FIA ACCIDENT REPORT FORM 1

FIA Accident Report Form 1
Version 2.0_EN - 17.03.15
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
FIA ACCIDENT REPORT FORM 1
Each ASN is encouraged to customize
their own front cover page
FIA Ref No.:
Date Completed: Name of Submitter:
Function of Submitter:
FIA Accident Report Form 1
Version 2.0_EN - 17.03.15
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
CORE DATA REPORT FORM
This report concerns any accident that falls into any of the 3 categories below:
1.
Fatal Accident - when death occurs within 30 days of the accident.
2.
Serious Accident - when a person is admitted to hospital with a prognosis of at least two months incapacitation.
and for FIA Championship, Trophy, Cup, Challenge or International Series competitions and for FIA-sanctioned international series using
FIAI-supplied ADRs only:
Significant Incident - when any of the following triggers occur:
3.
•
ADR trigger thresholds were exceeded
•
Concussion - where a person experiences a period of confusion, headache, nausea, vomiting or visual disturbance lasting longer than 24
hours, or any period of amnesia or loss of consciousness.
•
Spinal Injury - Any injury to the structure or integrity of the spinal column, including all vertebral fractures (however small), dislocation or
disruption, or any damage to the spinal cord, or injury resulting in neurological symptoms.
•
Has potential to cause serious injury
•
Incursion of vehicle into public area
•
Any other which the Race Director, Technical Delegate or Medical Delegate considers significant
Fill in as much of this report as possible, leaving blank any questions you are unsure of or don’t know the answer to.
A. Core Data
10 Open or Closed Cockpit
1 Accident Type
Fatal Accident
Open Cockpit
ADR Trigger
11 Vehicle Type
Concussion
Serious Accident
Spinal Injury
Single
Touring
Kart
Sports
GT
Le
Other
Dragster
Autocross
Truck
Silhouette
Mans
Seater
two-seater
(inc,
Prototype
Open
SUV &
Wheel
(LMP)
4x4)
Potential to cause serious Injury
Significant Incident
12 Left Hand Drive / Right Hand Drive
Incursion into public area
LHD
Any other significant
N/A
Internal
IC.
Other
Electrical
Electrical
Combustion
Hybrid (I.C)
14 Fuel Type
h
3 Sanctioning Authority
ASN Affiliate
RHD
13 Engine Type
2 Date of Accident DD MM YYYY hh mm
ASN
Closed Cockpit
Petrol
Compressed
Diesel
Methanol
I.C.
Other
Electrical
Petrol
Diesel
(Gasoline)
/ Electrical
Gas
Hybrid
15 Current or Historic (Appendix K)
Not ASN Recognised
Current
4 Country of Accident
Historic (Appendix K)
Other
16 Vehicle Make/Model
5 Status of Championship, Series or Event
17 Year of Construction
18 Competition Number
FIA/CIK
International
Zone
Regional
National
Club
Other
Event
Event
Event
Championship,
Series
Event
Trophy or Cup
6 Discipline
19 Driver’s Name (Family Name , First Name)
20 Age
7 Name of Championship or Series
21 Co-Driver’s Name (If Applicable)
22 Age
8 Name of Event
23 Team Name
9 Circuit or Location e.g. Silverstone National Circuit, S/S 14 Turini, etc
24 Total number of vehicles involved in the accident
Hill Climb
Karting
Circuit
Cross
Rally
Autocross
Dragster
Other
Cross
Country
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Version 2.0_EN - 17.03.15
FIA Accident Report Form 1
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
A. Core Data Cont...
25
27 Injuries Inflicted by fire or smoke inhalation
Injuries Inflicted during vehicle Impact event
Yes
No
Yes
26 Injuries Inflicted by flying object
Yes
No
28 Injuries Inflicted by “other”
e.g. Wheel
No
Yes
No
If “other”, Please add comments:
If you answered YES to any of the above questions please continue to question 29. If not, go to question 30.
