First Report of Incident Form

Choose one:  Incident Report Date and Time of Report: 1/19/2023

 Near Miss Report

Location: Tijuana
Employee (Name): Edgar M. Flores Vidrio, Time of Incident (Approx.):9:05 pm
Rafael Romero Zepeda, Miguel A. Valdez Tovar, José
A. Arévalo Sotelo
Employee Position Reported by (Name)
Maintenance EE
Select one Incident Type
 Employee  Injury / Illness
 Contractor  Property Damage
 Other  Environmental
 Other

Incident / Near Miss Description (if insufficient space - use reverse side of form. Attach a descriptive picture of the incident
location with the report)
Silo exit #3 was not loading material to the mixer, the mechanical valve to interrupt cement flow was not
working/obstructed , Maintenance team tried to remove material using a metal bar trough bottom gate (second page
pictures), as valve was not in place to interrupt cement flow the material start downloading to the bottom gate over
maintenance team employees.

Location Classification Type of Injury Part of Body

 Administration  Contracting  Fatality  Abrasion/Cut  Open Wound  Head  Eye
 Production  Job Site  Lost Time Injury (LTI)  Burn  Strain or Sprain  Hand  Foot
 Workshop  Off Site  Restricted Work Case (RWC)  Fracture/Break  Laceration or puncture  Limb  Chest
 QC  Other  Medical Treatment Case (MTC)  Skin Reaction  Other  Back  Other
 First Aid Case (FAC)
 PSHI

Current Status of Personnel:

All employees in good condition under medical follow-up.
Any known impact sustained by the community:
None
Any known impact on plant assets or operations:
Yes, about 45 cement tons were disposed. 90 minutes down time in two pour lines.
Immediate Actions Taken:
First aid to 4 employees.
Review current conditions on similar equipment and restrict to not manipulate silos without using valves.

Name of person completing report: Jessica Ramirez / Aldo Acuna Date:

1/19/23
Valve

Screw

Bottom gate