20161118 Cizek ProkopAgency Accident Number
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Reportable Accident On Emergency Amended GZHTL63
DOT Document Number Document Override Number
16111815383
16
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8
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16111802
16
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11/18/2016
4 - Accident Date
1025
5 - Time of Accident (Military Time)
01
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County RADISSON - 12, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
040
14 - On Hwy No.
NB
14 - On Street Name 14 - Bus/Frnt/Rmp
0.54 MI15 - Est. Distance NORTH15 - Hwy. Dir
16 - Fr/At Hwy No.BEDNARSKI LN16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.740228
12 - Latitude -91.22086813 - Longitude
OVERTURN80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
CURVE
113 - Road Curvature
LEVEL/FLAT
113 - Road Terrain
BLACKTOP, BITUMINOUS, OR ASPHALT - 2
Surface Type
NOT-PHYSICALLY-DIVIDED-(2-WAY TRAFFIC)115 - Traffic Way
SHOULDER-(OTHER THAN SHOULDER WITHIN MEDIAN OR GORE)
117 - Relation To Roadway
DAYLIGHT114 - Light Condition WET116 - Road Surface Condition RAIN118 - Weather
Hit and Run
9
Government Property
9
Fire
9
Photos Taken
9
Trailer or Towed
9
Truck, Bus, or Hazardous Materials
9
Load Spillage
9
Construction Zone
9
Names Exchanged
9
Supplemental Reports
101
Witness Statements
102
Measurements Taken
103 79 - E M S Number
Operator/Pedestrian
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Unit Status
OVERTURN
81 - Most Harmful Event: Collision With
NORTH
23 - Dir Of Travel
5524 - Speed Limit
A CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2021
31 - Expiration Year 34 - On Duty Accident
CIZEK
25 - Operator/Pedestrian Last Name
GEORGE
25 - First Name
J
25 - Middle Initial 25 - Suffix
09/12/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
LADYSMITH
27 - City
WI
27 - State
54848
27 - Zip Code
.
28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
40 - Safety Equipment
N - NO APPARENT INJURY
38 - Injury Severity
NON-DEPLOYED
41 - Airbag
NOT-EJECTED
42 - Ejected 44
Medical Transport
NOT-TRAPPED
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
NEGOTIATING-CURVE
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 162 - No. of Citations Issued
346.57(3)
64 - 1st Statute No.64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
SPEED-TOO-FAST-FOR-CONDITIONS, FAILURE-TO-HAVE-CONTROL
122 - Driver Factors
APPEARED NORMAL88 - Driver or Pedestrian Cond UNKNOWN
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHTL63 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
SOFT-SHOULDER
124 - Highway Factors
TRUCK
21 - Unit Type
TRUCK-TRACTOR- (SEMI-ATTACHED)
Vehicle Type
1
22 - Total Occupants
TS39854
56 - License Plate Number
TOR57 - Plate Type WI
58 - State
2016
59 - Exp Year
22363
55 - Vehicle Identification Number
2000
50 - Year
PTRB
51 - Make 52 - Model
TC - TRACTOR
53 - Body Style
GLD
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT PASSENGER SIDE, MIDDLE PASSENGER SIDE
94 - Vehicle Damage
MODERATE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96 97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
PROKOP
46 - Vehicle Owner Last Name
MICHAEL
46 - First Name
R
46 - Middle Initial 46 - Suffix
03/06/1
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HOLCOMBE48 - City WI48 - State 5474548 - Zip Code 49 - Telephone Number
ALLIED-WORLD-INSURANCE-CO63 - Liability Insurance Company Policy Holder Same As Owner60
PROKOP
61 - Policy Holder Last Name
MICHAEL
61 - Policy Holder First Name
61 - Policy Holder Company
01
01
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Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Trailer
01
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1
106 - Power Unit Number
667259
License Plate Number
STL
Plate Type
WI
State Expiration Year
WILSON TRA
Trailer Make
SEMI
Unit Type
7390
Vehicle Identification Number
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHTL63 2 424
105 - Photos By
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Diagram and Narrative
POPLIN
UNIT 1 WAS GOING NORTH ON STATE HWY 40. UNIT 1 IS A FULLY LOADED LOG TRUCK. THE DRIVER OF UNIT 1 SAID THE TRUCK
WAS LOADED WITH LIGHT LOGS SO THE LOGS WERE LOADED HIGH UP ON THE TRAILER. THE DRIVER OF UNIT 1 SAID HE
NEGOTIATED THE CORNER AND SAW THE TIRES ON THE TRAILER LIFTING OFF OF THE GROUND. THE DRIVER SAID HE TRIED TO
MOVE RIGHT TO STRAIGHTEN THE CORNER AND GET THE TIRES TO COME BACK DOWN. THE DRIVER SAID THE NEW GRAVEL ON THE SIDE OF THE ROAD WAS SOFT AND WHEN THE TRUCK HIT THE NEW GRAVEL THE ENTIRE THING TIPPED OVER. I OBSERVED
MODERATE DAMAGE TO THE TRACTOR AND TRAILER AND I CITED THE DRIVER FOR TOO FAST FOR CONDITIONS. INSPECTOR
KASTNER ALSO CAME TO THE SCENE TO COMPLETE A POST CRASH REPORT.
