Embed Size (px)
Citation preview
September 2015
C3RS User Group
Linda Connell, NASA ASRS & C3RS Program Director
Leslie E. Savoye, NASA C3RS Project Manager (BAH)
Program Overview
Booz AllenProgram ManagerTravis Trotter
IT Manager
Business AnalystElisa Marfise
Expert Analysts
IT Developers
Database Administrator
ASRS Project Manager
Report ProcessingAdministrator
BusinessManager
Technical Editor
Research Coordinator
Graphics Webmaster
IT Sys Admin
Organization and Roles
Ernest Montgomery
NASA ASRSProgram DirectorLinda Connell
Legend
C3RS Dedicated Staff
ASRS Dedicated Staff
Shared Resources
NASA Funded
Administrative Professional
Gary Hopson
Frank Simmer
Larry Valenzin
Ben Burns
Keith May
Report ProcessingAdministrator Yeraldin Sierra
C3RSProject ManagerLeslie Savoye
Michael Ballard
Programmatic Growth
REPORTING VOLUME
Volume is increasing rapidly and new carriers will also increase 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
2010
2011
2012
2013
2014
2015
Interagency Agreement Signed Carrier 3
Carrier 1
Carrier 4
Carrier 5
Rail Carrier Timeline
Carrier 6Carrier 7
Carrier 2
NASA’s C3RS Role Defined
Intergovernmental Partnership• Interagency Agreement between FRA and NASA
– Utilize NASA’s knowledge and experience To maximize the underlying trust of people working in rail industry to
report safety events Confidentiality, and ultimately anonymity, will result in improved
reporting Provide external and independent reporting avenue
Public/Private Partnership• IMOU between FRA and Carriers
– NASA shall act as owner of the data reported by employees– NASA shall protect the confidentiality of this information through
its own governance– NASA will de-identify data so that employee’s identity, any third
party reference, can no longer be determined through direct or indirect means.
Governing Documents and Data Protections
What is Confidential Data Protection?
• Promises of “confidentiality” are taken seriously in reporting systems
• Protections need to manage access through two potential paths:– Freedom of Information Act (FOIA)– Legal Discovery/Subpoena
Personally Identified Information (PII) Not Available for
Release Under Penalty of Law
• Privacy Act (PA), 5 USC 552a• NASA Human Experimental and Research Data and
System of Records (NASA 10HERD and SORN)• As required by law, NASA must respond to the
Freedom of Information Act (FOIA), 5 USC 552, - UNLESS the data falls within one or more of nine exemptions.
Exemption 6, the privacy exemption, would cover the data on individuals.
- Other exemptions can be considered in relation to each specific request
Federal Government and NASA Confidentiality Statutes
No Breach of Confidentiality has occurred in39 year history of ASRS and over 1.2M reports
(i)(1) Criminal penalties Any officer or employee of an agency, who by virtue of his employment or official position, has possession of, or access to, agency records which contain individually identifiable information the disclosure of which is prohibited by this section or by rules or regulations established thereunder, and who knowing that disclosure of the specific material is so prohibited, willfully discloses the material in any manner to any person or agency not entitled to receive it, shall be guilty of a misdemeanor and fined . . . .
THE PRIVACY ACT OF 19745 U.S.C. § 552a
De-identification Occurs Rapidly to Protect Data
• All reports read and reviewed by rail expert analyst(s).
• Reports de-identified for direct and indirect information
related to person who submitted report
• Reports de-identified concerning third-party references
(e.g. company, names, numbers etc.)
