DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

659

DEVELOPING AN EFFECTIVE CORRECTIVE ACTION 

PROCESS: LESSONS LEARNED FROM OPERATING A 

CONFIDENTIAL CLOSE CALL REPORTING SYSTEM

Jordan Multer1, Joyce Ranney1, Julie Hile2 and Thomas Raslear3

Volpe National Transportation Systems Center, 55 Broadway, RVT-81, 

Cambridge, MA. 02142 United States

Hile Group, 1100 N Beech St. Bldg 15, Normal, IL. 61761 United States

Federal Railroad Administration, 1200 New Jersey Ave. SE, RPD-32, 

Washington, DC. 20590 United States

In 2007, the Federal Railroad Administration (FRA) launched 

C3

RS, the Confidential Close Call Reporting System, as a 

demonstration project to learn how to facilitate the effective 

reporting and implementation of corrective actions, and assess the 

impact of reporting close call events on safety. This paper 

describes some of the challenges and remedies in establishing 

effective problem identification and corrective actions processes 

when setting up an event reporting system like C3

RS. 

Introduction

In high hazard industries, like railroad operations, bridging the gaps between 

event reporting, problem identification and implementation of solutions presents

significant challenges to the effectiveness of reporting systems. This paper tells 

the story of challenges that emerged during the implementation of a confidential 

close call reporting system in the U.S. railroad industry and efforts to address 

them. 

In 2007, the Federal Railroad Administration (FRA) launched C3

RS, the U.S. 

Confidential Close Call Reporting System, as a demonstration project. One goal 

was to learn how to facilitate effective reporting and implementation of 

corrective actions. A second goal was to assess the impact of reporting close call 
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

660

events on safety. Two freight and two passenger railroads participated in the 

demonstration project. Each railroad began participating one at time, over 4 

years. As new railroads joined C3

RS, we changed the implementation process

based on lessons learned from earlier experiences.

Prior to launching the system, stakeholders representing labour organizations, 

railroad management, and the regulator met to identify the principles that would 

underlie the system and create a framework for how the system would operate. 

The principles and processes were documented in a model Memorandum of 

Understanding (MOU).

C3RS system structure and operation

Figure 1 shows the reporting process. Before a railroad agreed to participate, the 

FRA’s implementation team educated the stakeholders (railroad management, 

labour, and FRA field staff) on how the reporting system worked. Since the 

model MOU lacked all the details necessary for implementation at each railroad,

the stakeholders negotiated the details to operate the reporting system. This new 

document was referred to as an Implementing Memorandum of Understanding 

(IMOU). For example, the IMOU specified the geographical boundaries where 

employees could submit reports and which labor crafts would participate.

Educating participants and customizing the IMOU played an important role in 

building trust among the stakeholders and modelling the partnership that 

continued when C3

RS began operation.

Following the agreement by the stakeholders, each party selected members from 

its own organization to participate on a Peer Review Team (PRT). The PRT 

analyzed event reports and recommended corrective actions to the railroad. This 

group also developed materials and communication strategies for educating 

employees and managers on how to use C3

RS and its benefits to the railroad.

Once the system began operation, employees submitted written reports to a third 

party. The third party interviewed the employee to clarify the information in the 

written report and requested additional details about how the event unfolded. The 

third party prepared a de-identified event report for the railroad’s use. The deidentified report removed information that could identify the reporter or people 

involved. If multiple employees submitted a report on the same event, the report 

included information from all reporters. After event reporting began, the railroad 

analyzed the reports, developed, and implemented corrective actions. Except for 

forming the PRT to identify causal factors, the railroad could choose whatever 

methods, tools, and processes to inform its analysis and take whatever actions it 

considered appropriate. 
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

661

The railroad was responsible for implementing corrective actions, monitoring 

their impact, and providing feedback to employees. The railroad also shared the 

results of its analyses, recommended and implemented corrective actions and 

their impacts, with the third party. This information served as a shared resource 

from which the regulator and the industry could learn about safety problems and 

effective ways to address them.

