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ATTRIBUTED TO EMPLOYEE HUMAN FACTOR
DEPARTMENT OF TRANSPORTATION
FEDERAL RAILROAD ADMINISTRATION (FRA) OMB No. 2130-0500
PART I - NOTICE TO RAILROAD EMPLOYEE (To be completed by reporting railroad)
Name of Reporting Railroad Date of Accident/Incident Accident/Incident No. Location of Accident/Incident
(State, nearest city/town)
_____/_____/_____
mo day year
Causes reported on Form FRA F6180.54
Code Description
Employee's Name (First, middle, last) Job Title Name of Employing Railroad
Employee's Home Address
PURPOSE OF THIS FORM A rail accident occurred that may have at least partly been caused by human error (human factor). The railroad
involved with this accident is sending you this form because it is required by federal law to send this form to any railroad employee it believes
may have at least been partly responsible for causing the accident/incident.
Since the railroad has named you as an employee who may have been involved in this accident, the railroad is required by federal law to complete
Part I of this form and give you an opportunity within 45 days from the date that the notice was mailed or hand delivered to you to give in Part II
of this form your version of events relating to this accident. If you would like to complete this form but are unable to do so within the time limit,
you must provide an explanation to FRA and the railroad for the need for more time. While the railroad is required by federal law to send this form
to you, you are not legally required to complete this form. If you decide to complete the form, the railroad may, upon reviewing your
supplement, decide to revise its accident report.
In Part II of this form, you may submit a supplemental statement to FRA on any aspect of the railroad's report. If you decide that you would like
to send the railroad and FRA a statement, please follow the INSTRUCTIONS.
Name of Railroad Representative Signature of Railroad Representative Date Signed Date Mailed/Hand Delivered
If the employee decides to return this form to the railroad, the form should be sent to: [name and address of railroad representative]
PART II - SUPPLEMENT - EMPLOYEE STATEMENT REGARDING RAILROAD ACCIDENT REPORT
I would like to supplement the railroad's accident report with the following statement:
I have carefully read this statement and confirm that it is true to the best of my knowledge and belief.
_____________________________________ ____________________ Date Mailed/Hand Delivered to FRA: ___________________
Signature Date Signed
NOTE: This Notice and Employee Supplement under 49 C.F.R. 225.12 are part of the reporting railroad's accident report to FRA 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 6180.78 (Rev. 08/10)
(Continue statement on separate sheet, if required, and mail with statement)
EMPLOYEE STATEMENT SUPPLEMENTING RAILROAD ACCIDENT REPORT
Applicable to this person?
Yes
Yes
No
No
Date Mailed/Hand Delivered to Railroad: ________________
OMB approval expires 02/28/2014
INSTRUCTIONS TO RAILROAD EMPLOYEE REGARDING COMPLETION OF PART II OF FORM FRA F 6180.78
FREQUENTLY ASKED QUESTIONS
If you decide to complete this form, please follow these instructions:
1. Complete only Part II of this form.
2. Print or type your statement.
3. You may attach any relevant supporting documents, diagrams, photographs, or other evidence.
4. Sign and date your statement.
5. Send your original statement to the Federal Railroad Administration (FRA) at the following address:
Operating Practices Division
Federal Railroad Administration
RRS-11, Mail Stop 25
1200 New Jersey Avenue, S.E.
Washington, D.C. 20590
6. Send a copy of your statement to your railroad.
7. Keep a copy of your statement for your own records.
8. Additional information concerning completion of this form may be obtained at FRA’s website at www.FRA.DOT.GOV .
Q. Who is a railroad employee?
A. FRA defines an employee for purposes of filling out this form as a Worker on Duty-Railroad Employee; Employee, Railroad
Employee not on duty; Worker on Duty-Contractor; or Worker on Duty-Volunteer. If you fit into any of these categories, you are a
railroad employee for purposes of filling out this form.
Q. Do I have to fill out the form?
A. No. Neither the railroad nor FRA requires you to fill out this form. Employee statements on this form are voluntary and
optional, not mandatory, and deciding not to send this form to FRA and the railroad does not imply that the employee admits or
endorses the railroad’s conclusions as to the cause of the accident or any other allegations. See 49 C.F.R. 225.12(g).
Q. Will my statements remain confidential?
A. Information that the employee wishes to withhold from the railroad must not be included in this Supplement. If the employee
wishes to provide confidential information to FRA, the employee should not use the Supplement form (part II of Form FRA F
6180.78), but rather provide such confidential information by other means, such as a letter to the employee’s collective
bargaining representative, or to the Office of Safety Assurance and Compliance, Federal Railroad Administration, RRS-10, Mail
Stop 25, 1200 New Jersey Avenue, S.E., Washington, D.C. 20590. The letter should include the name of the railroad making the
allegations, the date and place of the accident, and the rail equipment accident/incident number.
Q. Is this form part of the railroad’s accident report to FRA, and as such, may it be used in private litigation?
A. No. This form under 49 C.F.R. 225.12 is part of the railroad’s accident report to FRA 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).
Willful false statements can result in imposition of civil penalties.
This collection of information is mandatory under 49 CFR 225, and is used by FRA to monitor national rail safety. Public
reporting burden is estimated to average 10 minutes (Part I) and 1.5 hour (Part II) per response, including the time for
reviewing instructions, searching existing databases, gathering and maintaining the data needed, and completing and
reviewing the collection of information. The information collected is a matter of public record, and no confidentiality is
promised to any respondent. Please note that an agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for
this collection is 2130-0500.
DEPARTMENT OF TRANSPORTATION
FEDERAL RAILROAD ADMINISTRATION (FRA)
EMPLOYEE HUMAN FACTOR ATTACHMENT
OMB No. 2130-0500
FORM FRA F 6180.81 (Rev. 08/10)
This collection of information is mandatory under 49 CFR 225, and is used by FRA to monitor national rail safety. Public reporting burden is estimated
to average 15 minutes per response, including the time for reviewing instructions, searching existing databases, gathering and maintaining the data
needed, and completing and reviewing the collection of information. The information collected is a matter of public record, and no confidentiality is
promised to any respondent. Please note that an agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2130-0500.
Note: This form under 49 C.F.R. 225.12 is part of the railroad's accident report to FRA 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).
Note: Under 49 C.F.R. 225.29, any person who violates any requirement of 49 C.F.R. Part 225 or causes the violation of any such