29 Number of Persons
Fatally
Injured
Seriously
Injured
With
Concussion *
With
Spinal Injury *
Driver
Co-Driver
Officials
Spectators
Accredited Media
Pitlane Personnel
Other
* As per the WADB definition.
List below the details of all person(s) injured during the accident.
Person 1
Person 4
Category of Person
Category of Person
Accredited
Spectator
Official
Co-Driver
Driver
Pitlane
Other
Personal
Media
Person 2
Accredited
Spectator
Official
Co-Driver
Driver
Pitlane
Other
Personal
Media
Person 5
Category of Person
Category of Person
Accredited
Spectator
Official
Co-Driver
Driver
Pitlane
Other
Personal
Media
Person 3
Accredited
Spectator
Official
Co-Driver
Driver
Pitlane
Other
Personal
Media
Person 6
Category of Person
Category of Person
Accredited
Spectator
Official
Co-Driver
Driver
Pitlane
Other
Personal
Media
Accredited
Spectator
Official
Co-Driver
Driver
Pitlane
Other
Personal
Media
Name
Name
Name
Name
Name
Name
Complete a separate FIA Medical Report for each Driver and Co-Driver
30 Was the ADR Triggered
Yes
31 ADR Serial Number
No
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FIA Accident Report Form 1
Version 2.0_EN - 17.03.15
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
A. Accident Notes
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FIA Accident Report Form 1
Version 2.0_EN - 17.03.15
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
B. Accident Description
In the following section, an accident is broken into “phases”. A phase can be identified by the following: “Hit Other Race Vehicle” , “HIt
Object” , “Hit by Other Race Vehicle” , “Hit Person” , “Loss of Wheel or Part” , “Rollover, Pitchover or Launch” , “Subject Vehicle Hit by
Object” or “Fire”.
In the following question, break down the accident into these phases, in the order that they occurred, and answer the corresponding
question set associated with each phase.
33 Select Phase Type
Phase 1
Phase 4
Hit Person(s)
Loss
Rollover,
Subject
Other
Object
by
ofOther
Wheel
Vehicle
Pitchover
Race
Race
orVehicle
Hit
Part
Vechicle
or
by Launch
Object
Phase 2
Hit Person(s)
Loss
Rollover,
Subject
Other
Object
by
ofOther
Wheel
Vehicle
Pitchover
Race
Race
orVehicle
Hit
Part
Vechicle
or
by Launch
Object
Phase 3
Hit Person(s)
Loss
Rollover,
Subject
Other
Object
by
ofOther
Wheel
Vehicle
Pitchover
Race
Race
orVehicle
Hit
Part
Vechicle
or
by Launch
Object
Phase 5
Hit Person(s)
Loss
Rollover,
Subject
Other
Object
by
ofOther
Wheel
Vehicle
Pitchover
Race
Race
orVehicle
Hit
Part
Vechicle
or
by Launch
Object
Phase 6
Hit Person(s)
Loss
Rollover,
Subject
Other
Object
by
ofOther
Wheel
Vehicle
Pitchover
Race
Race
orVehicle
Hit
Part
Vechicle
or
by Launch
Object
Hit Person(s)
Loss
Rollover,
Subject
Other
Object
by
ofOther
Wheel
Vehicle
Pitchover
Race
Race
orVehicle
Hit
Part
Vechicle
or
by Launch
Object
For each phase, please complete the corresponding question set(s) below. Please note you may have to make multiple copies of this
form if you have more than one phase for the same type.
