Form OE-417 Electric Emergency Incident and Disturbance Report

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 xx/xx/xxxx Burden Per Response: 2.16 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: Submit your form via online submission using the link at https://www.oe.netl.doe.gov/OE417/ FAX: FAX your Form OE-417 to the following facsimile number: (202) 586-8485. Telephone: 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) See Instructions For More Information
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.		1. [ ] 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
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.		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)			Emergency Alert [ ] 1 Hour	Normal Alert [ ] 6 Hours		Update [ ] As required	Final [ ] 72 Hours
2.	Organization Name
3.	Address of Principal Business Office

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 xx/xx/xxxx Burden Per Response: 2.16 hours
SCHEDULE 1 -- ALERT NOTICE (page 2 of 3)
	INCIDENT AND DISTURBANCE DATA
4.	Geographic Area(s) Affected – State / County
5.	Date/Time Incident Began (mm-dd-yy/hh:mm) using 24-hour clock		_____ - _____ - _____ / _____: _____ [ ]Eastern [ ] Central [ ]Mountain mo dd yy hh mm [ ] Pacific [ ] Alaska [ ] Hawaii
6.	Date/Time Incident Ended (mm-dd-yy/ hh:mm) using 24-hour clock		_____ - _____ - _____ / _____: _____ [ ]Eastern [ ] Central [ ]Mountain mo dd yy hh mm [ ] Pacific [ ] Alaska [ ] Hawaii
7.	Did the incident/disturbance originate in your system/area? (check one)		Yes [ ]	No [ ]		Unknown [ ]
8.	Estimate of Amount of Demand Involved (Peak Megawatts)			Zero [ ]		Unknown [ ]
9.	Estimate of Number of Customers Affected			Zero [ ]		Unknown [ ]

10. Type of Emergency Check all that apply	11. Cause of Incident Check if known or suspected	12. Actions Taken Check all that apply
Physical Attack [ ]	Complete Electrical System Failure [ ]	Shed Firm Load [ ]
Cyber Event [ ]	Electrical System Separation – Islanding [ ]	Reduced Voltage [ ]
Major Transmission System Interruption [ ]	Inadequate Electric Resources to Serve Load [ ]	Made Public Appeals [ ]
Major Generation Inadequacy [ ]	Actual or Potential Attack/Event Physical Attack [ ] Cyber Event [ ] Vandalism [ ]	Implemented a Warning, Alert, or Contingency Plan [ ]
Major Distribution System Interruption [ ]	Transmission Equipment [ ]	Shed Interruptible Load [ ]
Other [ ]	Loss of Part or All of a High Voltage Substation or Switchyard (230 kV + for AC, 200 kV+ for DC). [ ]	Repaired/Restored [ ]
Additional Information/Comments:	Weather or Natural Disaster [ ]	Mitigation(s) Implemented [ ]
	Operator Action(s) [ ]	Other [ ]
	Fuel Supply Deficiency (e.g., gas, oil, water) [ ]
	Unknown Cause [ ]	Additional Information/Comments:
	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 xx/xx/xxxx

Burden Per Response: 2.16 hours

SCHEDULE 2 -- NARRATIVE DESCRIPTION (page 3 of 3)

Information on Schedule 2 will not be disclosed to the public to the extent that it satisfies the criteria for exemption under the Freedom of Information Act, e.g., exemptions for confidential commercial information and trade secrets or certain information that could endanger the physical safety of an individual.

	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

_____ - _____ - _____

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20. Name of Assets Impacted