• De-identified reports are captured in on-site, restricted
database
• De-identified reports are shared with company PRT’s
following telephone callback by C3RS Analyst or time limit
for return phone call expires
De-Identification Protections
Physical Protections
• NASA ASRS and C3RS office is located in a secure, coded-access facility
• All electronic reports are encrypted and received through secure IT process
• All paper reports stored in locked file cabinets with strict access procedures enforced
• Original reports are not retained after safety information has been captured
• All staff work under signed Non-Disclosure Agreements
Aviation Safety Reporting System 13Aviation Safety Reporting System
13
KoreaKAIRS (2000)
United StatesASRS (1976)
United KingdomCHIRP (1982)
CanadaCASRP (1985)SECURITAS (1995)
AustraliaCAIR (1988)REPCON (2007)
RussiaVASRP
BrazilRCSV (1997)
JapanASI-NET (1999)
TaiwanTACARE (2000)
SingaporeSINCAIR (2004)
FranceREC (2000)REX (2011)
ChinaSCASS (2004)
New ZealandICARUS
South AfricaCAHRS (2013)
GermanyEUCARE
ASRS Model Applied to International Aviation Community
International Confidential Aviation Safety Systems (ICASS)
SpainSNS/SRS (2007)
Report Processing
• Since the Go Live Date of February 1,
2011 the total number of NASA C3RS
reports received is:
Report Intake
2097*
*As of August 31, 2015
Year over Year Volume Comparison
*Report Intake for 2015 thru August 31, 2015.
NASA C3RS Report Process
How to Submit a Report –NASA C3RS Website
http://c3rs.arc.nasa.gov
How to Submit a Report –NASA C3RS Website
EngineeringMechanicalTransportation
How to Submit a Report to NASA
1. Submit report form on C3RS website (secure transmission)
or
2. Fill out form on C3RS website, print and mail to NASA
or
3. Locate form at designated carrier locations, Fill out and mail Paper Form (postage free)
EngineeringMechanicalTransportation
NASA C3RS ERS
As of August 31, 2015
78% of reports have been received through Electronic Report Submission (ERS)
In August 2015, 93% of reports were ERS
http://c3rs.arc.nasa.gov
Report Processing
Report Process - Multiple Reports
Single Reporters Multiple Reporters
89% 11%
Report Process Monitoring
Report Process - Callbacks
Callback Success Rate
87%
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
Provided to NASA Director
Transfer to PRT Portal
No later than 90 Calendar Days from Date of Receipt
Data Overview
Craft
* Categories are mutually exclusive from 1,475 incidents . Data thru August 31, 2015.
Engineering
Mechanical
Transportation
0 200 400 600 800 1000 1200 1400 1600 1800
6
28
1672
n = 1,706 reports*
Hostler - InsideOn Board Service
TrackmanCDL Vehicle Operator
Hostler - OutsideLaborer
ObserverMachinistForemanCarman
Pipe FitterManager
ElectricianYardmaster
Assistant EngineerOther
BrakemanTrainee
DispatcherAssistant Conductor
ConductorEngineer
0 100 200 300 400 500 600 700 800 900
1111223333491111111622
3783
168573
779
Incident Reporter Distribution
*Reports available in 1,475 records. Data thru August 31, 2015. Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than reporter function.
n = 1,706*
Reporter Location
*Reports available in 1,475 records. Data thru August 31, 2015..Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than reporter location.
Vehicle
On Track Equipment
Other Track
On / Under / Between Motive Power
On / Under / Between Rolling Equipment
Main Track
Shop
Office / Crew Facility
Yard
Yard Control Center
Other
Locomotive - Walkway / Steps
Dispatch Center
Station Platform
Train Car - Vestibule
Train Car - Car
Adjacent To Track / On Ground
Locomotive - Cab
0 100 200 300 400 500 600 700 800 900 1000
1
1
2
3
4
6
12
15
34
41
60
67
76
108
145
256
261
858
n = 1,706*
Other Track
Non - Controlled Siding
Controlled Siding
Road Crossing
Shop
Repair Facility
Adjacent To Track
Other
Passenger Station
Main Track
Yard
0 100 200 300 400 500 600 700
1
1
3
3
7
7
8
26
244
639
650
Train Location
*Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than train location. Data thru August 31, 2015.
