Accident Report Form For Federal Railroad Administration

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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.
1.
Name of Reporting Railroad
2.
Name of Other Railroad Involved in Train Accident/Incident
2a.
Alphabetic Code
2b.
Railroad Accident/Incident No.
3.
Name of Railroad Responsible for Track Maintenance
(single entry)
3a.
Alphabetic Code
3b.
Railroad Accident/Incident No.
Date of Accident/Incident
6.
Time of Accident/Incident
4.
U. S. DOT Grade Crossing Identification Number
5.
day
year
month
AM
PM
7.
Nearest Railroad Station
8.
Division
9.
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
o
F
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
1. Yes
3. Opposite side of vehicle approach
2. No
2. No
3. Unknown
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
52

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