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pdfOMB 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
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n
j Yes
k
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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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16A. Motor Vehicle Type
16B. Maximum Authorized Train Speed
Select...
MPH
16C. Posted Highway Speed
MPH
j Federal
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n
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
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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
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n
20B. Number of Employees Tested Under FRA-Post Accident Authority
20C. Were Employees Tested Under Railroad Authority
j Yes
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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)
OMB Approval Expires XXXX
Public reporting burden for this information collection is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. According to the Paperwork Reduction Act of 1995, 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
unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 2130-XXXX. All responses to this collection of
information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: Information
Collection Officer, Federal Railroad Administration, 1120 Vermont Ave., N.W., Washington D.C. 20590.
File Type | application/pdf |
File Title | Microsoft Office InfoPath - (Preview) Form 39i.draft |
Author | philip.maynard |
File Modified | 2007-09-06 |
File Created | 2007-09-06 |