Accident / Incident Report and Investigation - Sabre Industries

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Accident / Incident Report and Investigation

• Department

  Select Metal Fab Conduit Maintenance Shipping Warehouse Administrative EH&S Batch Plant Casting Paint & Blast Carpentry Install Electrical Building Movement Mobile Products Welding SMA Contract Labor

  • Metal Fab
  • Conduit
  • Maintenance
  • Shipping
  • Warehouse
  • Administrative
  • EH&S
  • Batch Plant
  • Casting
  • Paint & Blast
  • Carpentry
  • Install
  • Electrical
  • Building Movement
  • Mobile Products
  • Welding
  • SMA
  • Contract Labor

• Supervisor:

  Select Freddie Jackson Ryan Hodges Lane Edwards Shelton Smith Torrey O'Neal Jerry Lutterman Charles Tucker Willie Stanley Rudy Blackburn Kevin Bedsole Jason Lewis Jason Taylor Shannon Lee Rob Stewart John Miller Don Martin

  • Freddie Jackson
  • Ryan Hodges
  • Lane Edwards
  • Shelton Smith
  • Torrey O'Neal
  • Jerry Lutterman
  • Charles Tucker
  • Willie Stanley
  • Rudy Blackburn
  • Kevin Bedsole
  • Jason Lewis
  • Jason Taylor
  • Shannon Lee
  • Rob Stewart
  • John Miller
  • Don Martin

• Location of Incident:

  Select Metal Fab Conduit Maintenance Shipping Warehouse Administrative EH&S Batch Plant Casting Paint & Blast Carpentry Install Electrical Building Movement Mobile Products Welding SMA Contract Labor

  • Metal Fab
  • Conduit
  • Maintenance
  • Shipping
  • Warehouse
  • Administrative
  • EH&S
  • Batch Plant
  • Casting
  • Paint & Blast
  • Carpentry
  • Install
  • Electrical
  • Building Movement
  • Mobile Products
  • Welding
  • SMA
  • Contract Labor

• Type of incident:

  Select INJURY OR ILLNESS PROPERTY DAMAGE ENVIRONMENTAL RELEASE NEAR MISS PERSONAL MEDICAL

  • INJURY OR ILLNESS
  • PROPERTY DAMAGE
  • ENVIRONMENTAL RELEASE
  • NEAR MISS
  • PERSONAL MEDICAL

• Date of incident:

  Date

• Date reported:

  Date

INJURY OR ILLNESS

• Name of Injured:

• Part of Body Injured:

  Select Abdomen Ankle Left Ankle Right Arm Left Arm Right Back Brain Chest Digestive System Ear Left Ear Right Elbow Left Elbow Right Eye Left Eye Right Face Finger Left Finger Right Foot Left Foot Right Hand Left Hand Right Head Heart Hips Kidney, Bladder, Intestine Knee Left Knee Right Leg Left Leg Right Lungs Multiple Parts Shoulder Left Shoulder Right

  • Abdomen
  • Ankle Left
  • Ankle Right
  • Arm Left
  • Arm Right
  • Back
  • Brain
  • Chest
  • Digestive System
  • Ear Left
  • Ear Right
  • Elbow Left
  • Elbow Right
  • Eye Left
  • Eye Right
  • Face
  • Finger Left
  • Finger Right
  • Foot Left
  • Foot Right
  • Hand Left
  • Hand Right
  • Head
  • Heart
  • Hips
  • Kidney, Bladder, Intestine
  • Knee Left
  • Knee Right
  • Leg Left
  • Leg Right
  • Lungs
  • Multiple Parts
  • Shoulder Left
  • Shoulder Right

• Occupation:

  Select Welder Paint/Blast Material Handler Quality Control Lead Machine Operator Assembly Mechanic Conduit Tech Maintenance Supervisor Manager EH&S Specialist Special Projects Inventory Control Administrative Casting Shipping Parts Coordinator Electrical Tech Carpenter Building Movement Forklift Operator