n=1.475 incidents*
Missed Station Stop
Near Collision
Maintenance / Repair Action
Equipment Derailment
Regained Train Control
Equipment Problem Dissipated / Resolved
Requested Additional Authority
Cancelled / Delayed
Initiated Emergency Brakes
Overcame Equipment Problem
Unknown
Run Through Switch
Other
Requested Assistance / Clarification
Slowing Of Train / Equipment
Damage To Equipment / Facility
No Action Taken
Stopped Train / Equipment
Returned To Compliance
0 50 100 150 200 250 300 350 400
20
32
34
36
37
39
43
53
54
55
96
113
111
148
202
207
234
308
369
Event Outcome
*Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than one event outcome/result. Data thru August 31, 2015.
n=1475 incidents*
Contributing Factors
n=1475 incidents*
*Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than one anomaly. Data thru August 31, 2015.
Human Factors
Physiological - Other
Physical Limitation
Troubleshooting
Fatigue
Human - Machine Interface
Workload
Time Pressure
Training / Qualification
Confusion
Distraction
Communication Breakdown
Situational Awareness
0 200 400 600 800 1000 1200 1400
11
13
39
60
65
153
200
270
329
441
771
1281
n=1402*
*Reporter Human Factor counts are for all persons in a report record. Data thru August 31, 2015. Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than reporter human factor.
Procedural Deviation
Operating Cab / Car Event
Track Authority Violation
Track And Structures Problem
Signal Events
Braking Event
On Track Protection Deviation
Mechanical Problem
Speed Deviation
Encounter
0 500 1000 1500 2000 2500
1956
27
110
118
121
161
162
177
594
736
Top 10 Event Counts
*Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than one anomaly. Data thru August 31, 2015.
n=1475 incidents*
Equipment Based Speed Restriction
Maximum Authorized Speed
At Or Above 10MPH Deviation
Temporary Speed Restriction
0 50 100 150 200 250
29
134
202
229
Speed Deviation Counts
*Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than one anomaly. Data thru August 31, 2015.
n=594*
C3RS Initial Analysis - Over Speed
Procedural Deviation
Operating Cab / Car Event
Track Authority Violation
Track And Structures Problem
Signal Events
Braking Event
On Track Protection Deviation
Mechanical Problem
Speed Deviation
Encounter
0 500 1000 1500 2000 2500
1956
27
110
118
121
161
162
177
594
736
Top 10 Event Counts
*Categories are not mutually exclusive. Therefore, a single incident may be coded by C3RS analysts as involving more than one anomaly. Data thru August 31, 2015.
n=1475*
Filename/RPS Number
Key data fields have been selected for the data analysis
• There are over 400 fields of data collected with each over speed report• The analysis is focused on specific fields based on our understanding of
strong factorsDATA GROUPS• Time of Day• Environment (14 types)• Train track authority (dispatcher, etc.)• Communications (radio, signals, etc.)• Operating Rules (GCOR, NORAC, etc.)• Track configuration (single, multiple)• Train Rules / Train Type• Train Speed Restrictions (5 types)• Train Activity• Person Location / Organization / Shift / Craft / Function
/ Qualification / Certification / Experience• Safety Briefings• Human Factors (13 types)• Events Anomaly (43 types)• Events Detector (13 types)• Passengers involved (Yes/No)• Event Results (40 types)• Contributing Factors (21 types with multi-values)• Primary Problem (21 types)
