FRA F 6180.109 Motive Power & Equipment Violation Report Form

OMB No. 2130-0509
U.S. Department of Transportation
Federal Railroad Administration

Motive Power & Equipment Violation Report Form

1. Subject:

2. Violation of: [ ] 40 CFR
Part or Statute

[ ] 49 CFR

Rule

3. Report No.: 5. Inspection Report No. - Report Date:

[ ] Statute

Subrule

4. Related Viol. Rpt No.(s):
6. Additional Regulations Violated:

8. RR Initials:

7. Operating Railroad:

11. ID Number:

10. Name of Inspector(s):

9. RR Division:

13. Time of Violation:

12. Date(s) of Violation:

15. Track No./ Name:

14. Inspection Point:

16. Location of Inspection:

17. Location of Violation:

City

County

18. Location Where Equipment Originated:

State

City

County

State

19. Location Where Locomotives are Maintained and Previous Periodic & Daily Inspection Information:
City & State:

City or County

State

Periodic Inspection:

Daily Inspection:

Date:

Date:

City & State:

City & State:

Details Constituting Violation of Federal Regulation
20. Line Item:

21. Equipment Initials and No.:

22. Equipment Description:

23. Train ID:

24. Type of Service:
[ ] Passenger

[ ] Freight

25. Name of Defective Component:

26. Location of Defective Component:

27. Equipment Status:
28. Position of Equipment and/or Train with Relation to Some Fixed Object at Time of Inspection and/or Violation:
29. Defect is: [ ] Old [ ] New

30. How Long Had Equipment Been At Place of Violation:

31. Equipment Marked for Repairs: [ ] Yes [ ] No

Air Brake Related Information (Parts 232 and 238)
32. Failure to Perform Air Brake Test: [ ] Yes [ ] No

33. Type of Brake Test Required:

34. Brakes Overdue for Periodic Attention: [ ] Yes [ ] No

35. Brakes Overdue for Single Car Test: [ ] Yes [ ] No

37. Time
Locos/ Air
On

Brakes
Applied

Brakes
Released

36. SCT Device Available: [ ] Yes [ ] No

38. Train Consist - Locomotives - Cars - Operative Brakes
Train
Departed

Controlling Loco.
Initials & No.

Number of
Locomotives in Train

Number of Cars
in Train

Number of
Operative Brakes

Number of Non-air/
Inop/Cut-out Brakes

Percentage of
Operative Brakes

39. State Facts Which Determine Type of Air Brake Test Required:
40. Description of Use, Movement, or Events Constituting Violation:
41. Describe Repair Facilities:
42. Description of Non-compliance:
43. Railroad Response or Remedial Action Taken in Response to Violation:
44. Violation Narrative:
45. Date of Report:

46. Signature of Inspector(s):

47. Railroad Notification:

Time:

Date:

Name:
Title:

Public reporting burden for this information collection is estimated to average 4 hours 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 2130-0509. 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, Federal Railroad Administration, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

Form FRA F6180.109

(7/03)

OMB approval expires 05/31/2022