DOE Form for Emergency Events

U.S. Department of Energy

Electricity Delivery and Energy Reliability
Form OE-417

ELECTRIC EMERGENCY INCIDENT
AND DISTURBANCE REPORT

Form Approved
OMB No. 1901-0288
Approval Expires 01/31/15
Burden Per Response: 2.03 hours

NOTICE: This report is mandatory under Public Law 93-275. Failure to comply may result in criminal fines, civil penalties and other sanctions as provided by
law. For the sanctions and the provisions concerning the confidentiality of information submitted on this form, see General Information portion of the instructions.
Title 18 USC 1001 makes it a criminal offense for any person knowingly and willingly to make to any Agency or Department of the United States any
false, fictitious, or fraudulent statements as to any matter within its jurisdiction.
RESPONSE DUE: Within 1 hour of the incident, submit Schedule 1 and lines 13-17 in Schedule 2 as an Emergency Alert report if criteria 1-8 are met. Within 6
hours of the incident, submit Schedule 1 and lines 13-17 in Schedule 2 as a Normal Report if only criteria 9-12 are met. Submit updates as needed and a final
report (all of Schedules 1 and 2) within 72 hours of the incident.
METHODS OF FILING RESPONSE
(Retain a completed copy of this form for your files.)
Online:
E-mail:
FAX:
Telephone:

Submit your form via online submission using the link at http://www.oe.netl.doe.gov/oe417.aspx.
Submit your form via e-mail as an attachment to [email protected].
FAX your Form OE-417 to the following facsimile number: (202) 586-8485. (Use if e-mail is not available.)
If you are unable to e-mail or fax the form, please call and report the information to the following telephone number: (202) 586-8100.

SCHEDULE 1 -- ALERT NOTICE (page 1 of 3)
Criteria for Filing (Check all that apply)

If any box 1-8 on the right is
checked, this form must be filed
within 1 hour of the incident;
check Emergency Alert (for the
Alert Status) on Line 1 below.

If any box 9-12 on the right is
checked AND none of the
boxes 1-8 are checked, this
form must be filed within 6
hours of the incident; check
Normal Alert (for the Alert
Status) on Line 1 below.

1. [

See Instructions For More Information
] Physical attack that causes major interruptions or impacts to critical infrastructure facilities or to operations

2. [

] Cyber event that causes interruptions of electrical system operations

3. [

] Complete operational failure or shut-down of the transmission and/or distribution electrical system

4. [ ] Electrical System Separation (Islanding) where part or parts of a power grid remain(s) operational in an otherwise
blacked out area or within the partial failure of an integrated electrical system
5. [

] Uncontrolled loss of 300 Megawatts or more of firm system loads for more than 15 minutes from a single incident

6. [

] Load shedding of 100 Megawatts or more implemented under emergency operational policy

7. [

] System-wide voltage reductions of 3 percent or more

8. [

] Public appeal to reduce the use of electricity for purposes of maintaining the continuity of the electric power system

9. [ ] Physical attack that could potentially impact electric power system adequacy or reliability; or vandalism which targets
components of any security systems
10. [

] Cyber event that could potentially impact electric power system adequacy or reliability

11. [

] Loss of electric service to more than 50,000 customers for 1 hour or more

12. [

] Fuel supply emergencies that could impact electric power system adequacy or reliability

If significant changes have occurred after filing the initial report, re-file the form with the changes and check Update (for the Alert Status) on Line 1 below.
The form must be re-filed within 72 hours of the incident with the latest information and with Final (for the Alert Status) checked on Line 1 below
LINE
NO.

ORGANIZATION FILING

1.

Alert Status (check one)

2.

Organization Name

3.

Address of Principal Business Office

Emergency Alert [
1 Hour

]

Normal Alert [
6 Hours

]

Update [ ]
As required

Final [ ]
72 Hours

U.S. Department of Energy

Electricity Delivery and Energy Reliability
Form OE-417

ELECTRIC EMERGENCY INCIDENT
AND DISTURBANCE REPORT

SCHEDULE 1 -- ALERT NOTICE (page 2 of 3)

Form Approved
OMB No. 1901-0288
Approval Expires 01/31/15
Burden Per Response: 2.03
hours

INCIDENT AND DISTURBANCE DATA
4.