• Time of Day• Environment (14 types)• Person - Shift Duration• Person - Years of Experience (Total and In Craft)• Train Speed Restrictions (5 types)• Events Anomaly (43 types w/ 4 Speed Deviations)• Human Factors (13 types)• Event Results (40 types)• Events Detector (13 types)
Speed Deviations
Independent OccurrencesSpeed Deviation: At Or Above
10MPH DeviationSpeed Deviation: Equipment
Based Speed RestrictionSpeed Deviation: Maximum
Authorized SpeedSpeed Deviation: Temporary
Speed Restriction
159 27 109 16054% 9% 37% 54%
Overall OccurrencesType Speed Deviation: At Or Above
10MPH DeviationSpeed Deviation: Equipment
Based Speed RestrictionSpeed Deviation: Maximum
Authorized SpeedSpeed Deviation: Temporary
Speed Restriction Count %
2 Combo Yes Yes 92 31%Single Yes 63 21%Single Yes 61 21%
2 Combo Yes Yes 37 13%2 Combo Yes Yes 12 4%
Single Yes 11 4%Single Yes 9 3%
3 Combo Yes Yes Yes 4 1%3 Combo Yes Yes Yes 3 1%2 Combo Yes Yes 2 1%2 Combo Yes Yes 2 1%2 Combo Yes Yes 0 0%3 Combo Yes Yes Yes 0 0%3 Combo Yes Yes Yes 0 0%4 Combo Yes Yes Yes Yes 0 0%
Total 296 100%
Speed Deviation – Time of Day
n=296
Independent Occurrences Time of Day Count % 0001-0600 0601-1200 1201-1800 1801-2400 Unknown
Speed Deviation: At Or Above 10MPH Deviation 159 54% 16 50 38 48 7
Speed Deviation: Equipment Based Speed Restriction 27 9% 3 8 5 11 0
Speed Deviation: Maximum Authorized Speed 109 37% 11 34 33 28 3
Speed Deviation: Temporary Speed Restriction 160 54% 10 63 44 33 10
40 155 120 120 20
9% 34% 26% 26% 4%
Speed – Weather Conditions
Weather Condition
0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230Distinct count of ACN (Speed Deviation Spreadsheet)
Clear
Rain
Fog
Other
Null
Snow
Ice
Wind
Haze / Smoke
Thunderstorm / Lightning
Extreme Temperature
Occurence of Weather
Distinct count of ACN (Speed Deviation Spreadsheet) for each Weather Condition.
A strong majority (~65%) of incidents occurred under clear weather conditions
n=296
Speed – Human Factors
The top 4 Human Factors make up 77% of all reported contributing Human Factors (more than 1 may apply to each incident)
Human Factor Detail
0 20 40 60 80 100 120 140 160 180 200 220 240 260Distinct count of ACN (Speed Deviation Spreadsheet)
Situational Awareness
Distraction
Communication Breakdown
Confusion
Training / Qualification
Workload
Time Pressure
Fatigue
Troubleshooting
Human - Machine Interface
Null
Physiological - Other
Physical Limitation
Other / Unknown
Occurence of Human Factors
Distinct count of ACN (Speed Deviation Spreadsheet) for each Human Factor Detail.
n=296
PRT Interaction
PRT/NASA Synergy
• Data Access Through Portal– Continuous Coordination
• Telecons– Proposal for Scheduled Check-ins on
Quarterly Basis with Each PRT
• Feedback– Integration of PRT Feedback in Report
Processing
Future Developments
• Newsletter– First Draft Issue Under Review and Naming
• Search Request of Database– Initially Direct Request to C3RS Office– Planning for Password Protected Search
Capabilities
• Alert Messages and Scheduled Telecons– TBD
• Special Studies & Data Analyses
DRAFT Newsletter
Potential Newsletter Names
• Track Bulletin• Highball• The Line Up• Clear Block• First Out• Lantern• Signal• Timetable• Milepost
• Job Briefing• Train Orders• Synergy Daily• Journal• Points• All-Points Bulletin• Hot Journal• Inside the Rail• From the Cab
Questions?
Linda Connell, NASA
ASRS/C3RS Program Director
(408) 541-2827
Leslie Savoye, Booz Allen Hamilton
C3RS Project Manager
(408) 541-2829
Travis Trotter, Booz Allen Hamilton
ASRS/C3RS Program Manager
(408) 541- 2815