  • Welder
  • Paint/Blast
  • Material Handler
  • Quality Control
  • Lead
  • Machine Operator
  • Assembly
  • Mechanic
  • Conduit Tech
  • Maintenance
  • Supervisor
  • Manager
  • EH&S Specialist
  • Special Projects
  • Inventory Control
  • Administrative
  • Casting
  • Shipping
  • Parts Coordinator
  • Electrical Tech
  • Carpenter
  • Building Movement
  • Forklift Operator

• Add media

  Media

Property Damage

• Nature of Incident:

• Nature of Damage:

• Estimated Cost:

  Select 0.00 to 50.00 Dollars 51.00 to 100.00 Dollars 101.00 to 150.00 Dollars 151.00 to 200.00 Dollars 201.00 to 250.00 Dollars 251.00 to 300.00 Dollars 301.00 to 350.00 Dollars 351.00 to 400.00 Dollars 401.00 to 450.00 Dollars 451.00 to 500.00 Dollars 501.00 to 600.00 Dollars 601.00 to 700.00 Dollars 701.00 to 800.00 Dollars 801.00 to 900.00 Dollars 901.00 to 1000.00 1001.00 or Greater

  • 0.00 to 50.00 Dollars
  • 51.00 to 100.00 Dollars
  • 101.00 to 150.00 Dollars
  • 151.00 to 200.00 Dollars
  • 201.00 to 250.00 Dollars
  • 251.00 to 300.00 Dollars
  • 301.00 to 350.00 Dollars
  • 351.00 to 400.00 Dollars
  • 401.00 to 450.00 Dollars
  • 451.00 to 500.00 Dollars
  • 501.00 to 600.00 Dollars
  • 601.00 to 700.00 Dollars
  • 701.00 to 800.00 Dollars
  • 801.00 to 900.00 Dollars
  • 901.00 to 1000.00
  • 1001.00 or Greater

• Object/Equipment/Substance Fault

• Name of person(s) with most control:

• Loss Severity Potential:

  Select Major Serious Minor

  • Major
  • Serious
  • Minor

• Add media

  Media

ENVIRONMENTAL RELEASE

• Nature of Incident:

• Incident Cost if Applicable:

  Select 0.00 to 50.00 Dollars 51.00 to 100.00 Dollars 101.00 to 150.00 Dollars 151.00 to 200.00 Dollars 201.00 to 250.00 Dollars 251.00 to 300.00 Dollars 301.00 to 350.00 Dollars 351.00 to 400.00 Dollars 401.00 to 450.00 Dollars 451.00 to 500.00 Dollars 501.00 to 600.00 Dollars 601.00 to 700.00 Dollars 701.00 to 800.00 Dollars 801.00 to 900.00 Dollars 901.00 to 1000.00 1001.00 or Greater

  • 0.00 to 50.00 Dollars
  • 51.00 to 100.00 Dollars
  • 101.00 to 150.00 Dollars
  • 151.00 to 200.00 Dollars
  • 201.00 to 250.00 Dollars
  • 251.00 to 300.00 Dollars
  • 301.00 to 350.00 Dollars
  • 351.00 to 400.00 Dollars
  • 401.00 to 450.00 Dollars
  • 451.00 to 500.00 Dollars
  • 501.00 to 600.00 Dollars
  • 601.00 to 700.00 Dollars
  • 701.00 to 800.00 Dollars
  • 801.00 to 900.00 Dollars
  • 901.00 to 1000.00
  • 1001.00 or Greater

• Person Reporting Incident:

• Object / Equipment / Substance Fault:

• Person With Most Control:

• Probability of Occurance:

  Select Frequent Occasional Seldom

  • Frequent
  • Occasional
  • Seldom

• Add media

  Media

INCIDENT DESCRIPTION:

• Describe How the Event Occured:

Witness Statement

• Describe What the Witness Saw:

• Signature of Witness

  Sign

CAUSES: What Actions and Conditions Caused the Event?

