C3RS ENGINEERING FORM
Do not report train accidents or criminal activities on this form. Accidents and criminal activities are not included in the C3RS program
and should not be submitted to NASA. All identities contained in this report will be removed to assure complete reporter anonymity.
IDENTIFICATION STRIP: Please fill in all blanks to ensure return of ID strip to you. NO RECORD WILL BE KEPT OF YOUR IDENTITY.
EVENT LOCATION
Subdivision
Facility
Milepost
State
Nearest Station
CARRIER / RAILROAD
DATE OF OCCURRENCE (MM/DD/YYYY)
LOCAL TIME (24 HR. CLOCK) [HH:MM]
TELEPHONE NUMBERS where we may reach you for further details of this occurrence.
  Primary
Hours
  Alternate
Hours
NAME 
ADDRESS/PO BOX  
ADDRESS LINE 2  
CITY 
STATE ZIP
PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS WHICH APPLY TO THIS EVENT OR SITUATION.
REPORTER   



 












REPORTER EXPERIENCE    SHIFT DURING EVENT   REPORTER LOCATION  
Railroad Years:   yrs
Years in Craft:   yrs
WORK GROUP SIZE
Work Group Size: 
At time of incident, were you on:



Hours into Shift  hrs






WEATHER LIGHT / VISIBILITY
ACTIVITY   







 Were job / safety briefings completed?    
EQUIPMENT   
IF MORE THAN ONE EQUIPMENT WAS INVOLVED, PLEASE DESCRIBE ADDITIONAL EQUIPMENT IN THE "DESCRIBE EVENT / SITUATION" SECTION.
Describe event / situation
Keeping in mind the topics shown below, discuss those which you feel are relevant and anything else you think is important. Include what you believe really caused the problem, and what can be done to prevent a recurrence, or correct the situation.


chain of events     human performance considerations
- How the problem arose
- Contributing factors
- How it was discovered
- Corrective actions
    - Perceptions, judgments, decisions
- Factors affecting the quality of human performance
- Actions or inactions

NASA ARC 277H (September 2013) OMB No. 2700-0172 Exp 7/31/2022
 

From the NASA Confidential Close Call Rail Reporting System:

NASA, through agreements with the Federal Railroad Administration, is managing, operating, and accepting reports for the Railroad Confidential Close Call Reporting System (C3RS). The C3RS is expected to identify issues in the railroad system that could be addressed to provide improvements in safety. Your assistance in informing us about such issues is essential to the success of the project. Please fill out this form as completely as possible. The paper form is pre-addressed and postage paid. The C3RS website at http://c3rs.arc.nasa.gov provides two options: download, complete form, print, enclose in a sealed envelope, affix proper postage, and mail directly to us OR submit your report through a secure, electronic submission (ERS) process.

The FRA has agreed through MOU’s with rail carriers that the reports filed with NASA are prohibited from being used for FRA enforcement purposes. This report will not be made available to the FRA for disciplinary actions for violations. Your identity strip, date stamped by NASA, is proof that you have submitted a report to the C3RS. We can only return the ID strip to you if you have provided a mailing address. The information you provide on the identity strip will be used only by NASA to contact you for further information. We can often obtain additional useful information if our safety analysts can talk with you directly by telephone. For this reason, we have requested telephone numbers where we may reach you. THIS IDENTITY STRIP WILL BE RETURNED BY MAIL DIRECTLY TO YOU. The return of the identity strip assures your anonymity.

NOTE: TRAIN ACCIDENTS AND/OR CRIMINAL ACTS SHOULD NOT BE REPORTED ON THIS FORM. SUCH EVENTS SHOULD BE FILED THROUGH APPROPRIATE AUTHORITIES.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. ยง 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this information collection is 2700-0172 and it expires on 7/31/2022. We estimate that it will take about 30 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: P.O. Box 177 Moffett Field, CA 94035-0177. Send only comments relating to our time estimate to this address.NASA

Thank you for your contribution to railroad safety.