Railway Accident - Incident Report Form 1284

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Railway Safety Branch #400 - 88 - 6th. Street New Westminster BC V3L 5B3
Phone; 604 660 6286 Fax: 604 660 6215 Emergency: 1 800 360 3260 E-Mail: www.safetyauthority.ca
To be completed & submitted to the above noted address within 30 days of the event. Reporting Railway and/or Track Operator: Address of Reporting Railway: Telephone # E-Mail Address: Event Date: Event Time: Check box or fill in appropriate information. This Report is for: A Reportable Accident A Reportable Incident Cell # Fax #:
Event Location: (milage, sub-division, track designation, track section, nearest station, etc,)
Train or Movement Identification
General Description of Accident/Incident
Type of Railway Operation Common Carrier Industrial Commuter Street Car
Type of Train Movement Pulling Pushing Rolling Free Direction of Travel North Inbound South Outbound Names of Train Crew Conductor: Trainman: Hostler: Engineman: Yard Switchman: Other: Type of Railway Activity Passenger Train Work Train Other: (describe) Type of Accident Serious Injury or Death Train Collision Dangerous Goods Derailment Person Safety Threat Collision Human/Equipment Train Derailment Equipment Damage Crossing Collision Dangerous Goods Collision Fire/Explosion Environmental Threat Freight Train Yard Movement Mixed Train Track Maintenance East Yard West N/A Stationary
Property Damage
Risk of Collision Overlap of Authority Crew Incapacitation
Type of Incident Switch in Abnormal Position Exceeding Authority Dangerous Goods Leaking Damaged Rolling Stock/Equipment
Less Restricted Signal Runaway Rolling Stock Other:
Freight Cars: Passenger Cars: Powered Passenger Cars: Locomotives: Cabooses: Other: Serious Injuries Number of Employees Seriously Injured Number of Passengers Seriously Injured
Number of Other Persons Seriously Injured
Number Damaged Number Damaged Number Damaged Number Damaged Number Damaged Number Damaged
Number of Employee Fatalities Number of Passenger Fatalities Number of Other Person Fatalities Dangerous Goods
Number of Dangerous Goods Cars Damaged Number of Dangerous Goods Cars Ruptured Number of Dangerous Goods Cars Leaking Name of Dangerous Goods Involved: Amount of Dangerous Goods Released: Grade Crossing Accidents Name of Crossing: Type of Crossing Protection Gates Auto. Signals Crossing Signs Highway User Involved Car Heavy Truck Passenger Van Motor Cycle Other Crossing User: Action by Train Crew Ringing Bell Emergency Brake Applied Stopped Foul Blowing Whistle Other: Action by Crossing User Stopped on Crossing Outcome Train Was Struck User Was Struck Moving Over Crossing Engine Lights On Light Truck Heavy Truck & Trailer Farm Equipment Bi-Cycle Light Truck & Trailer Passenger Bus Industrial Equipment Pedestrian Stop Signs Flagged
Damage to Rolling Stock, Railway, Pipeline, Environment & Property Railway Damage Costs Non-Railway Damage Costs Causes & Corrective Action Identify the Primary Cause/s:
Identify the Contributing Factors:
Describe the Corrective Action:
Report Submitted by: Name: Signature: Title: Date: