Form ARC 277G ARC 277G Mechanical

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.

(SPACE BELOW RESERVED FOR NASA DATE/TIME STAMP)

TYPE OF EVENT/SITUATION ___________________________________________
INVOLVED CO-WORKERS _____________________________________________
____________________________________________________________________
EVENT LOCATION

TELEPHONE NUMBERS where we may reach you for further details of this occurrence

PRIMARY

Area ______ No. ________________ Hours ____________ O H O M O W

ALTERNATE Area ______ No. ________________ Hours ____________ O H O M O W

Subdivision ___________________________________
Facility ____________________________________
Milepost _____________

State _______________

NAME _________________________________________________________

Nearest Station _______________________________

ADDRESS ______________________________________________________

CARRIER / RAILROAD ________________________

______________________________________________________________

DATE OF OCCURRENCE ______________________

CITY __________________________ STATE _______ ZIP ______________

LOCAL TIME (24 hr. clock) ____________________

(MM/DD/YYYY)
(HH:MM)

PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS WHICH APPLY TO THIS EVENT OR SITUATION.

REPORTER

CERTIFICATION

o Boiler Maker

o Hostler (Inside)

o Pipe Fitter

o Carman

o Laborer

o Trainee

o Electrician

o Machinist

o Other:

o Foreman

o Manager

REPORTER EXPERIENCE
Railroad Years

yrs

Years in Craft

yrs

o Air Brake Inspections
o Blue Signal Protection
o Conductor Certification
o FRA Glazing
o Freight Car Inspection
o Locomotive Engineer Certification

o Locomotive Inspection
o Passenger Car Inspection
o Rear End Marker/EOT
o Safety Appliances
o Other:

SHIFT DURING EVENT

WORK GROUP SIZE
At time of incident, were you on

Work Group Size

o Assigned Shift

o Emergency Duty

o Overtime Duty

o Other:

Hours into Shift
hrs

WEATHER

REPORTER LOCATION

LIGHT / VISIBILITY

O Other Track

o Clear

o Snow

O Adjacent to
track/on ground

O On/under/between
Rolling Equipment

o Fog

o Wind

O Dawn

O Night

O High

O Low

O Office/Crew Facility

O Station Platform

o Hail

o Haze/Smoke

O Daylight

O Dusk

O Medium

O Off

O On/under/between
Motive Power

O Other:

o Ice

o Thunderstorm/Lightning
o Reduced Visibility

feet

O Yard

O Shop

o Rain

Outdoors

o Other:

Work Area Lighting

ACTIVITY
o Blocking/Jacking/Rerailing

o Installation

o Scheduled Maintenance

o Documentation

o Operating Vehicle/Equipment

o Testing

o Inspection

o Repair/Replace

o Other:

Were job/safety briefings
completed?

O Yes

O No

EQUIPMENT
Locomotives

Total Head End #
Locomotive Make/Model

Passenger
Freight

# of Cars

# in Service

Loads

Empties

Remote Control

O Yes

O No

Distributed Power

O Yes

O No

Cab Car Controlling
Tons

Status

Records complete
Required/correct documents on board
Maintenance deferred

O Yes
O Yes
O Yes

Type

O Passenger/Commuter

O Freight

O Other:

Location

o Main Track

o Passenger Station

Operating
Rules

O GCOR

o Yard
O NORAC

O No
O No
O No

Position in Train
O Yes

O No

Length
Released for service
Moving for repair

feet

O Yes
O Yes

O No
O No

Involved Car Kind
o Industry

o Repair Facility

O Other:

o Other:

Blue Signal Protection

O Yes

O No

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-XXXX Exp. mm/dd/yyyy

NATIONAL AERONAUTICS AND SPACE ADMINISTRATION

CONFIDENTIAL CLOSE CALL 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 at address below OR submit your report
through a secure, electronic submission (ERS) process.
Thank you for your contribution to railroad safety.

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. § 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-XXXX and it expires on mm/dd/yyyy. 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)

Page 2 of 3

HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions
- Actions or inactions
- Factors affecting the quality of human performance

DESCRIBE EVENT/SITUATION, continued...

CHAIN OF EVENTS
- How the problem arose
- How it was discovered
- Contributing factors
- Corrective actions

NASA ARC 277G (September 2013)

Page 3 of 3

HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions
- Actions or inactions
- Factors affecting the quality of human performance