Draft FRA F 6180,5 Rail Equipment Accident/Incident Report

RAIL EQUIPMENT ACCIDENT/INCIDENT REPORT

DEPARTMENT OF TRANSPORTATION
FEDERAL RAILROAD ADMINISTRATION (FRA)

OMB No. 2130-0500

1. Name of Reporting Railroad

1a. Alphabetic Code

1b. Railroad Accident/Incident No.

2. Name of Other Railroad or Other Entity with Consist Involved

2a. Alphabetic Code

2b. Railroad Accident/Incident No.

3a. Alphabetic Code

3b. Railroad Accident/Incident No.

3. Name of Railroad or Other Entity Responsible for Track Maintenance

(single entry)

5. Date of Accident/Incident

4. U.S. DOT Grade Crossing Identification Number

month

7. Type of Accident/
Incident (single
entry in code box)

AM

4. Side Collision

7. Hwy-rail crossing

10. Explosion-detonation

2. Head on collision

5. Raking collision

8. RR grade crossing

11. Fire/violent rupture

3. Rear end collision

6. Broken train collision

9. Obstruction

9. HAZMAT Cars
Damaged/Derailed

13. Nearest City/Town

10. Cars Releasing
HAZMAT

14. Milepost (to
nearest tenth)
18. Visibility
1. Dawn
2. Day

o F

(single entry)

Code

1. Clear
2. Cloudy

Code

Freight Train

5. Single Car

9. Maint./inspect. Car

D. EMU

Passenger Train-Pulling

6. Cut of cars

A. Spec. MoW Equip.

E. DMU

Commuter Train-Pulling

7. Yard/switching

B. Passenger Train-Pushing

8. Light loco(s)

C. Commuter Train-Pushing

28. Speed (recorded speed,
if available)
R - Recorded
E - Estimated

30. Type of Territory
Code
MPH

3. Rain
4. Fog

12. Subdivision

Code

1. Main
2. Yard

23. Annual Track
Density (gross
tons in millions)

1. North
2. South

26. Was Equipment
Attended?
1. Yes
2. No

Code

Code

3. East
4. West

27. Train Number/Symbol

30a. Remotely Controlled Locomotive?

(enter code(s) that apply)

2. Not Signaled

Method of Operation/Authority for Movement (Mandatory)
1. Signal Indication 2. Direct Train Control 3. Yard/Restricted Limits
4. Block Register Territory 5. Other Than Main Track

29. Trailing Tons (gross tonnage,
excluding power units)

Code

3. Siding
4. Industry

24. Time Table Direction

Signalization (Mandatory)
1. Signaled

20. Type of Track

5. Sleet
6. Snow

Code

Code

16. County

19. Weather (single entry)

22. FRA Track
Class (1-9, X)

4. Work train

12. Other impacts

Code

PM

13. Other
(describe in
narrative)

11. People
Evacuated
15. State
Abbr.

3. Dusk
4. Dark

21. Track Name/
Number
25. Type of Equipment 1.
2.
Consist
3.
(single entry)

6. Time of Accident/Incident

year

1. Derailment

8. Cars Carrying
HAZMAT

17. Temperature (F)
(Specify if minus)

day

Supplemental/Adjunct Codes (Mandatory*)

0 = Not a remotely controlled operation
1 = Remote control portable transmitter
2 = Remote control tower operation
3 = Remore control portable transmitter more than one remote
Code
control transmitter

* Mandatory to the extent that all applicable codes are entered

a. Initial and Number

31. Principal Car/Unit

b. Position in Train

c. Loaded (yes/no)

(1) First Involved
(derailed, struck, etc.)

(Exclude EMU, DMU, and
Cab Car Locomotives.)

Rear End
Mid Train
a. Head
b. Manual c. Remote d. Manual e. Remote
End

Empty
Loaded
b. Pass. c. Freight d. Pass.

35. Cars

(Include EMU, DMU, and a. Freight
Cab Car Locomotives.)

(1) Total in Train

(1) Total in Equipment
Consist

(2) Total Derailed

(2) Total Derailed

36. Equipment Damage
This Consist

38. Primary Cause
Code

37. Track, Signal, Way,
& Structure Damage

41. Firemen

Casualties to:

46. Railroad Employees

42. Conductors

43. Brakemen

44. Engineer/Operator
Hrs:

47. Train Passengers 48. Others

e. Caboose

39. Contributing
Cause Code
Length of Time on Duty

Number of Crew Members
40. Engineers/
Operators

45. Conductor
Mins:

49a. Special Study Block A

Hrs:

Mins:

49b. Special Study Block B

Fatal
Nonfatal
50. Latitude
52. Narrative Description

Drugs

33. Was this consist transporting passengers? (y/n)

(2) Causing (if mechanical,
cause reported)
34. Locomotive Units

32. If railroad employee(s) tested for drug/alcohol use,
enter the number that were positive in
Alcohol
the appropriate box.

51. Longitude
(Be specific, and continue on separate sheet if necessary)

53. Typed/Printed Name &
Title of Preparer

54. Signature

55. Date

NOTE: This report is part of the reporting railroad's accident report pursuant to the accident reports statute and, as such shall not “be admitted as evidence or used for any purpose in any suit
or action for damages growing out of any matter mentioned in said report...." 49 U.S.C. 20903. See 49 C.F.R. 225.7 (b).
Public reporting burden for this information collection is estimated to average 1 hour, 2 hours, or 2 hours and 3 minutes per response depending upon the level of detail needed and whether information about hazardous materials needs to be provided. This estimate includes 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 2130-0500. All responses to this collection of information are mandatory. Send
comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: Information Collection Officer, Office of Safety, Federal Railroad Administration, 1200 New Jersey Ave., SE., Washington D.C. 20590.

FORM FRA F 6180.54 (Rev. xx/xx)

OMB approval expires XX/XX/XXXX