NASA 2016 Main Presentation C3RS User Group April 2017 Linda J. Connell NASA ASRS & C3RS Program Director Elisa T. Marfise ASRS & C3RS Human Factors Manager Gary J. Hopson C3RS Outreach Coordinator

Program Overview LC

Background 2002 FRA forms Close Calls Steering Committee to study value of a close call reporting system for the railroad industry 2003 FRA conducts the Close Calls Human Factors Workshop 2005 Close Calls Steering Committee signs FRA sponsored C3RS Demonstration Project MOU 2007 FRA & Volpe Pilot Project Begins 2008 Release of H.R. 2095: Rail Safety Improvement Act of 2008 2010 Interagency Agreement signed between FRA and NASA Ames Research Center NASA C3RS Pilot Site Initiated 2011 NASA C3RS Began Receiving Reports LC

C3RS Report Process LC

Incident Reporting Model C3RS, like ASRS, is a closed loop process that supports system safety and human factors insights Government / Industry are provided safety information LC

Unique Aspects of C3RS Confidential Reporting Model System-Wide Perspective - capability to identify hazards identified by frontline personnel and match reports from all segments of railroad community System-Wide Alerting - national capability to provide Alert Messages to industry and government Data Processing through Railroad Expert Analysts C3RS Office staff include Expert Analysts with a combined total of over 120 years of experience in rail (Conductor, Engineer, Dispatcher, and other related crafts) Experts read and review 100% of reports and reliably code information to databases Comprehensive Coding Taxonomy Fixed Field Codes combined with Narrative Text yields qualitative data for further secondary analysis techniques (Perilog, special studies, focused analytic techniques, etc) LC

Unique Aspects of ASRS Confidential Reporting Model Strong Immunity and Legal Provisions Implementing Memorandum of Understandings (IMOUs) Rail Safety Improvement Act, 2008 Information Sharing - Industry and Government Largest source of railroad incident data collected in central location National and International Reputation Recognized Model for Proactive Contribution to Safety Processes Worldwide ASRS & C3RS Model Being Utilized by Other Domains for Safety Improvements LC

Confidential Reporting Model Applied to International Aviation Community United Kingdom CHIRP (1982) Russia VASRP Japan ASI-NET (1999) VOICES (2014) Germany EUCARE Canada CASRP (1985) SECURITAS (1995) France REC (2000) REX (2011) United States ASRS (1976) Spain SNS/SRS (2007) China SCASS (2004) South Korea KAIRS (2000) LC Taiwan TACARE (2000) Singapore SINCAIR (2004) Brazil RCSV (1997) Australia CAIR (1988) REPCON (2007) South Africa CAHRS (2013) New Zealand ICARUS International Confidential Aviation Safety Systems (ICASS) 8

International Rail Safety Programs Canada SECURITAS United Kingdom CIRAS United States C3RS LC Australia REPCON

International Rail Safety Programs Canada – SECURITAS http://www.bst-tsb.gc.ca/eng/securitas/#rail Australia – REPCON http://www.atsb.gov.au/voluntary/repcon-rail/ United Kingdom – CIRAS http://www.ciras.org.uk/ United States – C3RS https://c3rs.arc.nasa.gov LC

Guiding Principles VOLUNTARY PARTICIPATION: Railroad personnel voluntarily submit reports concerning events related to safety for the purpose of system alerting, understanding and learning CONFIDENTIALITY PROTECTION: Protection of identity is provided by NASA through de-identification of persons, companies, and any other identifying information NON-PUNITIVE: FRA will not use, nor will NASA provide, any report submitted for inclusion under C3RS guidelines or information derived therein for any disciplinary or adverse action INDEPENDENT: Necessary for trust building and unbiased dissemination of safety information LC

Concept and Mission Designed to collect front-line, first person reports Evaluate equipment, procedures, human-system interfaces and aid in the development of improvements to the railroad system as a whole to prevent accidents NASA participates to assist in the efforts to improve public safety in transportation and further NASA’s knowledge of human-system interface, automation technology, and complex architectures that has direct application to accident prevention in aeronautics and space activities LC Source: NASA / FRA Interagency Agreement

Objective of C3RS Develop and operate an independent confidential reporting system to obtain detailed descriptions of railroad safety events that occur within the passenger and freight rail transportation industry. Source: NASA / FRA Interagency Agreement LC