Figure 1: C3

RS Reporting and Corrective Action Process

Employee submits 

report

Third Party process 

reports

Railroad analyzes 

reports

Railroad reviews, 

prioritizes, and 

authorizes 

corrective actions

Railroad 

implements and 

monitors corrective 

actions

Railroad shares 

information 

Third Party analyzes 

trends across 

carriers and shares 

with stakeholders

Railroad prepares 

for participation

Reporting 

Process
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

662

Challenges encountered

In developing the C3RS model and implementing it, the FRA implementation 

team benefited from the existing literature on confidential close call reporting 

systems. Van der Schaaf, (1991); Johnson, (2003); Reason (1998); and Phimister 

(2000) provided valuable insights for setting up an effective reporting system. 

Our team learned from the Aviation Safety Reporting System (ASRS) and the 

United Kingdom’s Confidential Incident Reporting and Analysis System

(CIRAS); Davies et al., 2000). We applied the lessons learned from this research 

to our implementation of C3

RS. 

The decision to send event reports to the railroad for analysis arose from three 

ideas. First, local knowledge about organization dynamics and operating 

practices would enable the railroad to better identify problems than outsiders. 

Second, the involvement of multiple stakeholders in analysis and problem 

solving would contribute to a richer analysis and broader set of corrective 

actions. Third, the railroad’s involvement in identifying causes and development 

corrective actions would result in greater likelihood of implementation. 

Several challenges implementing C3

RS arose from the decision to send the event 

reports to the railroad. These challenges emerged around the problem 

identification and corrective action processes. The rest of this paper describes 

how the implementation team collaborated with the participating railroads to 

address these challenges. Many of these challenges involved organizational

barriers that contributed to ineffective problem solving and decision making

combined with the consequences of how C3

RS was implemented.

Challenge 1: Event analysis hampered by process for selecting PRT 

members and managing meetings

Several problems emerged from the process by which the railroad organized 

itself to analyze events and implement corrective actions. These processes 

involved selection of employees involved with C3

RS, communications, and 

meeting management. The first problem emerged from the process for selecting 

PRT members. The leadership within each stakeholder group selected members 

to participate on this team. Management and FRA leadership selected one or two 

members to participate. Labour leaders from each craft selected employees 

representing each geographical territory within the demonstration site. With 

multiple territories at each demonstration site, the labor representatives formed 

the largest stakeholder group. The size of the PRT ranged between 12 and 24

people. The large number of labour representatives grew out of a desire by the 

labour leaders to each choose representatives to represent their interests. While a

large group facilitated communications with employees and promoted credibility 
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

663

with the employees represented by the labor crafts, its size hampered effective 

event analysis. The size of the group limited the frequency with which it could 

meet due to budget constraints. Since the railroad paid for the time each manager 

and labor representative spent doing event analysis as well as for someone else to 

perform the work that the PRT members would normally do, management 

determined how much time was available through the budget they established. 

We developed a list of knowledge, skills and abilities (KSAs) that the 

stakeholder leaders could use in selecting future PRT members. While the use of 

these KSAs helped, stakeholder leaders also weighed other considerations in 

deciding which people to select. 

The large PRT group size also made it hard to manage. As a result, the PRT did 

not initially organize itself to manage all the activities needed to perform event 

analysis activities and use their time effectively. Who would lead the meetings? 

Who would document the results of their work? Who would communicate with 

the third party? We worked with the demonstration sites to create several 

strategies to address these constraints. We proposed a set of leadership roles 

within the PRT to assist them in managing their activities. These roles consisted 

of a facilitator to manage the meetings, a scribe to document their work, and a 

process manager to coordinate administrative issues such as when meetings 

would take place and obtaining resources. The people selected for these roles 

received additional training to perform their duties. Assigning people to the three 

roles contributed to more effective meetings.

To address the large membership, we recommended reducing the number of 

people attending each meeting. After learning about this challenge at the first 

site, we recommended that stakeholders at subsequent sites adopt the smallest 

group possible with representation from each organization. One PRT adopted a 

second strategy of alternating member participation at meetings. This procedure 

enabled members to maintain their skills, while keeping the group smaller. In a 

third strategy, a PRT formed a separate team to review the cases prior to event 

analysis by the larger group. This strategy enabled the group to prioritize the 

reports and spend their time on those reports that made the best use of their time.