ATTRIBUTED TO EMPLOYEE HUMAN FACTOR

DEPARTMENT OF TRANSPORTATION

FEDERAL RAILROAD ADMINISTRATION (FRA) OMB No. 2130-0500

PART I - NOTICE TO RAILROAD EMPLOYEE (To be completed by reporting railroad)

Name of Reporting Railroad Date of Accident/Incident Accident/Incident No. Location of Accident/Incident

(State, nearest city/town)

_____/_____/_____

mo day year

Causes reported on Form FRA F6180.54

Code Description

Employee's Name (First, middle, last) Job Title Name of Employing Railroad

Employee's Home Address

PURPOSE OF THIS FORM A rail accident occurred that may have at least partly been caused by human error (human factor). The railroad

involved with this accident is sending you this form because it is required by federal law to send this form to any railroad employee it believes

may have at least been partly responsible for causing the accident/incident.

Since the railroad has named you as an employee who may have been involved in this accident, the railroad is required by federal law to complete

Part I of this form and give you an opportunity within 45 days from the date that the notice was mailed or hand delivered to you to give in Part II

of this form your version of events relating to this accident. If you would like to complete this form but are unable to do so within the time limit,

you must provide an explanation to FRA and the railroad for the need for more time. While the railroad is required by federal law to send this form

to you, you are not legally required to complete this form. If you decide to complete the form, the railroad may, upon reviewing your

supplement, decide to revise its accident report.

In Part II of this form, you may submit a supplemental statement to FRA on any aspect of the railroad's report. If you decide that you would like

to send the railroad and FRA a statement, please follow the INSTRUCTIONS.

Name of Railroad Representative Signature of Railroad Representative Date Signed Date Mailed/Hand Delivered

If the employee decides to return this form to the railroad, the form should be sent to: [name and address of railroad representative]

PART II - SUPPLEMENT - EMPLOYEE STATEMENT REGARDING RAILROAD ACCIDENT REPORT

I would like to supplement the railroad's accident report with the following statement:

I have carefully read this statement and confirm that it is true to the best of my knowledge and belief.

