Form FRA F 6180.4a FRA F 6180.4a MP&E safety Concern and Recommendation Report

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OMB No. 2130-0565
U.S. Department of Transportation
Federal Railroad Administration

MP&E SAFETY CONCERN & RECOMMENDATION REPORT

Inspector(s) Name:

Inspector ID:

Date:

Region:

Built Date:

Type: (e.g. B, CH, AC, etc. use code from F6180.96 / RISPC table)

Name of Builder and/or Owner:

Location of Builder and/or Owner: (City & State)

Were Concern(s) Recorded On F6180.96:
Initial:

Number:

Approximate Number Of Units With

FRA Control No.:

9 Yes

9 No

If Yes, Indicate Inspector Initials Followed by Inspection Report No.(s):

0

Reporting Marks:

If Known, Approximate Number Of Units In Service With The Concern(s) Described Below:

CFR Section And Text Reference: (Cite Complete CFR Section, TB, and Corresponding Text Description)

Description Of Concern(s):

Cite Any Safety Concerns, Known History Of Injuries/Fatalities/Derailments, etc. Associated With This Issue: ( Names, Dates, Location, etc.)

Inspector Recommendation(s):

FRA F 6180.4a (11/04)

Pubic reporting burden for this information collection is estimated to average 60 minutes per response. This estimate
includes the time for completing the inspection and filling-out this form. According to the paperwork Reduction Act of
1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this collection of information is 2130-0565.

OMB No. 2130-0565

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