1. C3RS User Group Presentation
Aug 9-10, 2016

2. Agenda
Overview
Outreach
Summary
Case Distribution
Case Statistics
Discussion of Corrective Action Recommendations
Feedback & Challenges
Lessons Learned
Suggested Improvements

7. PRT Activities Q

8. Summary - Aug 2015 – April 2017 (Present)
120+ cases received
Approx. 95 unknown events vs. 33 known
3 major rules violations YTD 2017 inclusive of C3RS
Several recommended corrective actions, several in working stages and others implemented
Identifiable trends such as poor or rushed job briefings, poor communication, lack of experience and situational awareness, distractions, and self-induced time pressure

9. The first 2 Causes cover 48.15% of the Total Defects
Op Rule Violations- 4 signal violations, 5 Form D issues (Working Limits, Release of Time, Overlapping Limits), 7 improper issuance TSRs, 241s, Speed Summary Changes, 6 forgetting brake tests or hand brake left on, 1 failure to receive movement authority, 1 blind shove
The first 2 Causes cover 48.15% of the Total Defects

10. The first 2 Causes cover 48.15% of the Total Defects#
Causes
Defects
Cumulative% 1
SPEED RESTRICTION 28
25.9% 2
OPERATING RULE VIOLATION 24
48.1% 3
SWITCH HANDLING 14
61.1% 4
CROSSING VIOLATION 10
70.4% 5
MISC 6
75.9%
BLUE FLAG
79.6% 7
FORM D
83.3% 8
EQUIPMENT SPEED RESTRICTION
87.0% 9
SECURING EQUIPMENT
90.7%
STATION CUT-OUTS
93.5% 11
502B - REVERSING DIRECTION
96.3% 12
PRE-DEPARTURE PROCEDURES
98.1% 13
DERAILMENT
100.0%
Op Rule Violations- 4 signal violations, 5 Form D issues (Working Limits, Release of Time, Overlapping Limits), 7 improper issuance TSRs, 241s, Speed Summary Changes, 6 forgetting brake tests or hand brake left on, 1 failure to receive movement authority, 1 blind shove
The first 2 Causes cover 48.15% of the Total Defects

11. 77% of cases occurred on the road, 23% in the yard or terminal
Case Statistics
Speed restrictions and operating rule violations cover approx 48% of the close calls
Run through switches account for 13% of cases, Top 3 = 61% of all reports – slowly dropping
77% of cases occurred on the road, 23% in the yard or terminal
19 cases resulted in an occurrence – physical or near-miss
65% of cases had successful callbacks
Most notable cases involve train sliding through crossing w/ Line 12 in effect, trains (2 cases) entering through Track Foreman’s working limits, failure to blow the horn at a grade crossing due to fatigue, and Mechanical employee under a train w/o Blue Flag protection
18 cases involved T&E employees w/ <10 years of experience, 18 cases involved T&E employees w/ years of experience, 16 cases involved T&E employees w/ 20+ years of experience
Engineers submitted narrative and accepted callback most frequently (87% of cases), followed by dispatchers, and then conductors

12. Contributing Factors for Vital Few

13. Increase Situational Awareness
Recommendations
Increase Situational Awareness
Reminders for temporary speed restrictions – exploring pilot tools
Perform coached, non-punitive observations and training – speed, dispatch, shoving & yard moves
Address Crew Member Contributed, Poor Job Briefings, & Distraction
Increase awareness of importance and utilization of job briefing form 1440, and monitor for completion (Conductor iPhone)
Review promotion training with Training Dept in unison with 243 to incorporate targeted field experience
Evaluate crew resource management for fatigue, time management, spare boards, and familiarization with physical characteristics
Rulebook insert for C3RS overview and incorporation into block training and new-hire orientation

14. Operating Other than the Leading End Training – FRA & Keolis
Recommendations – Example of Implementation
Operating Other than the Leading End Training – FRA & Keolis
Safety Brief:
Location Newburyport Yard
First Aid/ CPR locating AED
Who calls 911?
Who meets medical?
Teams:
Conductor and Engineer
Team assignments
Trainers:
Locations and Responsibilities
Rule review 711/ 138g/ 116
Task:
Move assigned train operating from other than the leading end from Newburyport yard west to Rowley Station and back to Yard with a line 12 to stop and protect Hay ST in both directions.
Evaluate crew resource management for fatigue, time management, spare boards, and familiarization with physical characteristics
Rulebook insert for C3RS overview and incorporation into block training and new-hire orientation

15. Recommendations – Example of Implementation
Job Briefing:
Conductor training:
Train Handling review:
Special Instructions
TSRB/ Form D/ bulletins i.e. Summery for rule 116
Form of communication / what radio channel / hand motions
Means to stop the move
Physical characteristics
Position of crew members
Protection of crossings
Train identification
Any defects or enroute failures
Horn/ bell location
Radio set up
Automatic brake vale set up
Communication options bell / PA / Radio/Light
Head lights/ Markers
Emergency application of brakes
Evaluate crew resource management for fatigue, time management, spare boards, and familiarization with physical characteristics
Rulebook insert for C3RS overview and incorporation into block training and new-hire orientation
Operating from control car
Judging speed operating backwards
Operating from locomotive
Low power braking
Name:
Employee number:
Date:
Signature:
Trainer
Trainer Signature:
Location:
Team number:

16. Feedback and Challenges
Some employees still unfamiliar – either new, on weekend or night shift, or haven’t used it yet. Others may not trust, but consensus is improving.
OTP and Customer Service vs Railroading
Working with Training to address close-call
trends – knowledge and expertise
Meeting Service Requirements
Training curriculum to provide enough
locomotive engineers and trainmen
Program Outreach and CA Implementation
PRT willing to market, need dedicated time,
efficient techniques
Carrying out quicker, more effective actions with members
available – e.g. joint other-than-leading end training

17. Lessons Learned
Start incrementally on corrective actions
Biggest advocates are those who have benefited from program
Need to showcase what PRT has accomplished to improve employee recognition
Tracking matrix facilitates future case reviews and data analysis, helps business case
Increase in report quality, applicability, and number indicates heading in right direction
Employees need to be reminded of program – visuals, newsletters, job aids, rulebook inserts

18. Suggested Improvements
Review current callback process (again) and standardized info against what PRTs have recommended (additional info that can help MCIA)
PRT quarterly teleconference – NASA, FRA?
Further develop C3RSPRT website for railroad resources – share corrective actions and program successes

20. Recommendations – Pilot with Several Engineers – Best Reminder Tool?

21. Recommendations – Take 5 Campaign – In Progress

22. Recommendations – Taking Trending Areas

23. Recommendations – And Implementing in PC and OJT Training

25. Thank you