Granite Fact Finding Report For Incident & Injury Review

• Granite Fact Finding Report: (Nature of Incident)

• Client / Site:

• Conducted on

  Date

• Prepared By:

  Select Monika Buchanan - NA EHS Director Ron Wilson - Regional EHS Manager II Lee Hill - Regional EHS Manager II Greg Barker - Regional EHS Manager II Chris McKee - Regional EHS Manager II Lisa Block - Regional EHS Manager II Adam Scott - I&C EHS Manager II, Global

  • Monika Buchanan - NA EHS Director
  • Ron Wilson - Regional EHS Manager II
  • Lee Hill - Regional EHS Manager II
  • Greg Barker - Regional EHS Manager II
  • Chris McKee - Regional EHS Manager II
  • Lisa Block - Regional EHS Manager II
  • Adam Scott - I&C EHS Manager II, Global

Location of Accident

• Add location
  Address

• Location Photo

  Media

• Specific Location of Accident within the Site Location

Questionable Incident Activities

• This incident/injury is under investigation for its validity.

  Yes

  No

• Specific rationale and supporting documentation:

Red Flag Item

• Add media

  Media

TIME LINE OF EVENTS

• Will an event time line be included in this Fact Finding Report?

  Yes

  No

  N/A

• Enter Time Line Event

Time Line Event

• Select date

  Date

Employees involved in incident to include witnesses

• List all employees involved in this incident

Person

• Employee Name

• Employee Job Title

Fact Finding Meeting

• Was a fact finding meeting with Operations management, EHS and employee held for this event?

  Yes

  No

  N/A

• Identify who was part of the meeting.

• Enter name of meeting attendant and position

person

• Attended meeting

• Meeting was held:

  Date

• Why did the employee think the process he/she conducted was the right way to do it?

• INCIDENT REPORT

• Enter text from incident report description here.

• Capture picture of all pages of the incident report here. (Tab Z - Outage Safety Plan)

  Media

• STA/ POWRA RELATED TO THE INCIDENT

• Is the STA/ POWRA appropriate to the activity that was being performed?

  Yes

  No

  N/A

• Enter primary reason the STA/POWRA was not adequate to the task performed.

• Capture picture of all pages of the STA/POWRA here.

  Media

• Any additional information on the STA/POWRA not yet captured.

• Field Procedure(s)

• WAS THERE A FIELD PROCEDURE FOR THE ACTIVITY BEING PERFORMED.

  Yes

  No

  N/A

• Enter Field Procedure Name

• Add media

  Media

• Employee Statement

• Has the employee statement been obtained?

  Yes

  No

  N/A

• Copy text of employees statement here.

• Capture any pictures of the Employee's statement here. (You can capture a snap shot of the document from your email and then import it these fields)

  Media

• Witness Statement(s)

• Are there witness statements associated with this event?

  Yes

  No

  N/A

• Add witness statements here

person

• Name of witness for this statement

• Capture any pictures of the witness Statement here. (You can capture a snap shot of the document from your email and then import it these fields)

  Media

• Enter any key elements that need to be highlighted from the above witness statement here.

• Does employee statement contradict witness statements?

  Yes

  No

  N/A

• Enter details on how this witness statement conflicts with the employee statement.

• SUPERVISOR STATEMENT

• Has the Supervisor statement been obtained for this incident?

  Yes

  No

  N/A

• Name of Supervisor for this statement.

• Enter any key elements that need to be highlighted from the above Supervisor statement here.

• Capture any pictures of the Supervisor Statement here. (You can capture a snap shot of the document from your email and then import it these fields)

  Media

• SAFETY FLASH

• Is this incident severe enough to send out a Global Safety Flash ASAP? (EHS-006-SAF)

  Yes

  No

  N/A

• Capture screen shots of the Safety Flash here to be included within this investigation report. (You can capture a snap shot of the document from your email and then import it in these fields)

  Media

• RCA

• Will a Root Cause Analysis Story Board be completed for this incident for review on the Granite I&I Call?

  Yes

  No

  N/A

• Capture screen shots of the RCA Story Board here to be included within this investigation report. (You can capture a snap shot of the document from your email and then import it into these fields)

  Media

• NURSE TRIAGE

• Was Nurse Triage utilized for this incident?

  Yes

  No

  N/A

• What were the treatment recommendations from the Nurse Triage?

• What type of medical referral did Nurse Triage make?

  Self Care

  Occupational Clinic

  Emergency Room

  911

• Add media

  Media

• PHYSICIAN CARE

• Is there medical documentation to include drug and alcohol screening associated with this incident?