_____________________________________ ____________________ Date Mailed/Hand Delivered to FRA: ___________________

Signature Date Signed

NOTE: This Notice and Employee Supplement under 49 C.F.R. 225.12 are part of the reporting railroad's accident report to FRA 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 6180.78 (Rev. 08/10)

(Continue statement on separate sheet, if required, and mail with statement)

EMPLOYEE STATEMENT SUPPLEMENTING RAILROAD ACCIDENT REPORT

Applicable to this person?

Yes

No

Date Mailed/Hand Delivered to Railroad: ________________

OMB approval expires 02/28/2014

INSTRUCTIONS TO RAILROAD EMPLOYEE REGARDING COMPLETION OF PART II OF FORM FRA F 6180.78

FREQUENTLY ASKED QUESTIONS

If you decide to complete this form, please follow these instructions:

1. Complete only Part II of this form.

2. Print or type your statement.

3. You may attach any relevant supporting documents, diagrams, photographs, or other evidence.

4. Sign and date your statement.

5. Send your original statement to the Federal Railroad Administration (FRA) at the following address:

Operating Practices Division

Federal Railroad Administration

RRS-11, Mail Stop 25

1200 New Jersey Avenue, S.E.

Washington, D.C. 20590

6. Send a copy of your statement to your railroad.

7. Keep a copy of your statement for your own records.

8. Additional information concerning completion of this form may be obtained at FRA’s website at www.FRA.DOT.GOV .

Q. Who is a railroad employee?

A. FRA defines an employee for purposes of filling out this form as a Worker on Duty-Railroad Employee; Employee, Railroad

Employee not on duty; Worker on Duty-Contractor; or Worker on Duty-Volunteer. If you fit into any of these categories, you are a

railroad employee for purposes of filling out this form.

Q. Do I have to fill out the form?

A. No. Neither the railroad nor FRA requires you to fill out this form. Employee statements on this form are voluntary and

optional, not mandatory, and deciding not to send this form to FRA and the railroad does not imply that the employee admits or

endorses the railroad’s conclusions as to the cause of the accident or any other allegations. See 49 C.F.R. 225.12(g).

Q. Will my statements remain confidential?

A. Information that the employee wishes to withhold from the railroad must not be included in this Supplement. If the employee

wishes to provide confidential information to FRA, the employee should not use the Supplement form (part II of Form FRA F

6180.78), but rather provide such confidential information by other means, such as a letter to the employee’s collective

bargaining representative, or to the Office of Safety Assurance and Compliance, Federal Railroad Administration, RRS-10, Mail

Stop 25, 1200 New Jersey Avenue, S.E., Washington, D.C. 20590. The letter should include the name of the railroad making the

allegations, the date and place of the accident, and the rail equipment accident/incident number.

Q. Is this form part of the railroad’s accident report to FRA, and as such, may it be used in private litigation?

A. No. This form under 49 C.F.R. 225.12 is part of the railroad’s accident report to FRA 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).

Willful false statements can result in imposition of civil penalties.

This collection of information is mandatory under 49 CFR 225, and is used by FRA to monitor national rail safety. Public

reporting burden is estimated to average 10 minutes (Part I) and 1.5 hour (Part II) per response, including the time for

reviewing instructions, searching existing databases, gathering and maintaining the data needed, and completing and

reviewing the collection of information. The information collected is a matter of public record, and no confidentiality is

promised to any respondent. Please note that an agency may not conduct or sponsor, and a person is not required to

respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for

this collection is 2130-0500.

DEPARTMENT OF TRANSPORTATION

FEDERAL RAILROAD ADMINISTRATION (FRA)

EMPLOYEE HUMAN FACTOR ATTACHMENT

OMB No. 2130-0500

FORM FRA F 6180.81 (Rev. 08/10)

This collection of information is mandatory under 49 CFR 225, and is used by FRA to monitor national rail safety. Public reporting burden is estimated

to average 15 minutes per response, including the time for reviewing instructions, searching existing databases, gathering and maintaining the data

needed, and completing and reviewing the collection of information. The information collected is a matter of public record, and no confidentiality is

promised to any respondent. Please note that an agency may not conduct or sponsor, and a person is not required to respond to a collection of

information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2130-0500.

Note: This form under 49 C.F.R. 225.12 is part of the railroad's accident report to FRA 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).

Note: Under 49 C.F.R. 225.29, any person who violates any requirement of 49 C.F.R. Part 225 or causes the violation of any such