FRA F 6180.97 Employee Human Factor Attachment

INITIAL RAIL EQUIPMENT ACCIDENT/INCIDENT RECORD
DEPARTMENT OF TRANSPORTATION

OMB No. 2130-0500

FEDERAL RAILROAD ADMINISTRATION (FRA)

1. Date of Accident/Incident (YY/MM/DD)

AM

2. Time of Accident/Incident

PM
3. Name of Railroad

4. Incident Number

5. Other Railroad or Entity

6. Incident Number

7. Railroad or Other Entity Responsible for Track Maintenance

8. Incident Number

9. Type of Accident/Incident (Derailment, Collision, Obstruction, Other)

10. Number of Hazmat Cars Damaged or Derailed

11. Number of Hazmat Cars Releasing Product

12. Subdivision

14. County

16. Milepost (to nearest tenth)

13. Nearest City/Town

15. State

17. Specific Site

18. Speed

19. Train/Job Number

Actual
Estimated

20. Type of Equipment (Freight, Passenger, Yard/Switching, etc.)

21. Type of Track (Main, Yard, Siding, Industry)

22. Total Locomotive Units in Train

24. Total of Cars in Equipment Consist

23. Total Locomotives Derailed

25. Total Cars Derailed

26. Equipment Damage (in dollars)

27. Track, Signal, Way & Structure Damage (in dollars)

28. Primary Cause

29. Contributing Cause

30. Casualties

Nonfatal

Fatal

Nonfatal

Worker on duty – railroad employee

Worker on duty - contractor

Railroad employees not on duty

Contractor - other

Passengers on trains

Worker on duty - volunteer

Nontrespassers/on railroad property

Volunteer - other

Trespassers

Nontrespassers/off railroad property

Fatal

31. Narrative Description (Be specific, and continue on separate sheet if necessary)

32. Was this accident/incident reported to the FRA?
33. Name of Railroad Official

Yes

No

34. Signature

35. Telephone Number

36. Date initially
signed/completed

NOTE: This report is part of the reporting railroad's accident report 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).
This collection of information is mandatory under 49 CFR 225, and is used by FRA to monitor national rail safety by tracking – on a continual basis – all rail
accidents/incidents above a stipulated dollar threshold. Public reporting burden is estimated to average 30 minutes per response, including the time for
reviewing instructions, searching existing databases, gathering and maintaining the data needed, and completing and reviewing the collection of information.
The information collected is a matter of public record, and no confidentiality is promised to any respondent. Please note that an agency may not conduct or
sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number
for this collection is 2130-0500.

FORM FRA F 6180.97 (Rev. 06/07)

OMB approval expires XX/XX/200X

DRAFT 06/03/07