  Yes

  No

  N/A

• Is there documentation from a treating physician?

  Yes

  No

  N/A

• Capture any pictures of the physician's documentation here.

  Media

• Is there drug screen and or breath alcohol documentation available for this incident to include chain of custody forms?

  Yes

  No

  N/A

• Capture any pictures of the drug screen and breath alcohol documentation here. (You can capture a snap shot of the document from your email and then import it into these fields)

  Media

• Are there any positive drug screen or breath alcohol results related to this incident?

  Yes

  No

  N/A

• Has Human Resources been notified?

  Yes

  No

  N/A

• HIPPA AND MEDICAL RELEASE FORMS OBTAINED

• Has the HIPPA release form and medical release form been signed by the employee?

  Yes

  No

  N/A

• Include copy of the signed HIPPA and medical release forms.

HIPPA

• Add media

  Media

• EMAIL COMMUNICATION

• IS THERE APPLICABLE EMAIL COMMUNICATION?

  Yes

  No

  N/A

• Will E-Mail communication be included in this investigation?

  Yes

  No

  N/A

• Copy and paste e-mails into Microsoft Word and then into this report to avoid known errors experienced in the past.

E-Mails

• Enter E-Mail

• Shift Handovers from two days prior thru the time of the event

• Are shift Handovers available?

  Yes

  No

  N/A

• Insert JPEG copies

• Add media

  Media

• Tool Box Talks

• Are Tool Box Talks/ Safety Meeting sign in sheets available?

  Yes

  No

  N/A

• Insert electronic copies

• Add media

  Media

Injured Person Details

• Was an employee injured in this event?

  Yes

  No

  N/A

• Enter all injured individuals here

Person

• Employee type:

  Select Employee Customer Contractor Work Experience Temp Other

  • Employee
  • Customer
  • Contractor
  • Work Experience
  • Temp
  • Other

• Individuals name:

• Home Address:

Training Records

• It is recommended that training documents be reviewed. Will training records be included in this investigation?

  Yes

  No

  N/A

• Capture picture of all pages of PowerSource training screen and any additional relevant training here. (You can capture a snap shot of the document from your email and then import it into these fields)

  Media

• Describe training discrepancies if any:

Crane/ Rigging/ Forklift

• Was a Crane used in this operation?

  Yes

  No

  N/A

• What type of crane?

• Are crane certifications available?

  Yes

  No

  N/A

• Add media

  Media

• What company operated the crane?

  Granite

  Third Party

• Is the crane operators training documented for this investigation

  Yes

  No

  N/A

• Was this a Critical Lift? If yes, attach a copy of the critical lift plan.

  Yes

  No

  N/A

• Capture copy of the critical lift plan here.

  Media

• Is specific rigging information available for the rigging used for this incident?

  Yes

  No

  N/A

• Comments on Rigging.

• Pictures of rigging if available.

  Media

• Who had primary Rigging responsibility?

• Was a Fork Lift / extended boom lift or aerial lift involved in this incident?

  Yes

  No

  N/A

• Was the Forklift - Aerial Lift - Extended Boom Operator certified?

  Yes

  No

  N/A

• Attach proof of training.

  Media

Equipment Damage

• Was equipment damaged in this incident?

  Yes

  No

  N/A

• Define damaged Equipment.

• Granite Equipment?

  Yes

  No

  N/A

• GE Equipment?

  Yes

  No

  N/A

• Client Equipment?

  Yes

  No

  N/A

OSHA

• Date of Accident

  Date

• Accident Type

  Select Injury Illness HiPo First Aid Equipment Damage MVA

  • Injury
  • Illness
  • HiPo
  • First Aid
  • Equipment Damage
  • MVA

• Potential for Harm (HiPo)

  Select Fatal Major Serious Minor Non Injury Damage Only

  • Fatal
  • Major
  • Serious
  • Minor
  • Non Injury
  • Damage Only

• Does Accident meet OSHA Recordability criteria?

  Yes

  No

  N/A

• Fatality?

  Yes

  No

  N/A

• Amputation?

  Yes

  No

  N/A

• Loss of an eye?

  Yes

  No

  N/A

• Hospitalization?

  Yes

  No

  N/A

• Was the employee taken off of work for longer than the day of the incident?

  Yes

  No

  N/A

• Was the employee placed on restricted duties?

  Yes

  No

  N/A

• Did a licensed medical provider provide care beyond first aid?

  Yes

  No

  N/A

• Did the employee receive a prescription medication even if he/she did not have the prescription filled?

  Yes

  No

  N/A

• Insurers Notified

• Will Granite Insurance Companies be notified of the event?

