ATTACHMENT A

Name
Near Miss
First Aid
PMD Cracker Doctor Case Social Security Number Sex M F

Project OSHA Rec.

Badge Number
LWC Date of Birth

ACCIDENT / INCIDENT Fatality

Prop. Damage Job Title Service Date
INVESTIGATION Environmental
FORM FORM Other
RWC Supervisor General Foreman
Project Nam No.

Property Damage Injury / Illness

Equipment Damaged - Nature of Damage Nature of Injury & Body Parts

Date Damage was Reported Date Injury Reported or Illness Diagnosed

Estimated Repair Cost Treatment Administered:

Estimated Down Time Date Lost Time Began Work Days Lost

The Accident / Incident

Date of Accident / Incident Day of Week Time Exact Location of Accident / Incident

Job Injured was Performing Experience & Training On The Job

Description of Accident / Incident:

Accident Type or Contact

Check One
Struck By Struck Against Caught In Caught Between Different Level Fall Exposure
Contacted By Contact With Caught On Same Level Fall Strain/Over Exertion Other (Explain)

Frequency Potential Severity Potential

Frequent Occasional Rare Major Serious Rare
Name of Witness

579615181.xls
The Causes
Direct Personnel Causes
What did a person-the victim or someone else-do, or fail to do, that
contributed directly to this accident? Be specific, for example:
"Operated machinery without authority", "Used pipe wrench for
a hammer; Brushed fillings away with finger rather than a brush."
Direct Environmental Causes
What defective or otherwise unsafe condition(s) of tools, machinery,
equipment, product, working surface, structures, or work area
contributed directly to this accident? Be specific, for example:
"Hand - railing missing". "Badly worn brake linings", "Cracked
fork on lift truck."

Indirect Personnel Causes Indirect Environmental Causes

Check item(s) below which best indicate reasons why act Check item(s) below which best indicate reasons why
identified in above was commented. Write in information condition identified in above existed. Write in information
for indirect causes not listed. for indirect causes not listed.
1. Unaware of job hazards 8. Influence of emotions 1. Worn out from normal use 11. Faulty construction
2. Inattentive to hazards 9. Influence of fatigue 2. Abuse or misuse by users 12. Inadequate illumination
3. Unaware of safe method 10. Influence of illness 3. Required inspection not done 13. Lubrication failure
4. Low level of job skill 11. Influence of intoxicants 4. Inspection not required 14. Exposure to corrosion
5. Tried to gain or save time 12. Defective vision/hearing 5. Clean-up failure 15. Exposure to vibration
6. Tried to avoid extra effort 13. Unable to determine 6. Clean-up not required 16. Exposure to temp. extreme
7. Acted to avoid discomfort 14. Other (explain) 7. Clean-up not done 17. Tampering
8. Inadequate ventilation 18. Supervisor failed to correct
9. Congestion - lack of space 19. Unable to determine
10. Unsafe design 20. Other (explain)

Primary Unsafe Act Primary Unsafe Condition (Check One)

Cause Environmental Cause
1. Operating or using equipment without authority 1. Lack of inadequate guards and safety devices
2. Failure to secure against unexpected movement 2. Lack of or inadequate warning systems
3. Operating or working at an unsafe speed 3. Fire and explosion hazards
4. Failure to warn or signal as required 4. Unexpected movement hazards
5. Removing or making safety devices inoperative 5. Poor housekeeping hazards
6. Using defective tools or equipment 6. Protruding object hazards
7. Using tools or equipment unsafely 7. Close clearance and congestion hazards
8. Taking an unsafe position or posture 8. Hazardous atmospheric conditions
9. Servicing moving, energized or otherwise hazardous equipment 9. Hazardous arrangement, placement or storage
10. Riding hazardous moving equipment 10. Hazardous defects of tools, equipment, etc.
11. Horseplay, distracting, startling, teasing, etc. 11. Inadequate illumination; intense noise
12. Failure to wear personal protective equipment 12. Hazardous personal attire
13. Other than above 13. Other than above
14. None 14. None

The Correction
Corrective Action Taken
Check those actions taken to prevent recurrence. Fill in the appropriate box for corrective actions decided upon or planned by not yet
initiated or completed.
1. Reinstructed of those involved 8. Action to improve clean-up 15. Correction of necessary congestion
2. Reprimand of those involved 9. STA done 16. Improved personal protective equipment
3. Discipline of those involved 10. Revision of STA 17. Order regular pre-job instructions
4. Reinstruction of others doing the job 11. Equipment repair or replacement 18. Order use of safer materials
5. Temporary reassignment of person 12. Action to improve design 19. Check with manufacturer
6. Permanent reassignment of person 13. Action to improve construction 20. Inform all departmental supervision
7. Action to improve inspection 14. Installation of guard or safety device 21. Other than above
In all disabling and medical treatment injuries, describe details of your corrective action:

Person responsible for Corrective Action Target Date Date Completed

Signatures:

Investigated By: Date Site Manager Date

Safety Rep. _________________________________

Supervisor _________________________________________________