Form BTS-0020 Close Call Report Form

Close Call Report Form
(WMATA Employees)

OMB NO: 0000-0000
Expiration Date: 00-00-0000

Confirmation Number: ........................
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for
failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of
information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 0000-0000. Public
reporting of a close call is estimated to take approximately 20 minutes, including the time for reviewing instructions, completing and
reviewing the report. Reporting any information to the Confidential Close Calls Reporting System is voluntary. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Close Call Data
Collection Officer, Demetra Collia, US DOT/BTS, 1200 New Jersey Avenue SE, Room E36-302, Washington, D.C. 20590 or
email: [email protected].

Incident Details
Please provide your name, employee ID, and phone number where a close call transportion safety analyst can contact you to discuss your
report, if needed. Indicate the best time to call and if you authorize BTS to leave a voice mail message on your answering service. Please
provide an email address to recover a forgotten personal code.

Incident Date:

Incident Time (24 HR.)

Name

Line Segment

Job Title

Station

Yard

Chain Marker

Track

Department
Phone Number

Best Time to Call

Can BTS Staff Leave
a Voice Message?

PRIMARY
ALTERNATE

Railroad Experience

Years

Months

Yes

No

Yes

No

Experience in Current Classification

Years

Months

Immediate Co-Workers
Please provide the name and job title of any immediate co-workers involved in the incident eligible for protection from discipline. Please
encourage your immediate co-worker(s) to file their own report(s) so they receive a receipt confirming their participation in this incident.
You may send in your reports together or separately.

Name

Job Title

Name

Job Title

Name

Job Title

Name

Job Title

Name

Job Title

To receive protection from discipline, you must: a) Initiate reporting within 16 hours of incident time. b) Finalize online report within 24
hours of the incident time.

BTS-0020

Close Call Report Form
(WMATA Employees)

OMB NO: 0000-0000
Expiration Date: 00-00-0000

3-Day Work/Sleep History Information
3-day work shift history Shift type Regular start Regular end Swing 1st start Swing 1st end Swing 2nd start Swing 2nd end
Incident shift day
1 day before incident
2 days before incident
3-day sleep history
Sleep start time Sleep end time Sleep quality Rest quality Nap-Yes/No Nap start/end time
Last sleep before incident
Sleep period 1 day before
Sleep period 2 days before
Train #:

Lead Car #:

Consist #'s:
Total # of cars:

Direction

Pushing/Pulling:

Eastbound

Unit ID:

Westbound

Southbound

Northbound

Equipment:

Roadway Maintenance Machine Unit ID/Flatcar:

Weather
Clear

Cloudy

Lightning

Fog

Slight Rain

Hail Storm

Cold

Intense Rain

Snowing

High Winds

Hot

Visibility
Clear

Snow (on ground)

Temperature
Good

Poor

Extremely Poor

Above Ground

Aeria

30(F) and below

31 - 90(F)

91(F) and above

Elevation Level
Tunnel
Train Activity
Stopped

Revenue

Single Tracking

Non-Revenue
Yard Stop

Yard movement

ATO

Manual

Servicing Station

Other

Gang Activity
Pre-Trip Inspection
General Maintenance

Departure
Shutdowns

Maintenance/Station Activity:

BTS-0020

Arrival

Manually Throw Switch

Assisting Passengers

Other

Track Inspection

Close Call Report Form
(WMATA Employees)

OMB NO: 0000-0000
Expiration Date: 00-00-0000

Incident Description
Please use the space below to complete your description of the incident or condition you wish to report. Remember: the more detailed
your report is, the better prepared the Rail Safety Analyst Team (RSAT) member will be to conduct a thorough interview related to the
incident/condition. In addition, please help us prevent similar incidents from occurring by providing your suggestions to prevent this
incident from happening again.
You may find the following questions useful as you think through what information to provide.
What were you and your crew doing immediately prior to the close call incident?
What did you notice that made you think a problem was developing?
What factors (weather, light, terrain, equipment, human error, etc.) may have contributed to the incident?
What, if anything, was unusual or unfamiliar to you or your crew with respect to this job assignment?
If anything or anybody interfered with your ability to perform the assigned task safely, describe how.
What prevented this incident from becoming a more serious accident?
PLEASE PRINT CLEARLY, USE ADDITIONAL PAPER IF NEEDED.

The information you provide will be used for statistical purposes only. In accordance with the BTS confidentiality statute (49 U.S.C. 6307) and the
Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347, your responses will be kept confidential and will not be
disclosed in identifiable form to anyone other than BTS employees or BTS agents such as telephone interviewers. In accordance with these confidentiality
statutes, only statistical and non-identifying data will be made publicly available through reports. By law, every BTS employee and BTS agent has taken an
oath of confidentiality and is subject to a jail term of up to 5 years, a fine of up to $250,000, or both if he or she discloses ANY identifiable information
about the respondent. BTS will not release to FTA, WMATA, L-689 or any other public or private entity any information that might reveal the identity of
individuals or organizations mentioned in close call reports.

BTS-0020

Close Call Report Form
(WMATA Employees)
Incident Diagram
Use this page for diagrams or additional information.

BTS-0020

OMB NO: 0000-0000
Expiration Date: 00-00-0000