These strategies all contributed to more effective management of the PRT’s 

workload. Reducing the size of existing PRTs proved more difficult, since the 

members valued the opportunity to do this work. They universally felt the event 

analysis served a valuable purpose and wanted to stay involved. We continue to 

seek effective solutions to optimize PRT effectiveness and manage costs. 

To address the communication tasks, we recommended creating a group of 

“ambassadors” that would serve as a communication link between the PRT and 
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

664

employees. The ambassadors shared concerns from employees with the PRT and 

shared information that the PRT wanted to communicate with employees. This 

group matched the need of labour crafts leaders to play an important role for 

which they were well suited: sharing information between employees and PRTs. 

Program ambassadors also included managers to communicate the value of the 

program to their peers and to identify management concerns that needed to be 

addressed. By establishing a “larger” group of employees to facilitate 

communications, the railroad could keep the PRT smaller and focused on the 

analysis of event reports. Where it was used, the opportunity for face-to-face 

conversation with employees worked well as a mechanism to share information 

between PRTs and employees.

Challenge 2: Loss of project champions

A second challenge involved the loss of project champions. Project champions 

were people within the organization, usually managers, who took an active 

interest in the project and used their strong belief in the value of C3

RS, good

relationships with others, and authority to get others engaged in the project. They 

acted as vocal project proponents to articulate the project’s vision and inspired

others to participate. Articulating a vision and set of values (developing an 

environment of trust and collaboration) that contrasted with a more traditional 

rules-based, command and control culture took courage on the part of the project 

champions.

At each of the demonstration sites where the FRA implemented C3

RS, project 

champions left due to promotions, retirements, and job changes. Finding 

subsequent management champions who shared the same passion or appreciated 

the value of a close call reporting system proved difficult. The senior 

management replacement frequently lacked the same passion for the project or

lacked the vision for leveraging the project to benefit the railroad in new ways, 

as the initial champions did. Over time, some of the project champions changed 

from neutral participants to enthusiastic supporters. This process took time as 

they learned from experience how the reporting system benefited their 

stakeholder organization. Following the loss of a senior project champion, the 

program was vulnerable to a loss of support and resources. The challenge, which 

remains, is how to find subsequent project champions who believe in this 

initiative and want to participate. We worked with the railroad to set up 

succession planning so that the railroad could take responsibility for replacing 

key participants when they left. To address changes in PRT membership, we 

worked with stakeholders to insure that multiple people could serve in the PRT 

leadership roles. Overall, railroads with management champions at the most 

senior levels fared the best with this challenge.
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

665

Challenge 3: Addressing gaps in event reports

Close call reports provide an opportunity for employees to tell their story. These

explanations provided insights into the context for decisions and actions by 

employees that the railroad could use to better understand why an event unfolded 

as it did. However, unlike accident investigations in which investigators collect 

multiple sources of information, close call reports only provided one perspective:

that of the reporter. To gain a more complete picture of how an event unfolded 

requires the story from everyone who played a role in the event. In practice, this 

was infeasible, as employees located far away in space and time from event were

unaware that an unsafe event occurred. In addition, there was no way to collect 

information from a de-identified report on the state of track infrastructure or rail 

equipment unless the reporter addressed it. 

The PRT frequently expressed frustration with the gaps in the close call reports.

Gaps occurred for a variety of reasons. In some cases, the reporter observed the 

close call involving others, so they lacked information about those employees’ 

intentions. Other gaps occurred when an employee chose not to provide details 

that could help the PRT understand why the event occurred. PRT members cited 

lack of time, writing ability, and motivation as factors contributing to reporting 

gaps. Some reports lacked details because the third party analyst preparing the 

report missed the significance of the information and excluded it or removed it to 

protect the reporter’s confidentiality. The current process also protected all 

members of a team when only one member reported. To encourage reporting 

events involving rule noncompliance, employees received protection from 

discipline. This protection extended to an employee’s immediate coworkers, 

even when they did not submit a report. As a result, a team member whose report 

could improve the PRT’s understanding of the event might not submit a report.