34 Phase Types
A. Hit Other Race Vehicle
A1 Speed of bullet vehicle
km/h
A4 Impact position on target vehicle
Source:
Other
Driver
Helmet
Screen
Roof
Floor
Front-Left
Left
Left-Rear
Rear
Rear-Right
Right
Front-Right
Front
A2 Speed of target vehicle
km/h
A5 Estimated change of speed / over distance
KPH
Source:
A3 Impact position on bullet vehicle
Metres
Source:
Other
Driver
Helmet
Screen
Roof
Floor
Front-Left
Left
Left-Rear
Rear
Rear-Right
Right
Front-Right
Front
B. Hit Object
B4 Object hit
B1 Speed of bullet vehicle at loss of control
km/h
Source:
B2 Speed of bullet vehicle at impact
km/h
Safety Barrier
Kerb
Debris
Wall
Tree
Service
Other
Ground
Rock
Pole
Fence
Vehicle
B4a If “Safety Barrier” is selected:
Source:
B3 Impact position on buttet vehicle
TyreKnown
FIA
Alpina
Tecpro
"SAFER"
Guardrail
Concrete
Not
Other
Earthbank
"High
Barrier
Barrier
Wall
Speed"
B4b If “Tyre Barrier” is selected:
Number of rows:
Other
Driver
Helmet
Screen
Roof
Floor
Front-Left
Left
Left-Rear
Rear
Rear-Right
Right
Front-Right
Front
Conveyor Belt present:
Yes
C. Hit by Other Race Vehicle
C1 Speed of target vehicle
km/h
C4 Impact position on bullet vehicle
Source:
C2 Speed of bullet vehicle
km/h
Other
Driver
Helmet
Screen
Roof
Floor
Front-Left
Left
Left-Rear
Rear
Rear-Right
Right
Front-Right
Front
C5 Estimated change of speed / over distance
KPH
Source:
C3 Impact position on target vehicle
Metres
Other
Driver
Helmet
Screen
Roof
Floor
Front-Left
Left
Left-Rear
Rear
Rear-Right
Right
Front-Right
Front
D. Hit Person(s)
D1 Speed of bullet vehicle
km/h
D2 Person hit by
Source:
Subject Vehicle
Other
Wheel
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Source:
No
FIA Accident Report Form 1
Version 2.0_EN - 17.03.15
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
B. Accident Description Cont...
E. Loss of Wheel or Part
E1 Speed of bullet vehicle
km/h
Describe lost part:
Source:
E2 What was lost
Other
Wheel
F. Rollover, Pitchover or Launch
F1 Speed of bullet vehicle
km/h
F3 Vehicle rollover or pitchover
Source:
F2 Vehicle launch
If “Yes” Cause:
Yes
Yes
No
Other
Aerodynamic
Contact
G. Subject Vehicle Hit by Object
G3 Impact position on vehicle or driver
G1 Speed of bullet vehicle
km/h
Source:
Other
Driver
Helmet
Screen
Roof
Floor
Front-Left
Left
Left-Rear
Rear
Rear-Right
Right
Front-Right
Front
G2 Object
If Other:
Other (Describe)
Wheel
If Other:
H. Fire
H1 Object on fire
H2 Location of fire
SubjectCompeting
Other
Vehicle Vehicle
Fuel Tank
Engine
Cockpit
Other
35 Precise Location of Accident e.g. Turn 3, Km 00.75, GPS, etc...
40 Surface Gradient
36 Session
41 Weather Conditions
Not Known
Other
Banking
Hillcrest
Uphill
Downhill
Level
Not Known
Other
Snowing
Rain
Fog
Cloudy
Clear
Timed
Testing
Practice
Qualifying
Race
Super
Not
Other
Known
Special
Stage Stage
42 Visibility
37 Course Type
Permanent
Non-Permanent
Oval
Rally
Public
Dragstrip
Autocross
Hillclimb
Rallycross
Not
Other
Known
Circuit
Stage
RoadCircuit
Circuit
Not Known
Night
Poor
Fair
Good
Other
43 Temperature
38 Surface Type
Deg C
Not Known
Other
Desert
Gravel/Loose
Concrete
Asphalt
39 Surface Condition
Not Known
Other
Oil
Snow/Ice
Wet
Dry
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- or -
Not Known
No
FIA Accident Report Form 1
Version 2.0_EN - 17.03.15
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
B. Accident Description Cont...
Mark Clearly:
Position and designation of all marshals` and emergency posts within view of the accident.
