sampled crashes by hazmat group.
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From page 94... ...
presents representative analyses that were conducted using the Hazmat Accident Database. 4.9.7 Summary The Hazardous Materials Serious Crash Analysis: Phase 2 (Battelle 2005)
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