The PRT’s frustration with gaps in the event reports also grew out of a process 

that relied on information in the event reports to inform their analysis. With one 

important exception, they collected no other information, in spite of our urging to 

seek other sources. Where an event touched on operations outside the PRT’s 

expertise, (e.g., maintenance operations), the PRT consulted with subject matter 

experts to learn how employees in that domain performed their work related to 

the event. Other types of information we recommended the PRT seek included:

observations of current work processes, interviews with employees in the field, 

and automated data collected by the railroad such as from event recorders. 

If the PRT wanted to collect information from additional sources, they were

limited by several constraints. Given the time allocated to event analysis, most 

PRTs lacked the time and skills to conduct these investigations. Additionally, it 

was unclear whose job it was to conduct these additional investigations. While 
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

666

the C3

RS model specified that the PRT would support the events analysis, it did 

not preclude events analysis by others within the railroad. The model specified 

that the railroad was responsible for reviewing, authorizing, and implementing 

corrective actions. However, the C3

RS model did not specify where the analysis 

work of the PRT ended and analysis by others within the railroad began. In 

practice, if the PRT recommended additional investigation to better understand 

the problem, the railroad management might ask the PRT members to conduct 

this investigation. However, without sufficient skills, resources, and/or authority, 

they struggled to accomplish this work.

The PRTs adopted several strategies to close the information gaps that frustrated 

their analysis efforts. The PRTs worked with the third party to improve the 

quality of reports. The PRT provided questions on particular topics (e.g., job 

briefings) that the third party analyst would ask in subsequent interviews. The 

third party set up a process where employees could submit supplemental 

materials such as maps, and written documentation that played a role in the 

event. The PRT also reached out to employees to ask everyone involved in a 

close call event to submit their own reports. The PRT asked employees to 

encourage their team mates to report when they experienced a close call event. 

The PRTs also proposed changing the process for receiving protection from 

discipline to require each person to submit a report to receive protection. 

We worked with the PRTs to create report examples so employees understood 

what a well written report contained. Finally, we recommended including in their 

corrective action recommendations, the need to investigate the problem more 

deeply or to ask for resources to investigate the issue themselves when their 

analysis was incomplete. Without collecting additional sources of information 

and investigating the operating practices for which an employee submitted an 

event report, the PRT would miss valuable information for identifying how 

systemic factors impacted safety. We also recommended that the railroad align 

the PRTs work with other parts of the railroad engaged in similar work. 

While these strategies for improving the quality of the reports helped, the 

strategies could not bridge the gap associated with the processes and conditions

that lay outside of the PRT’s knowledge or understanding. Bridging this 

knowledge gap requires including people with the knowledge, skills, and abilities 

to collect additional information and investigate existing processes to understand 

how current operations created systemic risks. A future challenge is how to 

demonstrate to railroad management the value in learning from these events.
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

667

Challenge 4: Incorporating operational knowledge that goes beyond 

frontline employees

The benefits of including frontline workers and managers in the event analysis 

process lies in their knowledge of actual work practices compared to how work

is designed. They can offer insights into how work is done, that outside analysts 

cannot (Dekker, 2011; Meadows, 2008). The collaborative process of frontline 

employees and managers working together with the regulator built trust among 

the stakeholders as they learned to work together. The collaborative problem 

solving process also enabled them to appreciate different perspectives that lead 

to solutions that focus on problem solving rather than fixing blame.

However, the PRT’s expertise was limited by their domain knowledge of railroad 

operations (train and switching operations). Their event analysis and corrective 

action recommendations were constrained by their limited knowledge of other 

parts of railroad operations, (e.g., maintenance, supplier and customer 

operations, etc.). In the same way that railroad employees not involved in train 

operations lacked knowledge about train operations, PRT members lacked the 

knowledge and perspective that these other employees brought to the analysis. 

So PRTs, whose membership relied on frontline employees, identified causal 

factors with which they were familiar. However, they missed causal factors that 

lay outside of their work experience. Our review of their event analysis indicated

that PRTs produced corrective action recommendations that focused more on 

local solutions or problem symptoms than on systemic explanations. Identifying 

the systemic factors that originated elsewhere in the organization was difficult, 

because they lacked the awareness to consider these causal factors. This is 

consistent with the concept of bounded rationality in which people have finite 

capabilities and cannot consider all the possibilities that may be relevant in 

complex problems (Woods and Cook, 1999; Meadows, 2008). 