Organization and Roles Legend NASA ASRS Program Director Linda Connell NASA Funded Shared Resources Booz Allen Program Manager Dennis Doyle ASRS Dedicated Staff C3RS Dedicated Staff Administrative Professional Business Manager LC C3RS Interim Project Manager Expert Analyst Michael Ballard ASRS Project Manager IT Manager Gary Hopson Outreach Analyst Expert Analysts IT Developers Leslie Savoye Expert Analyst Larry Valenzin Expert Analyst Report Processing Administrator Database Administrator Report Processing Administrator Yeraldin Sierra Thomas Collard Expert Analyst Research Coordinator IT Systems Admin Technical Editor Human Factors Manager Elisa Marfise Graphics Webmaster

Volume is increasing and new carriers will also elevate intake numbers Programmatic Growth REPORTING VOLUME Volume is increasing and new carriers will also elevate intake numbers IT ENHANCEMENTS Enhancements, such as specific report forms for crafts and PRT web portal, Analyst Workbench, and database development EXPANSION More rail carriers and crafts are on the horizon with advocacy from highest levels of FRA and industry. Additional products such as newsletter, special studies, and alerts have been initiated. LC

Carrier and Craft Timeline Carrier 4 All Crafts 3/15 Carrier 5 Mechanical & Engineering 4/16 Carrier 6 & 7 Transportation Carrier 3 Mechanical Carrier 2 All Crafts Interagency Signed 5/10 8/15 11/16 2010 5/14 2015 LC 2010 2011 2012 2013 2014 2015 2016 Today 2/11 Carrier 8 Transportation Carrier 1 Transportation Carrier 3 Transportation Carrier 5 Transportation 12/14 4/15 12/16 Carrier 1 Mechanical Carrier 6 Mechanical & Engineering 4/16 7/16

Rail Carriers Reporting to C3RS 8 Total Carriers Carrier PRTs 8 Transportation 6 Mechanical 4 Engineering LC

Report Processing EM

NASA C3RS Report Process EM

Report Intake Since the Go Live Date of February 2011 the total number of NASA C3RS reports received 6395* EM *As of December 31, 2016 20

Year over Year Volume Comparison EM

2016 vs 2015 Intake by Month EM

How to Submit a Report – Three C3RS Forms EM Transportation Mechanical Engineering

How to Submit a Report to NASA EM Electronic Report Submission Submit report form on C3RS website (secure transmission) https://c3rs.arc.nasa.gov Print Form and Mail Fill out report form on C3RS website, print form and mail to NASA Mail Postage Free Paper Form Locate form at designated carrier locations, fill out and mail paper form 24 24

NASA C3RS Electronic Report Submission (ERS) As of December 2016, 95% of reports have been received through Electronic Report Submission (ERS) EM http://c3rs.arc.nasa.gov

Report Processing EM

Incidence of C3RS Multiple Reports Provides information from more than one person’s perspective on a single event Conductor Brakeman EM Conductor Conductor Dispatcher Ass’t Conductor 27 12% 100%

Report Processing EM

Analyst Coding – Workbench EM

Analyst Coding - Workbench EM

New Processing Flow *ALL Full Form Analysis vs Abbreviated EM Does Report contain critical safety information? No Yes Abbreviated Full Form Analysis Re-Evaluate Classification – Is this new or critical? EM Yes Does Analyst have additional questions? Yes No Abbreviated Call Reporter No Record* includes Reporter Provided Fixed Fields & De-ID Narrative Record includes All Coded Fixed Fields, De-ID Narrative, Callback Summary & Synopsis Record includes All Coded Fixed Fields, De-ID Narrative & Synopsis *All reports are described as records after multiple report classification

Triage Processing - 2016 Triage Processing (June – December 2016) Includes reports that have completed all stages of report processing during this timeframe LC

Report Process – 2016 Callbacks   GH Callback Success Rate 80% Reports that completed Full Form Analysis in 2016 (n=1,846)

Purpose of the Callback There are four purposes for conducting a Callback: To obtain supplementary information about a report. To reinforce confidentiality to the reporter Opportunity to educate reporters from new carriers and crafts about the C3RS program To potentially obtain information as part of a research study. The Callbacks are not intended to be an interrogation or investigation. Callbacks are an opportunity to further discuss the reported event, if needed. GH

