FRA F 6180.78 Notice to Railroad Employee Involved in Rail Equipment A

NOTICE TO RAILROAD EMPLOYEE INVOLVED IN RAIL EQUIPMENT ACCIDENT/INCIDENT
ATTRIBUTED TO EMPLOYEE HUMAN FACTOR
EMPLOYEE STATEMENT SUPPLEMENTING RAILROAD ACCIDENT REPORT
DEPARTMENT OF TRANSPORTATION
FEDERAL RAILROAD ADMINISTRATION (FRA)

OMB Approval No.: 2130-0500

PART I - NOTICE TO RAILROAD EMPLOYEE (To be completed by reporting railroad)
Name of Reporting Railroad

Date of Accident/Incident Accident/Incident No.
______/______/______
mo
day year

Applicable to this person?
Yes

No

Yes

No

Location of Accident/Incident
(State, nearest city/town)

Causes reported on Form FRA F6180.54
Code
Description

Employee's Name (First, middle, last)

Job Title

Name of Employing Railroad

Employee's Home Address
PURPOSE OF THIS FORM A rail accident occurred that may have at least partly been caused by human error (human factor). The railroad
involved with this accident is sending you this form because it is required by federal law to send this form to any railroad employee it believes
may have at least been partly responsible for causing the accident/incident.
Since the railroad has named you as an employee who may have been involved in this accident, the railroad is required by federal law to complete
Part I of this form and give you an opportunity within 45 days from the date that the notice was mailed or hand delivered to you to give in Part II
of this form your version of events relating to this accident. If you would like to complete this form but are unable to do so within the time limit,
you must provide an explanation to FRA and the railroad for the need for more time. While the railroad is required by federal law to send this form
to you, you are not legally required to complete this form. If you decide to complete the form, the railroad may, upon reviewing your
supplement, decide to revise its accident report.
In Part II of this form, you may submit a supplemental statement to FRA on any aspect of the railroad's report. If you decide that you would like
to send the railroad and FRA a statement, please follow the INSTRUCTIONS.
Signature of Railroad Representative
Date Signed
Name of Railroad Representative
Date Mailed/Hand Delivered

If the employee decides to return this form to the railroad, the form should be sent to: [name and address of railroad representative.]

PART II - SUPPLEMENT - EMPLOYEE STATEMENT REGARDING RAILROAD ACCIDENT REPORT
I would like to supplement the railroad's accident report with the following statement:

(Continue statement on separate sheet, if required, and mail with statement)
I have carefully read this statement and confirm that it is true to the best of my knowledge and belief.
______________________________________ __________________ Date Mailed/Hand Delivered to FRA: _______________________
Signature
Date Signed
Railroad: _______________________
Your Telephone Number
Your home or mailing address
(
)
Home: ____________________
(
)
Work: ____________________
NOTE: This Notice and Employee Supplement under 49 C.F.R. 225.12 are part of the reporting railroad's accident report to FRA pursuant to the accident
reports statute and, as such, shall not "be admitted as evidence or used for any purpose in any suit or action for damages growing out of any
matter mentioned in said report . . . ." 49 U.S.C. 20903. See 49 C.F.R. 225.7 (b).
FORM FRA F 6180.78 (Revised March 2003)

INSTRUCTIONS TO RAILROAD EMPLOYEE REGARDING COMPLETION OF PART II OF FORM FRA F 6180.78

If you decide to complete this form, please follow these instructions:
1. Complete only Part II of this form.
2. Print or type your statement.
3. You may attach any relevant supporting documents, diagrams, photographs, or other evidence.
4. Sign and date your statement.
5. Send your original statement to the Federal Railroad Administration (FRA) at the following address:
Federal Railroad Administration,
Office of Safety Analysis (RRS-22), Stop 25
1120 Vermont Ave., N.W.,Washington, D.C. 20590
6. Send a copy of your statement to your railroad.
7. Keep a copy of your statement for your own records.
8. Additional information concerning completion of this form may be obtained at FRA's website at www.FRA.DOT.GOV.
FREQUENTLY ASKED QUESTIONS

Q. Who is a railroad employee?
A. FRA defines an employee for purposes of filling out this form as a Worker on Duty-Employee; Employee, Employee not on
duty; Worker on Duty-Contractor; or Worker on Duty-Volunteer. If you fit into any of these categories, you are a railroad
employee for purposes of filling out this form.
Q. Do I have to fill out the form?
A. No. Neither the railroad nor FRA requires you to fill out this form. Employee statements on this form are voluntary and
optional, not mandatory, and deciding not to send this form to FRA and the railroad does not imply that the employee admits or
endorses the railroad's conclusions as to the cause of the accident or any other allegations. See 49 C.F.R. 225.12(g).
Q. Will my statements remain confidential?
A. Information that the employee wishes to withhold from the railroad must not be included in this Supplement. If the employee
wishes to provide confidential information to FRA, the employee should not use the Supplement form (part II of Form FRA F
6180.78), but rather provide such confidential information by other means, such as a letter to the employee's collective
bargaining representative, or to the Federal Railroad Administration, Office of Safety Assurance and Compliance, RRS-11, 400
Seventh Street, SW., Washington, D.C. 20590. The letter should include the name of the railroad making the allegations, the
date and place of the accident, and the rail equipment accident/incident number.
Q. Is this form part of the railroad's accident report to FRA, and as such, may it be used in private litigation?
A. No. This form under 49 C.F.R. 225.12 is part of the railroad's accident report to FRA pursuant to the accident reports statute
and as such shall not "be admitted as evidence or used for any purpose in any suit or action for damages growing out of any
matter mentioned in said report . . ." 49 U.S.C. 20903. See 49 C.F.R. 225.7(b).

Willful false statements can result in imposition of civil penalties.