Step 1 of 5 / ID Strip

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.

Personal Information
* Required
* Required
* Required
* Required
* Required

Telephone

Event Details

Event Location
* Required

Date of Occurrence

Local Time

Step 2 of 5 / Reporter Information

Reporter

Certification

Reporter Experience
Work Group Size

Shift During Event

 At the time of incident, were you on:

Hours into Shift

Reporter Location

Step 3 of 5 / Environment

Weather

Light / Visibility

Step 4 of 5 / Train Information

Activity
Were job / safety briefings completed?

Equipment

Locomotives

 

 

Remote Control
Distributed Power

Passenger
Cab Car Controlling

Freight

Status
Records Complete
Required / correct documents on board
Maintenance deferred
Released for Service
Moving for repair

Type

Train Location

Operating Rules

Step 5 of 5 / Description

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.

Describe Event / Situation
* Required
DESCRIBE THE CHAIN OF EVENTS:
  • How the problem arose
  • Contributing factors
  • How it was discovered
  • Corrective actions
DESCRIBE HUMAN PERFORMANCE CONSIDERATIONS:
  • Perceptions, judgments, decisions
  • Factors affecting quality of human performance
  • Actions or inactions
NASA ARC 277G (September 2013)  vx
OMB No. x

The Confidential Close Call Reporting System (C3RS) is a partnership between the National Aeronautics and Space Administration (NASA), the Federal Railroad Administration (FRA), in conjunction with participating railroad carriers and labor organizations.