Callback Process Upon receipt, Expert Analysts will triage the report to determine if it will receive Full Form Analysis or Abbreviated processing. Full Form reports will be further triaged to determine Callback or No Callback Two attempts to contact the reporter will be made If no contact on second try, letter is sent to encourage reporter to contact C3RS directly within 15 days. If reporter does not contact us – original report is de- identified and released to PRT. GH

PRT Interaction Expansion from 9 PRTs in 2015 to 18 PRTs in 2016 C3RS transferred 2,596 reports to the Portals in 2016 (compared to 1,446 in 2015) Improvements to PRT Output since last User Group Added additional fields (YYYYMM & Event Location) Improved ability to download multiple records at once Improved naming convention for sorting of A or “Abbreviated” Added 4 subfolders: xml, newsletters, DBQT training, and Alerts in each portal GH

PRT / NASA Coordination PRT Portal - Continuous Coordination DataBase Query Tool (DBQT) – TBD Alert Bulletin & Newsletter Distribution PRT Support from C3RS Team Integration of PRT Feedback in Report Processing GH We encourage an open dialogue with PRT members.

Data Overview EM

Report Processing Timeline Screening Initial Screening and Secondary Screening by 2 Expert Analysts within 3 Working Days from Date of Receipt Return ID Strips 30 – 90 Working Days from Date of Receipt Accident / Criminal Reports Provide to NASA Transfer to PRT Portal No sooner than 30 Calendar Days from Date of Receipt and No later than 90 Calendar Days from Date of Receipt EM

2016 Craft Report Volume* EM * Categories are mutually exclusive. Craft counts are for all persons in a report record. Screening Data for Jan – Dec 2016. n=3364

2016 Incident Reporter Distribution* EM *Reporter function counts are for all persons in a report record. Screening Data for Jan – Dec 2016. n=3364 Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than reporter function.

Train Location EM *Reporter function counts are for all persons in a report record. Screening Data for Jan – Dec 2016. n=3364 Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than train location.

2016 Event Category / Anomaly EM *Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than one anomaly. Screening Data for Jan – Dec 2016. n=3364

Event Outcome – Top 10 EM *Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than one event outcome/result. Full Form Data for Jan – Dec 2016. n=2425 44

Contributing Factors EM *Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than one contributing factor. Full Form Data for Jan – Dec 2016. n=2425

Human Factors Twelve Human Factors coded by C3RS Expert Analysts Situational Awareness Communication Breakdown Distraction Confusion Training / Qualification Time Pressure Workload Human – Machine Interface Fatigue Troubleshooting Physiological – other Physical Limitation EM

Human Factors Top 3 Human Factors coded by C3RS Expert Analysts Situational Awareness Communication Breakdown Distraction EM

C3RS Products

Newsletter “Inside The Rail” C3RS Products Alert Messages Critical safety information provided to organizations in positions of authority for evaluation and potential corrective actions Newsletter “Inside The Rail” Rail safety newsletter in a lessons learned format with sample de-identified report excerpts Focused Studies Studies / Research conducted on safety topics of interest in cooperation with FRA & rail stakeholders Database Searches Data is available using DataBase Query Tool (DBQT) search tool or by search request to C3RS LC 49 49

Incident Reporting Model

Newsletter “Inside The Rail” C3RS Products Alert Messages Critical safety information provided to organizations in positions of authority for evaluation and potential corrective actions Newsletter “Inside The Rail” Rail safety newsletter in a lessons learned format with sample de-identified report excerpts Focused Studies Studies / Research conducted on safety topics of interest in cooperation with FRA & rail stakeholders Database Searches Data is available using DataBase Query Tool (DBQT) search tool or by search request to C3RS LC 51 51

Alerting Pyramid Alert Bulletins For Your Information Notices Safety Teleconferences & Other Safety Communications For Your Information Notices Alert Bulletins Time critical safety information provided to organizations in positions of authority for evaluation and potential corrective actions. LC Less urgent / less detailed safety information is provided in For Your Information (FYI) Notices Alert Bulletins & FYI Notices determined appropriate for an in-depth discussion could be included in a teleconference with the FRA and stakeholders. C3RS acts through and with the cooperation of others and has no direct authority due to the nature of the third party, honest broker role.