Trackside protection.
All relevant dimensions including width of track and verge.
Flag situation at site immediately prior to accident.
Vehicle direction of travel and yaw angles in degrees.
NORTH
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FIA Accident Report Form 1
Version 2.0_EN - 17.03.15
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
D1. Safety Equipment
(For karting, complete section D2 on next page)
45 Rollcage
47 Headrest Material
Not Known
Other
FIA
FIA Known
Not
Other
Appendix J - Article 253
If Other:
If Other:
46 Rollcage Padding
48 Safety Fuel Bladder
Not Known
Other
FIA
FIA Known
Not
Other
FT3-1999
FT3.5-1999
FT5-1999
If Other:
If Other:
Driver Safety Equipment
Make
Model
49 Frontal Head Restrant
NoneKnown
FIA
Not
Other
8858-2002
8858-2010
50 Helmet
FIA31.1/2
SFI
Not
Other
Known
8859-2015
8860-2010
8860-2004
Snell
SA(H)
M
K
51 Racesuit
FIA known
None
CIK-FIA
Not
Other
8856-2000
2013-1
2001-1
52 Gloves
FIA Known
None
Not
Other
8856-2000
53 Under Garments
FIA Known
None
Not
Other
8856-2000
54 Seat
NoneKnown
FIA
Not
Other
8862-2009
8855-1999
55 Seat Brackets
Not Known
Other
FIA
None
56 Harness
NoneKnown
FIA
Not
Other
8853-1998
8854-1998
Number of Harness Attachment
Points
57 Door Foam Package
58 Racing Nets
Standard
Left
Right
Not Known
Other
FIA
None
Both
Not Known
Other
SFI
FIA
None
59 Window Nets
Not Known
Other
SFI
FIA
None
Co-Driver Safety Equipment (If Applicable)
Make
Model
60 Frontal Head Restrant
NoneKnown
FIA
Not
Other
8858-2002
8858-2010
61 Helmet
FIA31.1/2
SFI
Not
Other
Known
8859-2015
8860-2010
8860-2004
Snell
SA(H)
M
K
62 Racesuit
FIA known
None
CIK-FIA
Not
Other
8856-2000
2013-1
2001-1
63 Gloves
FIA Known
None
Not
Other
8856-2000
64 Under Garments
FIA Known
None
Not
Other
8856-2000
65 Seat
NoneKnown
FIA
Not
Other
8862-2009
8855-1999
66 Seat Brackets
Not Known
Other
FIA
None
67 Harness
NoneKnown
FIA
Not
Other
8853-1998
8854-1998
Number of Harness Attachment
Points
68 Door Foam Package
69 Racing Nets
Standard
Left
Right
Both
Not Known
Other
FIA
None
Not Known
Other
SFI
FIA
None
70 Window Nets
Not Known
Other
SFI
FIA
None
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FIA Accident Report Form 1
Version 2.0_EN - 17.03.15
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
D2. Safety Equipment - Karting
71 Chassis
73 Bodywork & Bumpers
Not Known
Other
CIK-FIA
Not Known
Other
CIK-FIA
If Other:
If Other:
72 Brakes
Not Known
Other
CIK-FIA
If Other:
Driver Safety Equipment
Make
Model
74 Neck Brace
Standard
Not Known
Other
None
75 Helmet
FIA31.1/2
SFI
Not
Other
Known
8859-2015
8860-2010
8860-2004
Snell
SA(H)
M
K
76 Racesuit
FIA known
None
CIK-FIA
Not
Other
8856-2000
2013-1
2001-1
77 Gloves
FIA Known
None
Not
Other
8856-2000
D. Safety Equipment Comments
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FIA Accident Report Form 1
Version 2.0_EN - 17.03.15
FEDERATION INTERNATIONALE DE L’ AUTOMOBILE
E. Additional Notes
9/9