Accident Report Form For Federal Railroad Administration printable pdf download

Railroad-Highway Grade Crossing Handbook—Revised Second Edition

Figure 5. Accident Report Form for Federal Railroad Administration

HIGHWAY-RAIL GRADE CROSSING

DEPARTMENT OF TRANSPORTATION

ACCIDENT/INCIDENT REPORT

FEDERAL RAILROAD ADMINISTRATION (FRA)

OMB Approval No.: 2130-0500

1a.

Alphabetic Code

1b.

Railroad Accident/Incident No.

Name of Reporting Railroad

Name of Other Railroad Involved in Train Accident/Incident

2a.

Alphabetic Code

2b.

Railroad Accident/Incident No.

Name of Railroad Responsible for Track Maintenance

(single entry)

3a.

Alphabetic Code

3b.

Railroad Accident/Incident No.

Date of Accident/Incident

Time of Accident/Incident

U. S. DOT Grade Crossing Identification Number

day

year

month

Nearest Railroad Station

Division

County

10.

State

Code

Abbr.

11.

City

(if in a city)

12.

Highway Name or Number

Public

Private

Highway User Involved

Rail Equipment Involved

13.

Type

Code

17.

Equipment

4. Car(s)

(moving)

(specify)

Code

8. Other

C. Truck-trailer

F. Bus

J. Other motor vehicle

1. Train

(units pulling)

A. Train pulling- RCL

5. Car(s)

(standing)

A. Auto

D. Pick-up truck

G. School bus

K. Pedestrian

2. Train

(units pushing)

6. Light loco(s)

(moving)

B. Train pushing- RCL

B. Truck

E. Van

H. Motorcycle

M. Other

(specify)

(standing)

3. Train

(standing)

7. Light loco(s)

C. Train standing- RCL

14.

Vehicle Speed

15.

Direction

(geographical)

Code

18.

Position of Car Unit in Train

(est. mph at impact)

1. North 2. South 3. East 4. West

16.

Position

Code

19.

Circumstance

Code

1. Stalled on crossing 2. Stopped on crossing 3. Moving over crossing 4. Trapped

1. Rail equipment struck highway user

2. Rail equipment struck by highway user

20a.

Was the highway user and/or rail equipment involved

Code

20b.

Was there a hazardous materials release by

Code

in the impact transporting hazardous materials?

1. Highway user

2. Rail equipment

3. Both

4. Neither

1. Highway user

2. Rail equipment

3. Both

4. Neither

20c.

State here the name and quantity of the hazardous material released, if any.

21.

Temperature

(specify if minus)

22.

Visibility

(single entry)

Code

23.

Weather

(single entry)

Code

1. Dawn 2. Day 3. Dusk 4. Dark

1. Clear

2. Cloudy

3. Rain

4. Fog

5. Sleet

6. Snow

24.

Type of Equipment

1. Freight train

4. Work train

7. Yard/switching

A. Spec. MoW Equip.

25.

Track Type Used by Rail

Code

26.

Track Number or Name

Consist

2. Passenger train

5. Single car

8. Light loco(s).

Equipment Involved

Code

(single entry)

3. Commuter train

6. Cut of cars

9. Maint./inspect. car

1. Main 2. Yard 3. Siding 4. Industry

27.

FRA Track

28.

Number of

29.

Number

30.

Consist Speed

(Recorded speed,

Code

31.

Time Table Direction

Code

if available)

Class (1-9, X)

Locomotive Units

of Cars

R - Recorded

1. North

3. East

E - Estimated

MPH

2. South

4. West

32.

Type of

1. Gates

4. Wig wags

7. Crossbucks

10. Flagged by crew

33.

Signaled Crossing Warning

Code

34. Whistle Ban

Code

(specify)

5. Hwy. traffic signals

8. Stop signs

11. Other

Crossing

2. Cantilever FLS

(See reverse side for

1. Yes

Warning

3. Standard FLS

6. Audible

9. Watchman

12. None

instructions and codes)

2. No

Code(s)

3. Unknown

35.

Location of Warning

Code

36.

Crossing Warning Interconnected

Code

37.

Crossing Illuminated by Street

Code

Lights or Special Lights

with Highway Signals

1. Both sides

2. Side of vehicle approach

1. Yes

3. Opposite side of vehicle approach

2. No

3. Unknown

38.

Driver's

39.

Driver's Gender

Code

40.

Driver Drove Behind or in Front of Train

Code

41.

Driver

Code

Age

and Struck or was Struck by Second Train

1. Drove around or thru the gate

4. Stopped on crossing

1. Male

5. Other

2. Stopped and then proceeded

(specify)

1. Yes

2. No

3. Unknown

2. Female

3. Did not stop

42.

Driver Passed Standing

Code

43.

View of Track Obscured by

(primary obstruction)

Code

Highway Vehicle

1. Permanent structure

3. Passing train

5. Vegetation

7. Other

(specify)

1. Yes

2. No

3. Unknown

2. Standing railroad equipment

4. Topography

6. Highway vehicles

8. Not obstructed

44.

Driver was

Code

45.

Was Driver in the Vehicle?

Code

Casualties to:

Killed

Injured

1. Killed

2. Injured

3. Uninjured

1. Yes

2. No

46. Highway-Rail Crossing Users

47.

Highway Vehicle Property Damage

48.

Total Number of Highway-Rail Crossing Users

(est. dollar damage)

(include driver)

50.

Total Number of People on Train

51.

Is a Rail Equipment Accident/

Code

49. Railroad Employees

(include passengers and train crew)

Incident Report Being Filed?

52. Passengers on Train

1. Yes

2. No

53a. Special Study Block

53b. Special Study Block

54. Narrative Description

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

55. Typed Name and Title

56. Signature

57. 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).

FORM FRA F 6180.57 (Revised March 2003)

* NOTE THAT ALL CASUALTIES MUST BE REPORTED ON FORM FRA F 6180.55A

Accident Report Form For Federal Railroad Administration

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