Unknown [

Geographic Area(s) Affected
Date/Time Incident Began
(mm-dd-yy/hh:mm) using 24-hour clock
Date/Time Incident Ended
(mm-dd-yy/ hh:mm) using 24-hour clock
Did the incident/disturbance originate in your
system/area? (check one)
Estimate of Amount of Demand Involved
(Peak Megawatts)

5.
6.
7.
8.
9.

_____ - _____ - _____ / _____: _____
mo
dd
yy
hh
mm
_____ - _____ - _____ / _____: _____
mo
dd
yy
hh
mm
Yes [

]

No [

[
[
[
[

]Eastern
] Pacific
]Eastern
] Pacific

[
[
[
[

] Central
] Alaska
] Central
] Alaska

]

Estimate of Number of Customers Affected

10. Type of Emergency
Check all that apply

11. Cause of Incident
Check if known or suspected

Physical Attack

[

]

Cyber Event

[

]

Electrical System Separation – Islanding

Major Transmission System Interruption

[

]

]Mountain
] Hawaii
]Mountain
] Hawaii

Unknown [

]

Unknown [

]

Unknown [

]

12. Actions Taken
Check all that apply

]

Shed Firm Load

[

]

Reduced Voltage

[
[

]
]

Inadequate Electric Resources to Serve Load [

]

Made Public Appeals

[

]

[
[
[
[

]
]
]
]

Implemented a Warning, Alert, or Contingency
[ ]
Plan

Complete Electrical System Failure

[

Major Generation Inadequacy

[

]

Actual or Potential Attack/Event
Physical Attack
Cyber Event
Vandalism

Major Distribution System Interruption

[

]

Transmission Equipment

Other

[

]

Loss of Part or All of a High Voltage Substation
or Switchyard (230 kV + for AC,
200 kV+ for DC).
[

]

Weather or Natural Disaster

[

Operator Action(s)
Fuel Supply Deficiency (e.g., gas, oil, water)
Unknown Cause
Other
Additional Information/Comments:

[
[
[
[

Additional Information/Comments:

[
[
[
[

]

Shed Interruptible Load

[

]

Repaired/Restored

[

]

]

Mitigation(s) Implemented

[

]

]
]
]
]

Other

[

]

Additional Information/Comments:

U.S. Department of Energy

Electricity Delivery and Energy Reliability
Form OE-417

ELECTRIC EMERGENCY INCIDENT
AND DISTURBANCE REPORT

Form Approved
OMB No. 1901-0288
Approval Expires 01/31/15
Burden Per Response: 2.03 hours

SCHEDULE 2 -- NARRATIVE DESCRIPTION (page 3 of 3)
THIS INFORMATION IS CONSIDERED PROTECTED

NAME OF OFFICIAL THAT NEEDS TO BE CONTACTED FOR FOLLOW-UP AND ANY ADDITIONAL INFORMATION
13.
Name
14.
Title
15.
Telephone Number
(
)-(
)-(
)
16.
FAX Number
(
)-(
)-(
)
17.
E-mail Address
Provide a description of the incident and actions taken to resolve it. Include as appropriate, the cause of the incident/disturbance, change in frequency,
mitigation actions taken, equipment damaged, critical infrastructures interrupted, effects on other systems, and preliminary results from any
investigations. Be sure to identify: the estimate restoration date, the name of any lost high voltage substations or switchyards, whether there was any
electrical system separation (and if there were, what the islanding boundaries were), and the name of the generators and voltage lines that were lost
(shown by capacity type and voltage size grouping). If necessary, copy and attach additional sheets. Equivalent documents, containing this information can
be supplied to meet the requirement; this includes the NERC EOP-004 Disturbance Report. Along with the filing of Schedule 2, a final (updated) Schedule 1
needs to be filed. Check the Final box on line 1 for Alert Status on Schedule 1 and submit this and the completed Schedule 2 no later than 72 hours after
detection that a criterion was met.
18. Narrative:

19. Estimated Restoration Date for all Affected Customers
Who Can Receive Power
20. Name of Generator(s) and
Voltage Line(s) system reference
(terminal points)
(For these losses, please group by
generator type and voltage size)

21. Identify Name of Lost High
Voltage Substation(s) and/or
Switchyards
(230 kV + for AC -- 200 kV+ for DC)
22. Identify Electrical System
Separation: Islanding
Boundaries
(DOE needs a basic

description/understanding of the linked
generating resources to load pockets

_____ - _____ - _____
mo
dd
yy