  Yes

  No

  N/A

• Who Notified

• When Notified

  Date

Investigation Information Gathering

• How did the adverse event happen?

• What activities were being carried out at the time?

• Anything unusual or different about the working conditions?

• Were there adequate safe working procedures and were they followed?

• Nature and extent of injuries and ill health effects, if any.

• Was the risk known? If so, why wasn't it controlled?

• Did the organisational arrangements of the work influence the adverse event?

• Was maintenance and cleaning sufficient. Did it influence the adverse event?

• Were the people involved competent and suitable?

• Did the workplace layout influence the event?

• Did the nature or shape of materials influence the adverse event?

• Did difficulties using plant or equipment influence the adverse event?

• Was safety equipment provided and was it adequate?

• Did any other conditions influence the adverse event?

Photographic Evidence

• Will additional photographic evidence be included in this fact finding report?

  Yes

  No

  N/A

• Photo

photographic evidence

• Add media

  Media

Control Risk Measures

• Select control measures

  Select Change of Work Practices Eliminate Hazards Isolate Hazards Review Engineering Standards Re-Engineer to control hazard Inspections Improve Risk Analysis through Risk Assessment - STA Personal Protective Equipment Housekeeping Training Tools and Equipment Review Performance Expectations Proper Incident Reporting Procedures to be followed Assure competent persons are assigned to crane operations Safety Stand Down Barricade open holes Do not walk/ work while vision is obstructed Revoke Training Certifications Two Minute Drill Keep hands/ feet away from pinch points Provide additional tooling Review mechanical verses manual techniques used

  • Change of Work Practices
  • Eliminate Hazards
  • Isolate Hazards
  • Review Engineering Standards
  • Re-Engineer to control hazard
  • Inspections
  • Improve Risk Analysis through Risk Assessment - STA
  • Personal Protective Equipment
  • Housekeeping
  • Training
  • Tools and Equipment
  • Review Performance Expectations
  • Proper Incident Reporting Procedures to be followed
  • Assure competent persons are assigned to crane operations
  • Safety Stand Down
  • Barricade open holes
  • Do not walk/ work while vision is obstructed
  • Revoke Training Certifications
  • Two Minute Drill
  • Keep hands/ feet away from pinch points
  • Provide additional tooling
  • Review mechanical verses manual techniques used

• The following control measures are additionally recommended.

Control Measure

• Control Measure

Risk Control Actions

• The following action plan should be carried out

Actions

• Action or Control

• To be completed by

  Date

Gensuite Data

• Will Gensuite data be captured for input in this investigation?

  Yes

  No

  N/A

• Is case work related?

  Yes

  No

  N/A

• Investigation start date and time

  Date

• Investigation Team

  Select Monika Buchanan - NA EHS Director Ron Wilson - Regional EHS Manager II Lee Hill - Regional EHS Manager II Greg Barker - Regional EHS Manager II Chris McKee - Regional EHS Manager II Lisa Block - Regional EHS Manager II Adam Scott - I&C EHS Manager II, Global

  • Monika Buchanan - NA EHS Director
  • Ron Wilson - Regional EHS Manager II
  • Lee Hill - Regional EHS Manager II
  • Greg Barker - Regional EHS Manager II
  • Chris McKee - Regional EHS Manager II
  • Lisa Block - Regional EHS Manager II
  • Adam Scott - I&C EHS Manager II, Global

• Core Activity

  Select asbestos removal assembly operations blasting bending brazing business management / event / travel cafeteria operations chemical production operations cleaning operations compounding compressed gas cylinder operations confined space operations construction cutting operations demolition disassembly operations electrical work elevated work operations equipment de-installation equipment installation equipment operation extrusion forming housekeeping inspecting laboratory operations ladder operations lifting loading / unloading machining maintenance material handling non-specific site activity office work packaging pipeline operations plating press operations railcar movement repair security / emergency response operations shipping / receiving surface cleaning surface coating testing vehicle operations vessel inserting / purging waste management welding woodworking

  • asbestos removal
  • assembly operations
  • blasting
  • bending
  • brazing
  • business management / event / travel
  • cafeteria operations
  • chemical production operations
  • cleaning operations
  • compounding
  • compressed gas cylinder operations
  • confined space operations
  • construction
  • cutting operations
  • demolition
  • disassembly operations
  • electrical work
  • elevated work operations
  • equipment de-installation
  • equipment installation
  • equipment operation
  • extrusion
  • forming
  • housekeeping
  • inspecting
  • laboratory operations
  • ladder operations
  • lifting
  • loading / unloading
  • machining
  • maintenance
  • material handling
  • non-specific site activity
  • office work
  • packaging
  • pipeline operations
  • plating
  • press operations
  • railcar movement
  • repair
  • security / emergency response operations
  • shipping / receiving
  • surface cleaning
  • surface coating
  • testing
  • vehicle operations
  • vessel inserting / purging
  • waste management
  • welding
  • woodworking