UNIT 1 WAS GOING NORTH ON STATE HWY 40. UNIT 1 IS A FULLY LOADED LOG TRUCK. THE DRIVER OF UNIT 1 SAID THE TRUCK
WAS LOADED WITH LIGHT LOGS SO THE LOGS WERE LOADED HIGH UP ON THE TRAILER. THE DRIVER OF UNIT 1 SAID HE
NEGOTIATED THE CORNER AND SAW THE TIRES ON THE TRAILER LIFTING OFF OF THE GROUND. THE DRIVER SAID HE TRIED TO
MOVE RIGHT TO STRAIGHTEN THE CORNER AND GET THE TIRES TO COME BACK DOWN. THE DRIVER SAID THE NEW GRAVEL ON THE SIDE OF THE ROAD WAS SOFT AND WHEN THE TRUCK HIT THE NEW GRAVEL THE ENTIRE THING TIPPED OVER. I OBSERVED
MODERATE DAMAGE TO THE TRACTOR AND TRAILER AND I CITED THE DRIVER FOR TOO FAST FOR CONDITIONS. INSPECTOR
KASTNER ALSO CAME TO THE SCENE TO COMPLETE A POST CRASH REPORT.
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125 - First Name 125 - Middle Initial
Officer Information
POPLIN
125 - Officer Last Name
JAY 352
131 - Officer ID
129 - Law Enforcement Agency No.
SAWYER COUNTY SHERIFFS DEPT
130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET
126 - Law Enforcement Agency Address Street & Number
HAYWARD
127 - City
WI
127 - State
54843
127 - Zip Code
(715) 634-4858 EXT.
128 - Telephone Number
11/18/2016
132 - Date Notified 1025133 - Time Notified (Military Time)1055134 - Time Arrived (Military Time)
11/18/2016
135 - Date Of Report
16111815383 16111802 19 - Special Study
18 - Agency Space
136136
Truck and Bus
A truck or truck combination > 10,000 lbs
GVWR/GCWR
Any vehicle displaying a hazardous materials
placard
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHTL63 3 4
136 136 136
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A vehicle designed to carry 9 or more people, including the driver
136
Fatal Injury Medical Transport
One or more vehicles towed from the scene due to disabling damage
01Unit Number
137 - Hazardous Materials Class Numbers
137 - Hazardous Materials "UN" Nos.HazMat Placard Displayed Hazardous Cargo Was Released
137 - Name Of Hazardous Materials in this Load 137 - Name Of Hazardous Materials Released
Interstate Carrier138 1077948140 - US DOT No.140 - ICC MC No.81117LC No.IC No.DRIVER141 - Source
MICHAEL R PROKOP
139 - Carrier Name
142 - Carrier Address
HOLCOMBECity WIState 54745Zip Code
80,000
143 - GVWR (Lbs)
6
144 - Total No. of Axles
LOG TRUCK
145 - Vehicle Configuration
LOG-TRUCK
147 - Cargo Body Type
OVERTURN-(ROLLOVER)146 - First Event CARGO-LOSS-OR-SHIFT146 - Second Event
BLANK
146 - Third Event
BLANK
146 - Fourth Event
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHTL63 4 4