To address this challenge, we made several recommendations. We recommended 

including subject matter experts from other domains or departments to support 

the event analysis. Second, we recommended expanding the PRT’s analysis 

beyond the event reports themselves to investigate the underlying business 

processes and operational practices. Third, we proposed that the railroad create a 

cross functional group to augment the PRT’s work, which we called a Support 

Team. The Support Team’s responsibility was to review the event analysis and 

corrective action recommendations and decide how to proceed. They could 

recommend additional investigation and/or authorize implementation of 

corrective actions. As employees who were not involved directly in train 

operations, they could provide a broader perspective on the recommended 

corrective actions.
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

668

The subject matter experts from other departments and domains provided 

valuable insights into how these other groups performed their work. Their 

support contributed to a variety of effective corrective actions. Support Teams 

increased the engagement of railroad managers and they provided a valuable 

perspective to event analysis reviews and corrective action recommendations. 

However, the Support Teams lacked time to contribute to insights that could 

provide a more systemic view of why unsafe events occurred. Bridging this gap 

could involve delegating their work to staff with a comparable view.

Conclusions

So what do these challenges to the event analysis and corrective action process 

tell us about implementing event reporting systems? We adapted the lessons 

from other close call reporting systems and the existing research on how to 

design effective reporting systems (Van der Schaaf, 1991; Johnson, 2003, and 

Phimester eta al, 2000), to meet the needs of the railroad industry stakeholders. 

We learned that our implementation process interacted with the organizational 

structures at the participating railroads to produce unintended consequences. We 

learned how our ability to implement this reporting system was constrained by 

the organizational factors within each railroad as well as by the C3

RS

implementation process itself. 

The decision to send event reports to the railroad to identify and implement 

systemic corrective actions posed a variety of unanticipated challenges. These 

challenges included:

• Identifying who should do this work and how to manage meetings.

• Sustaining the system when project champions leave.

• Addressing gaps in event reports.

• Collecting perspectives that address multiple layers within the organization.

• Identifying systemic issues and their corrective actions.

• Setting up a cost effective project structure.

Working with the participating railroads, we implemented a variety of actions to 

address these challenges. These corrective actions varied in their effectiveness. 

Multiple overlapping factors contributed to these challenges at each railroad.

These factors included physical, psychological, and social structures (Repenning 

and Sterman, 2001). In complex systems, no one has a complete view of how 

new technologies and processes will impact the organization (Meadow, 2002). 

Addressing this complexity calls for including people across the organization to 

manage the many ways that problems arise in organizations. Managing 

complexity also requires a systems or holistic view of the organization where 
DOT/FRA/ORD-13/12

Multer, J., Ranney, J., Hile, J. & Raslear, T. (2013). Developing an effective corrective action 

process: Lessons learned from operating a confidential close call reporting system. In N. Dadashi, A. 

Scott, J. R Wilson, & A. Mills (Eds.), Rail Human Factors: Supporting reliability, safety and cost 

reduction. London: Taylor & Francis, pp. 659-669.

669

interactions between organizational elements can be addressed Dekker, 2002; 

Meadows, 2008; Leveson, 2011). Safety professionals should expect these 

challenges when introducing complex safety tools, methods and processes to 

railroads, airlines, hospitals, and other high hazards industries. 

The kinds of challenges we faced in implementing an event reporting system for 

the U.S. railroad industry reflect the complex nature of sociotechnical systems.

These challenges can be found in many other high risk systems from aviation to 

nuclear power (Carroll et. al, 2002). The dynamic nature of organizations means 

that sustaining the system will require the ability to monitor these systems for 

emerging challenges and adapting to these changes. Just as learning from failure 

requires trial and error, sustaining an event reporting and corrective actions 

process requires a continuous improvement process to adapt to the challenges 

that emerge over time. 

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in the United States. Foreign copyrights may apply.