Reasonable Cause

Please check at least one checkbox:

Accident / Incident (check those applicable):

Major Train Accident

Impact Accident

Passenger Train Accident

Fatal Train Incident

Human-Factor Highway-Rail Crossing Accident-Incident

Please check at least one checkbox:

Behavior (check those applicable)

Appearance (check those applicable)

Speech (check those applicable)

Slurred, Thick

Loud, Boisterous

Nonsensical, Silly

Incoherent

Rapid, Pressured

Cursing, Inappropriate Speech

Exaggerated Enunciation

Excessively Talkative

Body Odors (check those applicable)

Alcohol

Marijuana

Name	Employee ID Number (EIN)

Accident / Incident (check those applicable):

Damages that meet the current reporting threshold

Highway-rail grade crossing

Train incident with damages under reporting threshold but involving any reportable injury

Please check at least one checkbox:

Noncompliance with a train order, track warrant, track bulletin, track permit, stop and flag order, timetable

Noncompliance with a signal indication, special instruction

Unauthorized occupancy of a block or other segment of track

Failure to clear a track to permit opposing or following movement to pass

Moving across a railroad crossing at grade without authorization

Passing an absolute restrictive signal

Passing a restrictive signal without stopping. If required

Failure to protect on-track equipment, including leaving on-track equipment fouling an adjacent track

Failure to take appropriate action, resulting in the enforcement of a positive train control system

Operation of a train or other speedometer-equipped on-track equipment at a speed that exceeds the maximum authorized speed by at least 10 miles per hour or by 50% of such maximum authorized speed, whichever is less

Alignment of a switch in violation of a railroad rule, failure to align a switch as required for movement, operation of a switch under on-track equipment, or unauthorized running through a switch

Failure to display blue signals in accordance with 218.25 through 218.30 of this chapter

Failure to perform a required brake test, or having knowledge that a required brake test was not performed, pursuant to the Class I, Class IA, Class II, or Class III, or transfer train brake test provisions of part 232, or the running brake test provisions of part 238, of this chapter

Failure to comply with prohibitions against tampering with locomotive mounted safety devices, or permitting a train to be operated with an unauthorized disabled safety device in the controlling locomotive

Failure to restore and secure a main track switch as required

Failure to apply brakes or stop short of derail as required

Failure to secure a hand brake or sufficient hand brakes, as required

Entering a crossover before both switches are lined for movement or restoring either switch to normal position before the crossover movement is completed

Failure to provide point protection by visually determining that the track is clear and giving the signals or instructions necessary to control the movement of on-track equipment when engaged in a shoving or pushing movement

In the case of a person performing a dispatching function or block operator function, issuance of a mandatory directive or establishment of a route that fails to provide proper protection for on-track equipment

Failure to have a derailing device in proper position and locked if required in accordance with 218.109 of this chapter

Interference with the normal functioning of any grade crossing signal system or any signal or train control device without first taking measures to provide for the safety of highway traffic or train operations which depend on the normal functioning of such a device

Failure to perform stop-and-flag duties necessary as a result of a malfunction of a grade crossing signal system

Failure of a machine operator that results in a collision between a roadway maintenance machine and on-track equipment or a regulated employee

Failure of a roadway worker-in-charge to notify all affected employees when releasing working limits

Failure of a flagman or watchman/lookout to notify employees of an approaching train or other on-track equipment

Failure to ascertain that provision was made for on-track safety before fouling a track

Improper use of individual train detection in a manual interlocking or control point

Failure to apply three-point protection (fully apply the locomotive and train brakes, center the reverser, and place the generator field switch in the off position) that results in a reportable injury to a regulated employee

Additional Comments:

Please check at least one checkbox:

Accident / Incident (check those applicable):

Human Fatality

Bodily Injury with immediate medical treatment away from the scene

Disabling damage to any motor vehicle requiring tow away from scene

If person is other than a Norfolk Southern employee, enter 8888888 for their EIN, and indicate name of the foreign line railroad or contractor here:

If you have any problems or questions about this form, please contact Manager Compliance @ 757-629-2442

Last Name

First Name

Middle

Employee ID

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Confidential

Form 6891 (Guidelines Here)

Review of Key Criteria