• Job Activity Type

  not a normal part of job

  normal part of job, performed routinely

  normal part of job, but performed infrequently

• Serious Incident Factors

  Select confined space entry emergency shut down procedures high potential energy jobs ( all energy types) jobs that require LOTO lifting operations (crane/hoist) manual handling mobile equipment (operations and interactions with pedestrians) none process instability / process upset/ unexpected changes unexpected maintenance working at height

  • confined space entry
  • emergency shut down procedures
  • high potential energy jobs ( all energy types)
  • jobs that require LOTO
  • lifting operations (crane/hoist)
  • manual handling
  • mobile equipment (operations and interactions with pedestrians)
  • none
  • process instability / process upset/ unexpected changes
  • unexpected maintenance
  • working at height

• Time on job task

  Select 0 - 6 months 6 - 12 months 1 - 5 years 5 - 10 years 10 - 20 years > 20 years

  • 0 - 6 months
  • 6 - 12 months
  • 1 - 5 years
  • 5 - 10 years
  • 10 - 20 years
  • > 20 years

• Years of GE service

  Select 0 - 6 months 6 - 12 months 1 - 5 years 5 - 10 years 10 - 20 years > 20 years

  • 0 - 6 months
  • 6 - 12 months
  • 1 - 5 years
  • 5 - 10 years
  • 10 - 20 years
  • > 20 years

• Equipment used in job

• Appropriate PPE for job

  Select safety glasses, cut resistant gloves, steel toe boots hearing protection welding PPE

  • safety glasses, cut resistant gloves, steel toe boots
  • hearing protection
  • welding PPE

• Operational impact

  minor

  serious

  major

• Type of job

  Routine

  Non-Routine

• Unsafe Condition

  Select administration workplace control not followed allergic reaction congested or tight space defective/worn/maladjusted facil, vehicle defective/worn/maladjusted tool/equipment ergonomically inadequate workstation or rotation excessive noise/ vibration/light, inadequate light exposure to animals/insects/ plants exposure to bloodborne pathogens exposure to extreme weather exposure to ionizing radiation exposure to non-ionizing radiation exposure to smoke/ dust/fumes/ or vapors fire or explosion hazard guest/visitor high or low contact high or low air temperature high or low surface temperature housekeeping/unsafe placement/ slip,trip hazards improperly fitting parts, materials, fasteners inadequate guards, barriers, or warning system inadequate time allotted to task inadequate/faulty/no PPE assigned or available loss of utilities Overpressure/ Underpressure sharp edge on part, workstation, or equipment spilled/splashed chemicals or leaking containers unsafe food or drink wet, icy, snowy road or walkway

  • administration workplace control not followed
  • allergic reaction
  • congested or tight space
  • defective/worn/maladjusted facil, vehicle
  • defective/worn/maladjusted tool/equipment
  • ergonomically inadequate workstation or rotation
  • excessive noise/ vibration/light, inadequate light
  • exposure to animals/insects/ plants
  • exposure to bloodborne pathogens
  • exposure to extreme weather
  • exposure to ionizing radiation
  • exposure to non-ionizing radiation
  • exposure to smoke/ dust/fumes/ or vapors
  • fire or explosion hazard
  • guest/visitor
  • high or low contact
  • high or low air temperature
  • high or low surface temperature
  • housekeeping/unsafe placement/ slip,trip hazards
  • improperly fitting parts, materials, fasteners
  • inadequate guards, barriers, or warning system
  • inadequate time allotted to task
  • inadequate/faulty/no PPE assigned or available
  • loss of utilities
  • Overpressure/ Underpressure
  • sharp edge on part, workstation, or equipment
  • spilled/splashed chemicals or leaking containers
  • unsafe food or drink
  • wet, icy, snowy road or walkway

• Unsafe Act

  Select ascending/ descending stairs improperly assigned rotation or rest intervals not used did not heed warning, signals, lights, sounds employee awareness/attentiveness employee in danger zone/ line of fire equipment/tool used improperly failed to execute LOTO failed to use proper fall protection failed to worn or barricade horseplay or distracting behavior improper force / posture/ position improper lifting improper loading (overloading of racks/vehicles) improperly placed/secured,matls,tools,furniture) inadequate check for obstacles in vehicle path inadequate clearance for safely stopping vehicles inattention to established procedures (SOPs, STAs) intentional deviation normalized deviation operated vehicle improperly proper PPE not used for task removed or disabled safety devices or guard unintentional deviation (Human Error) used area not intended for walking/working wrong/ defective item used

