1. 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

2. Program Overview LC

3. 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

4. C3RS Report Process LC

5. 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

6. 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

7. 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

8. 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

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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. Report Processing EM

19. NASA C3RS Report ProcessEM

20. 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

21. Year over Year Volume ComparisonEM

22. 2016 vs 2015 Intake by Month EM

23. How to Submit a Report – Three C3RS FormsEM
Transportation
Mechanical
Engineering

24. How to Submit a Report to NASAEM
Electronic Report Submission
Submit report form on C3RS website (secure transmission)
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

25. NASA C3RS Electronic Report Submission (ERS)
As of December 2016, 95% of reports have been received through Electronic Report Submission (ERS) EM

26. Report Processing EM

27. 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%

28. Report Processing EM

29. Analyst Coding – WorkbenchEM

30. Analyst Coding - WorkbenchEM

31. 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

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

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

34. 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

35. 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

36. PRT Interaction Expansion from 9 PRTs in 2015 to 18 PRTs in 2016
C3RS transferred 2,596 reports to the Portals in (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

37. 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.

38. Data Overview EM

39. 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

40. 2016 Craft Report Volume* EM
* Categories are mutually exclusive. Craft counts are for all persons in a report record. Screening Data for Jan – Dec n=3364

41. 2016 Incident Reporter Distribution*EM
*Reporter function counts are for all persons in a report record. Screening Data for Jan – Dec n=3364
Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than reporter function.

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

43. 2016 Event Category / AnomalyEM
*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 n=3364

44. 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 n=2425 44

45. 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 n=2425

46. 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

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

48. C3RS Products

49. 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

50. Incident Reporting Model

51. 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

52. 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.

53. 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

54. 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

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

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

57. Alert Message System GH

58. 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

59. 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

60. Newsletter – Email Subscription
Text C3RS to to subscribe
Or send an to
Sign up at table for individual subscription or bulk mailings GH

61. 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

62. 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

63. 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

64. C3RS Database Query Tool (DBQT)EM

65. 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

66. 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

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

68. 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

69. Questions?
Linda J. Connell, NASA ASRS/C3RS Program Director (408)
Gary J. Hopson, Booz Allen Hamilton
C3RS Outreach Analyst
(410)
Elisa T. Marfise, Booz Allen Hamilton
Human Factors Manager
(408)