Alert Bulletins Alert Bulletin # 1: Alert Bulletin # 2: Maintenance Track Authority Issues Alert Bulletin # 2: Access to Restricted Areas of the Train Alert Bulletin # 3: Coordination of Track Authority and Protection Alert Bulletin # 4: Protection at Grade Crossings GH

Alert Bulletin Alert Bulletin # 2 Distributed electronically on 09/16/2016 Topic: Access to Restricted Areas of the Train 3 C3RS Reports were included GH

Alert Bulletin Alert Bulletin # 3 Distributed electronically on 03/16/2017 Topic: Coordination of Track Authority and Protection 3 C3RS Reports were included GH

Alert Bulletin Alert Bulletin # 4 Distributed electronically on 03/16/2017 Topic: Protection at Grade Crossings 3 C3RS Reports were included GH

Alert Message System GH

Newsletter “Inside The Rail” C3RS Products Alert Messages Critical safety information provided to organizations in positions of authority for evaluation and potential corrective actions Newsletter “Inside The Rail” Rail safety newsletter in a lessons learned format with sample de-identified report excerpts Focused Studies Studies / Research conducted on safety topics of interest in cooperation with FRA & rail stakeholders Database Searches Data is available using DataBase Query Tool (DBQT) search tool or by search request to C3RS GH 58 58

Newsletter – Inside The Rail Issue 1 – Overview and Newsletter Introduction Published November 2015 Issue 2 – Job Briefings Published September 2016 Issue 3 – Doors Opened Off Platform Available today! GH

Newsletter – Email Subscription Text C3RS to 22828 to subscribe Or send an email to arc-dl-c3rs@mail.nasa.gov Sign up at table for individual subscription or bulk mailings GH

Newsletter “Inside The Rail” C3RS Products Alert Messages Critical safety information provided to organizations in positions of authority for evaluation and potential corrective actions Newsletter “Inside The Rail” Rail safety newsletter in a lessons learned format with sample de-identified report excerpts Focused Studies Studies / Research conducted on safety topics of interest in cooperation with FRA & rail stakeholders Database Searches Data is available using DataBase Query Tool (DBQT) search tool or by search request to C3RS EM 61 61

C3RS Focused Studies Proposed Research Study Methods - TBD In-depth secondary review of C3RS database records on a selected topic Formal Research Projects (includes Structured Callback Studies) Voluntary participation by reporters to expand event information Supplemental data gathering – “Structured Callback” Telephone contact requesting participation in supplemental question set Web-based completion of supplemental question set EM

Newsletter “Inside The Rail” C3RS Products Alert Messages Critical safety information provided to organizations in positions of authority for evaluation and potential corrective actions Newsletter “Inside The Rail” Rail safety newsletter in a lessons learned format with sample de-identified report excerpts Focused Studies Studies / Research conducted on safety topics of interest in cooperation with FRA & rail stakeholders Database Searches Data is available using DataBase Query Tool (DBQT) search tool or by search request to C3RS EM 63 63

C3RS Database Query Tool (DBQT) EM

Future Access to C3RS DataBase Query Tool (DBQT) Awaiting final determination of de-identification protocols Status has been determined to be “pre-decisional” in regards to FOIA requests to the Federal Government LC

FOIA “Personal information, references to third-parties and other data identifying the incident attached to the records that may identify the person reporting will be exempt from release to the extent permissible under 5 USC 552(b) of the Freedom of Information Act” “After the records are stripped of their identifiers, they will be entered in the C3RS NASA database” “NASA will respond to FOIA requests for this non-identified data” Source: NASA / FRA Interagency Agreement, Section V C. Confidentiality LC

Triage Processing - 2016 Triage Processing (June – December 2016) Includes reports that have completed all stages of report processing during this timeframe LC

Impacts on Process - 2017 Consequences of Funding Reduction Staffing Reduced Report Processing Alerts – No Impact Decreased Full Form and Callbacks Increased Abbreviated (Potentially 50%) Newsletter Questionable Outreach Reduced LC

Questions? Linda J. Connell, NASA ASRS/C3RS Program Director (408) 541-2827 linda.j.connell@nasa.gov Gary J. Hopson, Booz Allen Hamilton C3RS Outreach Analyst (410) 302-6632 gary.hopson@nasa.gov Elisa T. Marfise, Booz Allen Hamilton Human Factors Manager (408) 541-2838 elisa.a.taube@nasa.gov