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Iowa |
Kansas |
Kentucky |
Louisiana |
Maine |
Maryland |
Massachusetts |
Michigan |
Minnesota |
Mississippi |
Montana |
7. Total Employee Hours for the Year |
9. Typed Name and Title |
8. Total Casualties During the Year |
10. Signature 11. Date |
Nebraska |
Nevada |
New Hampshire |
New Jersey |
New Mexico |
New York |
North Carolina |
North Dakota |
Ohio |
Oklahoma |
Oregon |
Pennsylvania |
Rhode Island |
South Carolina |
South Dakota |
Tennessee |
Texas |
Utah |
Vermont |
Virginia |
Washington |
West Virginia |
Wisconsin |
Wyoming |
Missouri |
1. Name of Reporting Railroad 1b. Railroad Accident/Incident No. |
7. Nearest Railroad Station |
11. City (if in a city) 12. Highway Name or Number |
Code |
1a. Alphabetic Code |
2a. Alphabetic Code 2b. Railroad Accident/Incident No. |
3a. Alphabetic Code 3b. Railroad Accident/Incident No. |
4. U.S. DOT Grade Crossing Identification Number 5. Date of Accident/Incident 6. Time of Accident/Incident |
AM PM |
month day year |
8. Subdivision 10. State |
Abbr. |
9. County |
OMB No. 2130-0500 |
HIGHWAY-RAIL GRADE CROSSING |
ACCIDENT/INCIDENT REPORT DEPARTMENT OF TRANSPORTATION |
FEDERAL RAILROAD ADMINISTRATION (FRA) |
FORM FRA F 6180.57 (Rev. 08/10) |
55. Typed Name & 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). |
OMB approval expires 02/28/2014 |
Public Private |
13. Type |
A. Auto |
B. Truck |
C. Truck-trailer |
D. Pick-up truck |
E. Van |
F. Bus |
G. School bus |
H. Motorcycle |
J. Other motor vehicle |
K. Pedestrian |
M. Other (specify) |
Code |
Highway User Involved Rail Equipment Involved |
17. Equipment |
1. Train (units pulling) Code |
2. Train (units pushing) |
3. Train (standing) |
4. Car(s) (moving) |
5. Car(s) (standing) |
6. Light loco(s) (moving) |
7. Light loco(s) (standing) |
8. Other (specify) |
A. Train pulling – RCL |
B. Train pushing – RCL |
C. Train standing – RCL |
D. EMU Locomotive(s) |
E. DMU Locomotive(s) |
14. Vehicle Speed |
(est. mph |
at impact) |
15. Direction (geographical) |
1. North 2. South 3. East 4. West |
Code 18. Position of Car Unit in Train |
19. Circumstance |
1. Rail equipment struck highway user 2. Rail equipment struck by highway user |
16. Position Code |
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