Form DOT F 5800.1 (01-2004)
Reproduction of this form is permitted
Hazardous Materials
Incident Report
U.S. Department of Transportation
Pipeline and Hazardous Materials
Safety Administration
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
mandatory and will take 96 minutes to complete
.
INSTRUCTIONS:
Submit this report to the Information Systems Manager, U.S. Department of Transportation, Pipeline and Hazardous Materials
Safety Administration, Offi ce of Hazardous Materials Safety, DHM-63, Washington, D.C. 20590-0001. If space provided for any item is inadequate,
use a seperate sheet of paper, identifying the entry number being completed. Copies of this form and instructions can be obtained from the
Offi ce of Hazardous Materials Website at http://hazmat.dot.gov. If you have any questions, you can contact the Hazardous Materials Information
Center at 1-800-HMR-4922 (1-800-467-4922) or online at http://hazmat.dot.gov.
Form Approval OMB No.
2137-0039
PART I - REPORT TYPE
1.
This is to report:
A) A
C) A
(1)
int
hazardous material incident
B)
An undeclared shipment with no release
specifi cation cargo tank 1,000 gallons or greater containing any hazardous materials that
received structural damage to the lading retention system or damage that requires repair to a system
ended to protect the lading retention system and (2) did not have a release.
An initial report
A supplemental (follow-up) report
Additional Pages
2.
Indicate whe
ther this is:
ENERAL INCIDENT IN
ent:
PART II - G FORMATION
3.
Date of Incid
4.
Time of Incident (use 24-hour time):
5.
Enter National Response Center Report Number (if applicable):
6.
If you submitted a report to another Federal DOT agency, enter the agency and report number:
7.
Location of Incident:
City:
County:
State:
ZIP Code (if known):
Street Address/Mile Marker/Yardname/Airport/Body of Water/River Mile
8.
Mode of Transportation
Air
In Transit
Highway
Loading
Rail
Unloading
Water
In Transit Storage
9.
Transportation Phase
10.
Carrier/Reporter
Name
Street
City
Federal DOT ID Number
Hazmat Registration Number
State
ZIP Code
11.
Shipper/Offeror
Name
Street
City
Waybill/Shipping Paper
Hazmat Registration Number
State
ZIP Code
12.
Origin
(if different from
shipper address)
Street
City
State
ZIP Code
13.
Destination
Street
City
State
ZIP Code
14.
Proper Shipping Name of Hazardous Material:
15.
Technical/Trade Name:
16.
Hazardous Class/
Division:
17.
Identifi cation
Number:
(E.g. UN2764, NA 2020)
18.
Packing
Group:
(if applicable)
19.
Quantity
Released:
(Include Measurement Units)
20.
Was the material shipped as a hazardous waste?
No
No
Yes
Yes
If yes, provide the EPA Manifest Number:
21.
Is this a Toxic by Inhalation (TIH) material?
If yes, provide the Hazard Zone:
No
Yes
22.
Was the material shipped under an Exemption, Approval, or Competent Authority Certifi cate?
No
Yes
23.
Was this an undeclared hazardous materials shipment?
If yes, provide the Exemption, Approval, or CA number:
Page
1
Form DOT F 5800.1 (01-2004)
Reproduction of this form is permitted
PART III - PACKAGING INFORMATION
24.
Check Packaging Type (check only one - if more than one, list type of packaging, copy Part III, and complete for each type:
Cylinder
Non-bulk
RAM
IBC
Portable Tank
Cargo tank Motor Vehicle (CTMV)
Other
Tank Car
25.
See instructions and enter the appropriate failure codes found at the end of the instructions. Be sure to enter the codes from the list
that corresponds to the particular packaging type checked above. Enter the number of codes as appropriate to describe the incident.
Enter the most important failure point in line 1. If there are more than two failure points, provide in this format in part VI.
1. What Failed:
2. What Failed:
How Failed:
How Failed:
Causes of Failure:
Causes of Failure:
26a.
Provide the packaging identifi cation markings, if available.
Identifi cation Markings:
(Examples: 1A1/Y1.4/150/92/USA/RB/93/RL, UN31H1/Y0493/USA/M9339/10800/1200, DOT - 105A - 100W (RAIL), DOT 406 (HIGHWAY), DOT 51, DOT 3-A)
26b.
For Non-bulk, IBC, or non-specifi cation packaging, if identifi cation markings are incomplete or unavailable, see instructions and
complete the following:
Single Package or Outer Packaging:
Single Package or Inner Packaging (if any):
Packaging Type:
Material of Construction:
Head Type (Drums only):
Removable
Non - Removable
Packaging Type:
Material of Construction:
27.
Describe the package capacity and the quantity:
Single Package or Outer Packaging:
Package Capacity:
Amount in Package:
Number in Shipment:
Number Failed:
Single Package or Inner Packaging (if any):
Package Capacity:
Amount in Package:
Number in Shipment:
Number Failed:
28.