  • ascending/ descending stairs improperly
  • assigned rotation or rest intervals not used
  • did not heed warning, signals, lights, sounds
  • employee awareness/attentiveness
  • employee in danger zone/ line of fire
  • equipment/tool used improperly
  • failed to execute LOTO
  • failed to use proper fall protection
  • failed to worn or barricade
  • horseplay or distracting behavior
  • improper force / posture/ position
  • improper lifting
  • improper loading (overloading of racks/vehicles)
  • improperly placed/secured,matls,tools,furniture)
  • inadequate check for obstacles in vehicle path
  • inadequate clearance for safely stopping vehicles
  • inattention to established procedures (SOPs, STAs)
  • intentional deviation
  • normalized deviation
  • operated vehicle improperly
  • proper PPE not used for task
  • removed or disabled safety devices or guard
  • unintentional deviation (Human Error)
  • used area not intended for walking/working
  • wrong/ defective item used

• Root Cause Job Factor

  Select inadequate communication inadequate control system setup or failure inadequate engineering inadequate inspection/ auditing inadequate job planning, instruction, supervision inadequate mechanical integrity, maintenance management inadequate procedures/work instructions/work standards inadequate sourcing/ supplier control inadequate maintained tools/equipment knowing misuse or abuse work environment not controlled by GE

  • inadequate communication
  • inadequate control system setup or failure
  • inadequate engineering
  • inadequate inspection/ auditing
  • inadequate job planning, instruction, supervision
  • inadequate mechanical integrity, maintenance management
  • inadequate procedures/work instructions/work standards
  • inadequate sourcing/ supplier control
  • inadequate maintained tools/equipment
  • knowing misuse or abuse
  • work environment not controlled by GE

• Personal/ Behavioral Factor

  Select difficult for employee to execute intentional deviation lack of knowledge or skill not under direct control of employee physical capability physical or psychological stress unintentional deviation (Human Error)

  • difficult for employee to execute
  • intentional deviation
  • lack of knowledge or skill
  • not under direct control of employee
  • physical capability
  • physical or psychological stress
  • unintentional deviation (Human Error)

• Descriptive Root Cause

• Management Systems Principle Management System Applicable

  Select EHS framework element contractor management dangerous good distributed workforce defenses EHS processes and systems emergency preparedness and response environmental defenses exposure defenses highly hazardous processes leadership and accountability preventative maintenance regulatory applicabilit risk assessment safety defenses

  • EHS framework element
  • contractor management
  • dangerous good
  • distributed workforce defenses
  • EHS processes and systems
  • emergency preparedness and response
  • environmental defenses
  • exposure defenses
  • highly hazardous processes
  • leadership and accountability
  • preventative maintenance
  • regulatory applicabilit
  • risk assessment
  • safety defenses

• Additional Management System Applicable

  Select EHS framework element contractor management dangerous good distributed workforce defenses EHS processes and systems emergency preparedness and response environmental defenses exposure defenses highly hazardous processes leadership and accountability preventative maintenance regulatory applicabilit risk assessment safety defenses

  • EHS framework element
  • contractor management
  • dangerous good
  • distributed workforce defenses
  • EHS processes and systems
  • emergency preparedness and response
  • environmental defenses
  • exposure defenses
  • highly hazardous processes
  • leadership and accountability
  • preventative maintenance
  • regulatory applicabilit
  • risk assessment
  • safety defenses

• Follow Up Corrective Actions

• Follow-Up status

  Open

  Closed

• Select date

  Date

• Closure comments

Documentation Review

• The following documentation should be reviewed as a result of this adverse event

• Safety Policy

• Written Field Procedures

• Safety Responsibilities

• Risk Assessments (STA)

• Safe Operating Procedures

• Training

• Other documentation to be reviewed?

Report Circulation

• This report should be circulated to the following groups and or people

• Regional EHS Manager

• Job Site EHS Manager

• Granite Job Site Supervisor

• Granite Service Manager

• Granite Service Director

• Granite HR Manager

Circulation to Outside Agencies

• GE EHS

• GE Management

• Third Party Safety Advisor on site.

Other Circulation

• This report should also be circulated to the following groups

• Other Circulation

Sign Off

• Typed name of individual completing report and signature.

• Add signature

  Sign