HomeMy WebLinkAbout23-14477 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-14477 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFH1C;l F ❑ LOCAL AOENC 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN ✓ CITY# ❑
cowsloN 12 - 1-- 2023 1809 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
128TH AVE SE BLOCK NO. e✓ 16400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YEs No ,/ D:8086004344 1 4 30
6❑ LAST NAME JOHNSON FIRSTNAME CIARA MIDDLE R 1 1 2 31
INITIAL
STREET ❑, 131ST AVE SE CITY RENTON ST WA Zlp' 98058 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]No✓ INTERLOCKYEs NO✓ YES R No
8❑ LDRIVER # STATE WA SEX'F MID
.O B 10 — 07 — 1994 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10� PICENSE1I ATE 14 BXV3285 STATE WA VIN# 5YJYGDEE7MF073724
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
rRLR. TRLR 1 5 33
12 0 0 VIN#' VIN#'
2021 TESL MODEL SD ❑ FROM
34
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE
13 2 DAMAGE YES NO ✓ YES NO✓
REGISTEREDOWNERINFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILI INSURANCE U INSURANCE CO FARMERS 384440262.0 4
IN EFFECT &POLICY# 9TOP
VEIF" CHARGE 5 36
LECALLv res❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 8 7 6
UNIT 02 VEHICCLE CYCLE ❑ PEDESTRIAN ❑ OWNERRTY ❑ DYES✓ NO OLD MET PHONE
16❑
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET CITY RENTON ST ZIP
17❑ NEW ADDRESS❑ ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INTERLOCK YEs❑NOR INTERLOCK YEs❑NOF YEs❑NO❑
19 LLIICENS RIVER# SEX U MMDDYY 39
WELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG g RESTR 9 EJECT '1 USE 9 CLASS 0 ❑
21❑ LICENSE I C54159Y TATe WA VIN# 3TMDZ58N3MM101923
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR 2021 MAKE TOYT MODEL TACOMA STYLE TR VEHICLE TOWED TO BLIN TOWEDey GOS HI 44
L4❑ DAMAGE YES NO,� YES NO✓
REGISTERED OWNER INFO DOMINIC VANDERJAGT 17338 SE 185TH PL RENTON WA 98058 D:2535084543 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU PORGY#E CO PARKED UNOCCUPIEDIN 1 9TOP 5
VEHICLE ,.I—I CITATION# CHARGE
25 i o BOTTOM
LEGALLY YES❑ N
$
OF
NAME(PRINT) OFFICER PHONE BADGE OR ID# [AGENCY
OF 1 EDIGER 12807 WA0171300
26
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE35794
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14477
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 12/17/2023 at approximately 1812 hours I was dispatched to an accident at 16425 128th Ave SE,
in the City of Renton, County of King, State of Washington.
I arrived on scene and contacted all parties involved. I identified unit 1 as a 2021 Tesla Model Y
(WA/Lic: BXV3285 Vin #5YJYGDEE7MF073724). Unit 1 was being driven by Ciara R Johnson (DOB
10/07/1994). 1 identified unit 2 as a 2021 Toyota Tacoma (WA/Lic: C54159Y Vin#
3TMDZ5BN3MM101923). Unit 2 was legally parked and unoccupied on the west side of 128th Ave
SE, facing southbound. The registered owner of unit 2 is Dominic G Vanderjagt (DOB 10/16/1994).
The driver of unit 1 stated that she was driving her vehicle on autopilot mode, southbound on 128th
Ave SE at the time of the collision. The vehicle's auto pilot did not recognize that unit 2 was parked off
the roadway and failed to avoid the vehicle. The driver of unit 1 stated that the vehicle is supposed to
be able to be driven without having to operate the steering wheel or pedals for the majority of the
time.
Unit 1 hit the rear driver's side of unit 2, causing significant damage to unit 2. Unit 1 sustained
damage on the front passenger side around the wheel well.
There were no injuries in this collision. I took pictures of each car and uploaded those images through
Axon.
I provided the driver of Unit 1 and the owner of Unit 2 with the case number for this incident.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
TYLER EDIGER 12-17-23 07:19 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 1 12/31/2023 1:03:09 AM
BADGE OR ID# 1Y807 ORI# WA0171300 TIME POLICE DISPATCHED 6:11 PM TIME POLICE ARRIVED',6:20 PM
PART Ei PAGE IT]OF
REPORT NO. EE35794 CASE# ' 23-14477 DATE AND TIME 12/17/23 18:09
OF COLLISION
Unit, I
U ni t 2
77
Not drawn to scale
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