Provide packaging construction and test information, as appropriate:
Manufacturer:
Serial Number:
Material of Construction:
Design Pressure:
Manufacture Date:
Last Test Date:
Shell Thickness:
Head Thickness:
Service Pressure:
If valve or device failed:
Type:
Manufacturer:
Model:
(if Tank Car, CTMV, Portable Tank, or Cylinder)
(if Tank Car, CTMV, Portable Tank)
(if Tank Car, CTMV, Portable Tank)
(if Tank Car, CTMV)
(if Cylinder)
29.
If the packaging is for Radioactive Materials, complete the following:
Packaging Category:
Packaging Certifi cation:
Nuclide(s) Present:
Activity:
Transport Index:
Critical Safety Index:
Self Certifi ed
Type A
U.S. Certifi cation
Type B
Type C
Certifi cation Number
Industrial
Excepted
Page
2
(if present and legible)
(if present and legible)
Form DOT F 5800.1 (01-2004)
Reproduction of this form is permitted
PART IV - CONSEQUENCES
30.
Result of Incident (check all that apply):
Vapor (Gas) Dispersion
Spillage
Environmental Damage
Fire
No Release
Explosion
Material Entered Waterway/Storm Sewer
31.
Emergency Response : The following entities responded to the incident: (Check all that apply)
Fire/EMS Report #
Police Report #
In-house cleanup
Other Cleanup
32.
Damages: Was the total damage cost more than $500?
If yes, enter the following information: If no, go to question 33.
Yes
No
Material Loss:
$
Carrier Damage:
$
Property Damage:
$
Response Cost:
$
Remediation/Cleanup Cost:
$
(See damage defi nitions in the instructions)
33a.
Did the hazardous material cause or contribute to a human fatality?
Yes
No
If yes, enter the number of fatalities resulting from the hazardous material:
Fatalities:
Employees
Responders
General Public
33b.
Were there human fatalities that did not result from the hazardous material?
Yes
No
If yes, how many?
34.
Did the hazardous material cause or contribute to personal injury?
Yes
No
If yes, enter the number of injuries resulting from the hazardous material:
Hospitalized (Admitted Only):
Employees
Responders
General Public
Non-Hospitalized:
Employees
Responders
General Public
(e.g.: On site fi rst aid or Emergency Room observation and release)
35.
Did the hazardous material cause or contribute to an evacuation?
Yes
No
If yes, provide the following information:
Total number of general public evacuated
Total number of employees evacuated
Total Evacuated
Duration of the evacuation
(hours)
36.
Was a major transportation artery or facility closed?
Yes
No
If yes, how many?
(hours)
37.
Was the material involved in a crash or derailment?
Yes
No
If yes, provide the following information:
Estimated speed (mph):
Weather conditions:
Yes
No
Yes
No
Vehicle overturn?
Vehicle left roadway/track?
PART V - AIR INCIDENT INFORMATION
(please refer to § 175.31 to report a discrepancy for air shipments)
38.
Was the shipment on a passenger aircraft?
Yes
No
If yes, was it tendered as cargo, or as passenger baggage?
Cargo
Passenger baggage
39.
Where did the incident occur (if unknown, check the appropriate box for the location where the incident was discovered)?
Air carrier cargo facility
Baggage area
Sort center
By surface to/from airport
During loading/unloading of aircraft
During fl ight
40.
What phase(s) had the shipment already undergone prior to the incident? (Check all that apply)
Shipment had not been transported
Transport by air (subsequent fl ights)
Transported by air (fi rst fl ight)
Initial transport by highway to cargo facility
Transfer at sort center/cargo facility
Page
3
Form DOT F 5800.1 (01-2004)
Reproduction of this form is permitted
Page
4
PART VI - DESCRIPTION OF EVENTS & PACKAGE FAILURE
Describe the sequence of events that led to the incident and the actions taken at the time it was discovered. Describe the package failure,
including the size and location of holes, cracks, etc. Photographs and diagrams should be submitted if needed for clarifi cation. Estimate
the duration of the release, if possible. Describe what was done to mitigate the effects of the release. Continue on additional sheets if
necessary.
PART VII - RECOMMENDATIONS/ACTIONS TAKEN TO PREVENT RECURRENCE
Where you are able to do so, suggest or describe changes (such as additional training, use of better packaging, or improved operating
procedures) to help prevent recurrence. Provide recommendations for improvement to hazardous materials transportation beyond the
control of your individual company. Continue on additional sheets if necessary.
PART VIII- CONTACT INFORMATION
Contact’s Name (Type or Print):
Contact’s Title:
Business Name and Address:
E-mail Address:
Telephone Number: ( )
Fax Number: ( )
Hazmat Registration Number (if not already provided):
Date:
Preparer is:
Carrier
Shipper
Facility
Other
SUBMIT