• Unsafe Acts:

  Select Operating Equip. without authority Failure to warn Failure to secure Operating at Improper speed Making safety devices inoperable Removing safety devices Using equipment improperly Failure to use proper PPE Failure to correctly use PPE Using defective equipment Improper loading Improper material placement Improper lifting Improper position for task Servicing equip. while in operation Horseplay Under influence of alcohol and/or drugs Failure to follow rules Failure to use proper/ available equipment

  • Operating Equip. without authority
  • Failure to warn
  • Failure to secure
  • Operating at Improper speed
  • Making safety devices inoperable
  • Removing safety devices
  • Using equipment improperly
  • Failure to use proper PPE
  • Failure to correctly use PPE
  • Using defective equipment
  • Improper loading
  • Improper material placement
  • Improper lifting
  • Improper position for task
  • Servicing equip. while in operation
  • Horseplay
  • Under influence of alcohol and/or drugs
  • Failure to follow rules
  • Failure to use proper/ available equipment

• Unsafe Conditions

  Select Inadequate guards or barriers Inadequate or improper protective equipment Defective tools, equipment or materials Congestion or restricted action Inadequate warning system Fire and explosion hazards Poor housekeeping; disorder Hazardous environmental conditions: gases, dusts, smokes, fumes, vapors Noise exposures Radiation exposures High or low temperature exposures Inadequate or excess illumination Inadequate ventilation Poor design/ layout causing awkward body positioning

  • Inadequate guards or barriers
  • Inadequate or improper protective equipment
  • Defective tools, equipment or materials
  • Congestion or restricted action
  • Inadequate warning system
  • Fire and explosion hazards
  • Poor housekeeping; disorder
  • Hazardous environmental conditions: gases, dusts, smokes, fumes, vapors
  • Noise exposures
  • Radiation exposures
  • High or low temperature exposures
  • Inadequate or excess illumination
  • Inadequate ventilation
  • Poor design/ layout causing awkward body positioning

OTHER FACTORS

• What specific Personal or Job Factors Caused or Could Cause This Event?

  Select inadequate capability Lack of knowledge Lack of skill Lack of training Life stress Improper Motivation Lack of supervision Poor engineering Poor planning Poor purchasing Poor maintenance Poor tools/ equipment Poor work standards Wear and tear Abuse or misuse

  • inadequate capability
  • Lack of knowledge
  • Lack of skill
  • Lack of training
  • Life stress
  • Improper Motivation
  • Lack of supervision
  • Poor engineering
  • Poor planning
  • Poor purchasing
  • Poor maintenance
  • Poor tools/ equipment
  • Poor work standards
  • Wear and tear
  • Abuse or misuse

TYPE OF CONTACT

• TYPE OF CONTACT

  Select Struck against Struck by Caught in Caught on Caught between Slip Fall on same level Fall to lower level or elevation Overexertion Exposure

  • Struck against
  • Struck by
  • Caught in
  • Caught on
  • Caught between
  • Slip
  • Fall on same level
  • Fall to lower level or elevation
  • Overexertion
  • Exposure

• CONTACT WITH

  Select Electricity Heat / Exposed fire Hot metal Dusts Hazardous Chemicals Moving hoisted load Heavy pinch point / roll-over High noise Hazardous Light Heavy/Blunt Object Acids or Caustics Falling Object Sharp edges Over-exertion

  • Electricity
  • Heat / Exposed fire
  • Hot metal
  • Dusts
  • Hazardous Chemicals
  • Moving hoisted load
  • Heavy pinch point / roll-over
  • High noise
  • Hazardous Light
  • Heavy/Blunt Object
  • Acids or Caustics
  • Falling Object
  • Sharp edges
  • Over-exertion

SUPERVISOR'S CORRECTIVE ACTIONS:

• What will be done to control the causes listed and prevent reoccurrence?

• Signature of Supervisor:

  Sign

• Signature of Employee:

  Sign

EHS REVIEW: To be completed by HR or Safety

• I concur with Supervision's corrective or remedial actions.

• After review I recommend the following corrective and/or remedial actions or add these comments:

• EHS/ HR COMMENTS

• Signature of Safety Representative

  Sign

• Incident Classification

  Select Non-Injury Event First Aid OSHA Recordable Not Work Related

  • Non-Injury Event
  • First Aid
  • OSHA Recordable
  • Not Work Related