RBMN – Unusual Occurrence Report

Office Use Only

Report No.

Incident No.

Date Filed

FRA Reportable

Y N

Officer Initials

Date & Time of Occurrence

Date

Time

Status

Type of Occurrence (check all that apply)

Location

Division

Track

Mile Post (nearest tenth)

Street / Highway

DOT #

Nearest City / Town

County

Zip Code

Type of Track

Describe Exact Location & Physical Characteristics

Equipment & Train Information

Type of Equipment

Train / Job #

Speed (MPH)

Delay in Schedule

Engine #s

Total Locomotive Units

Total Locomotives Derailed

Total Cars in Consist

# Cars Derailed

Hazardous Materials

Hazmat Involved

Y N

# Hazmat Cars Damaged / Derailed

# Hazmat Cars Releasing Product

Weather & Conditions

Weather

Temperature (°F)

Notifications Made

Reported to Dispatcher

Y N

Reported to Police

Y N

Emergency Response Agency

Y N

Telephone #

Damage & Cause

Equipment Damage ($)

Track / Signal / Way & Structure Damage ($)

Estimate or Actual?

Actual Estimated

Primary Cause

Contributing Cause

Name of Other RR Involved

RR Responsible for Track Maintenance

Persons Injured / Killed

Category	Injured	Killed
Worker on Duty – Employee
Employees Not on Duty
Worker on Duty – Contractor
Contractor – Other
Worker on Duty – Volunteer
Volunteer – Other
Passengers on Trains
Nontrespassers on RR Property
Nontrespassers / Off RR Property
Trespassers

Persons Involved (crew / others involved / injured / ill)

Name (Last, First)	Job Title	Address	Phone

Narrative Description of Occurrence

Include a detailed description of all damages & personal injuries. Be specific.

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Reporting Employee

Name of Employee

Signature

Date

Reading Blue Mountain & Northern Railroad · Unusual Occurrence Report Page 2 — Narrative Continuation

Narrative Description of Occurrence (continued from Page 1)

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