Fillable NASA - C3RS Mechanical Report Form

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NASA - C3RS Mechanical Report Form

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DO NOT REPORT TRAIN ACCIDENTS OR CRIMINAL ACTIVITIES ON THIS FORM. ACCIDENTS AND CRIMINAL ACTIVITIES ARE NOT INCLUDED IN THE C
3
RS 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.
(SPACE BELOW RESERVED FOR NASA DATE/TIME STAMP)
NO RECORD WILL BE KEPT OF YOUR IDENTITY.
TYPE OF EVENT/SITUATION ___________________________________________
INVOLVED CO-WORKERS _____________________________________________
__________________________________________________________________
_
_
EVENT LOCATION
TELEPHONE NUMBERS where we may reach you for further details of this occurrence
Subdivision _________________________
__________
PRIMARY
Area
______
No.
________________
Hours
____________
O W
acility
H O M O
F ____________________________________
ALTERNATE
Area
______
No.
________________
Hours
____________
O H O M O
Milepost _____________ State _______________
W
NAME _________________________________________________________
Nearest Station ________________________
ADDRESS ______________________________
_
______
_____________
___________
CARRIER / RAILROAD ________________________
___________________________________________________________
___
DATE OF OCCURRENCE ______________________
(MM/DD/YYYY)
CITY __________________________ STATE _______ ZIP _____________
_
LOCAL TIME (24 hr. clock) ________________
____
(HH:MM)
PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS WHICH APPLY TO THIS EVENT OR SITUATION.
REPORTER
CERTIFICATION
o Boiler Maker o Pipe Fitter
o
o Hostler (Inside)
Air Brake Inspections
o Locomotive Inspection
Carman Laborer
o
o
o o
o Trainee
Blue Signal Protection
Passenger Car Inspection
o Conductor Certication
o Rear End Marker/EOT
o Electrician o Machinist
o Other:
o FRA Glazing
o Safety Appliances
o Foreman o
o Freight Car Inspection
o
o Locomotive Engineer Certication
Manager
Other:
REPORTER EXPERIENCE
WORK GROUP SIZE
SHIFT DURING EVENT
Railroad Years
yrs
At time of incident, were you on
Work Group Size
Hours into Shift
o Assigned Shift o Emergency Duty
Years in Craft
hrs
o
yrs
Overtime Duty o Other:
REPORTER LOCATION
WEATHER
LIGHT / VISIBILITY
O Yard O Other Track
Clear
o Snow
Outdoors
Work Area
between
O Dawn O Night
O Shop
o
Lighting
O Adjacent to O On/under/
o Fog
o Wind
O High O Low
track/on ground
Rolling Equipment
o Hail
o Haze/Smoke
O Daylight O Dusk O Medium O O
O Oce/Crew Facility
O Station Platform
o Ice
O On/under between
Rain
o Thunderstorm Lightning
/
O Other:
Motive Power
/
o
o Other:
ACTIVITY
o Blocking/Jacking/Rerailing
Installation
o
Reduced Visibility
feet
o
o Scheduled Maintenance
Were job/safety briefings
completed?
o Documentation
o Operating Vehicle/Equipment
o T
o Repair/Replace
o
esting
o Inspection
Other:
O Yes O No
EQUIPMENT
Locomotives
Total Head End #
Remote Control
O Yes O No
Locomotive Make/Model
Distributed Power
O Yes O No Position in Train
Passenger
# of Cars # in Service Cab Car Controlling O Yes O No
Freight
Loads Empties Tons Length feet
Yes O No
Status
Records complete O Released for service O Yes O No
Required/correct documents on board O Yes O No Moving for repair O Yes O No
Maintenance deferred O Yes O No
Type
O Passenger/Commuter O Freight O Other:
Involved Car Kind
Location
o Main Track o Yard o Passenger Station o Industry o Repair Facility o Other:
Operating
O GCOR O NORAC O Other: Blue Signal Protection O Yes O No
Rules
If more than one equipment was involved, please describe additional equipment in the "Describe Event/Situation" section.
NASA ARC 277G (September 2013) C3RS MECHANICAL FORM OMB No. 2700-0172 Exp 7/31/2022
Reset Form
NATIONAL AERONAUTICS AND SPACE ADMINISTRATION
CONFIDENTIAL CLOSE CALL REPORTING SYSTEM
NASA, through agreements with the Federal Railroad Administration, is
The FRA has agreed through MOU’s with rail carriers that the reports filed
managing, operating, and accepting reports for the Railroad Confidential
with NASA are prohibited from being used for FRA enforcement purposes.
Close Call Reporting System (C
3
RS). The C
3
RS is expected to identify
This report will not be made available to the FRA for disciplinary actions
issues in the railroad system that could be addressed to provide
for violations. Your identity strip, date stamped by NASA, is proof that you
improvements in safety. Your assistance in informing us about such
have submitted a report to the C
3
RS. We can only return the ID strip to
issues is essential to the success of the project. Please fill out this form
you if you have provided a mailing address. The information you provide
as completely as possible. The paper form is pre-addressed and postage
on the identity strip will be used only by NASA to contact you for further
paid. The C
3
RS website at http://c3rs.arc.nasa.gov provides two options:
information. We can often obtain additional useful information if our safety
download, complete form, print, enclose in a sealed envelope, affix proper
analysts can talk with you directly by telephone. For this reason, we have
postage, and mail directly to us at address below OR submit your report
requested telephone numbers where we may reach you. THIS IDENTITY
through a secure, electronic submission (ERS) process.
STRIP WILL BE RETURNED BY MAIL DIRECTLY TO YOU. The return
of the identity strip assures your anonymity.
Thank you for your contribution to railroad safety.
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. § 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 189 Moffett Field, CA 94035-0189. Send only
comments relating to our time estimate to this address.
If you want to mail this form, please fold both pages (and additional pages if required), enclose in a sealed,
stamped envelope, and mail to:
NASA CONFIDENTIAL CLOSE CALL REPORTING SYSTEM
POST OFFICE BOX
177
MOFFETT FIELD, CALIFORNIA 94035-0177
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.
(USE ADDITIONAL PAPER IF NEEDED)
CHAIN OF EVENTS
- How the problem arose - How it was discovered
- Contributing factors - Corrective actions
NASA ARC 277G (September 2013)
HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions - Actions or inactions
- Factors affecting the quality of human performance
Page 2 of 3
DESCRIBE EVENT/SITUATION, continued...
Page 3 of 3
CHAIN OF EVENTS
- How the problem arose - How it was discovered
- Contributing factors - Corrective actions
NASA ARC 277G (September 2013)
HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions - Actions or inactions
- Factors affecting the quality of human performance
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NASA - C3RS Mechanical Report Form

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Completed 25 May 2020

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