Form FRA F 6180.39i FRA F 6180.39i Railroad Accident/Incident Notification and Initial Inve

OMB Control No. 2130-XXXX

RAILROAD ACCIDENT/INCIDENT NOTIFICATION
AND INITIAL INVESTIGATION REPORT
Accident/Incident Severity Level n
j High n
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j Medium n
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j Low
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Federal Railroad Administration

09/06/2007

Date

Report Number

Time 02:21:49 PM

ACCIDENT/INCIDENT SUBMITTER AND RAILROAD/COMPANY/SHIPPER INFORMATION
3A. Name

3B. Title

3C. Phone

3D. Email

4A. Railroad\Company Name

4B. Railroad Code

4C. Railroad\Company Name

4D. Railroad Code

4E. Railroad\Company Name

4F. Railroad Code

5A. State

5B. County

5E. Railroad Subdivision

Filter Railroad
Class I
Filter Railroad
Class I
Filter Railroad
Class I

ACCIDENT/INCIDENT TYPE, LOCATION, DATE & TIME
5C. Town/City
5D. RR Milepost
5F. Latitude

5H. Accident/Incident Type
Select...

5G. Longitude

5I. Accident/Incident Time
Select...

5J. Accident/Incident Date

METHOD OF OPERATIONS TRAIN/EQUIPMENT INFORMATION
6A. Method of Operations
6B. Description
Select...

7. Train Kind
No
1 Select...

Train No.

Direction

Number
of Loco(s)

Number
of Cars

Select...

Speed

Equipment Derailed

MPH
j Est. n
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n
j Rec.
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CASUALTIES
8A. Classification of Casualties (check all that apply and complete the number killed, seriously injured, and/or slightly injured)
c Rail Employee
d
e
f
g

c Rail Passenger
d
e
f
g

No. Killed
0
No. Seriously Injured
0
No. Slightly Injured
0

No. Killed:
0
No. Seriously Injured
0
No. Slightly Injured
0

8B. Total Number Killed
0

c Contractor
d
e
f
g
No. Killed:
0
No. Seriously Injured
0
No. Slightly Injured
0

c Hwy User
d
e
f
g
No. Killed:
0
No. Seriously Injured
0
No. Slightly Injured
0

8C. Total Number Seriously Injured
0

c Trespasser
d
e
f
g
No. Killed:
0
No. Seriously Injured
0
No. Slightly Injured
0

c Other
d
e
f
g
No. Killed:
0
No. Seriously Injured
0
No. Slightly Injured
0

8D. Total Number Slightly Injured
0

HAZARDOUS MATERIALS CARS DERAILED OR SIGNIFICALY DAMAGED & EVACUATION INFO
9. Car Type

1

Init. No.

Cargo Name

Cargo Hazard Material
Class

Cargo Qty

Select...

Select...

Select...
10. Number of Cars Derailed or

11. Populated Area
j Yes n
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n
j No
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Damaged

12. Evacuation
j Yes n
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n
j No
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Fire,
Explosion,
Etc.
j Yes
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n
j No
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n

13. Number of People Evacuated

HIGHWAY-RAIL INTERFACE ACCIDENT/INCIDENT INFORMATION
14A. Highway-Rail Crossing Incident
14B. DOT Grade Crossing Number
14C. Grade Crossing Address or Name
j Yes
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n
j No
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n
15A. Warning Device
15C. Quiet Zone

j Active
k
l
m
n

j Yes
k
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m
n

j No
k
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n

j Passive
k
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n

15B. Device Operational n
j Yes n
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j No n
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j Unknown
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j Unknown
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n

15D. Highway Traffic Signal Pre-emption Interconnection
j Yes n
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n
j No
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m
16A. Motor Vehicle Type
16B. Maximum Authorized Train Speed
Select...
MPH

16C. Posted Highway Speed
MPH

j Federal
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18A. Was this incident investigated by a law enforcement or other official agency? Select...
18B. If this incident was investigated, provide the name, address and phone number of the investigating agency

17A. Type of Roadway

j City
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n

19A. Estimated Property Damage
Select...

j County
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n

j State
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n

j Private
k
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n

OTHER PERTINENT INFORMATION
20A.This A/I Meets The Criteria for FRA-Post Accident Toxicological Testing
j Yes
k
l
m
n
j No
k
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n

20B. Number of Employees Tested Under FRA-Post Accident Authority
20C. Were Employees Tested Under Railroad Authority

j Yes
k
l
m
n

j No
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n

20D. No. of Employees Tested Under Railroad Authority
21. Location of Locomotive for Inspection Purposes (Applies LAX A/Is Only {49 CFR Part 229.17})
22a. Contributing Cause(s)

22b. Probable Cause of Accident

SYNOPSIS OF ACCIDENT/INCIDENT

FRA F 6180.39i (9-04)

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