Incident Investigation

  • NOTE: Do not move anything prior to the investigation. Take pictures from all appropriate angles.

  • Take as many photos of the scene as possible.

  • Describe, in detail, what occurred. Include the exact task being done (include any tools, machinery or equipment being used and comment on condition):

  • What type of incident occurred?

  • Date and time of incident

  • Date and time injured employee began work

  • Affected Employee and Position:

  • Location of near miss/injury incident:

  • Employment Status of Injured Person

  • Severity

  • Nature of Injury

  • Body Parts Affected

  • Injury Type

  • Injury Type (Contact by):

  • Injury Company/Involved Equipment

  • Stationary Powered Equipment

  • Vehicles

  • Miscellaneous

  • Procedures

  • Personal Protective Equipment

  • Ergonomic Considerations

  • Was on-site first aid treatment given?

  • Who administered first aid?

  • What first aid was performed? (Ice, bandage, anti-bacterial cream, etc.)

  • Is the employee requesting/in need of medical attention? Tap Here to enter details.

  • Immediately Contact Jeff Schlagel (920) 344-3420, Shelly Cupery (920) 296-0307, and Department Manager.

  • Date:

  • Start Time:

  • End Time:

  • Name of Person Reporting Spill:

  • HAZMAT First Responders:

  • Location of spill:

  • Source of spill:

  • Approximately how much material spilled?

  • Contact Tim Rivers and or Department Manager.

Safety Precautions

  • Sources Removed That Could Cause Fire or Explosions:

  • Evacuated Spill Area

  • Barricade Spill Area

  • Warning Signs Placed

  • What material Spilled?

  • ~ 2 minutes / 1 Pump Stroke_104SA_ETHYL ALCOHOL (ETHANOL)_20%_1000 ppm_3300 ppm_55 deg F_19.0%_3.3%

    ~ 1.5 minutes / 1 Pump Stroke_111U_ETHYL ACETATE_40%_400 ppm_2000 ppm_24 deg F_11.5%_2.0%

    ~ 1.5 minutes / 1 Pump Stroke_151U_N-PROPYL ACETATE_40%_200 ppm_1700 ppm_55 deg F_8.0%_1.7%

  • ~ 1.5 minutes / 1 Pump Stroke_111U_ETHYL ACETATE_100%_400 ppm_2000 ppm_24 deg_11.5%_2.0%

  • ~ 1.5 minutes / 1 Pump Stroke_111U_ETHYL ACETATE_60-90%_400 ppm_2000 ppm_24 deg F_11.5%_2.0%

    ~ N/A NITROCELLULOSE_5-10%

  • ~ 2 minutes / 1 Pump Stroke_124SA_TOLUENE_39%_100 ppm_500 ppm_40 deg F_ 7.1%_1.1%

    ~ XYLENE_6%_100 ppm_900 ppm_90deg F_6.7%_9.0%

    ~ 1.5 minutes / 1 Pump Stroke_150U_N-PROPYL ALCOHOL (N-PROPANOL)_3%_200 ppm_800 ppm_72 deg F_13.7%_2.2%

    ~ ETHYL BENZENE_1%_100 ppm_800 ppm_55deg F_6.7%_0.8%

  • ~ 1.5 minutes / Pump Stroke_111U_ISOPROPYL ACETATE_9-47%_250 ppm_1800 ppm_36 deg F_8%_1.8%

    ~ 2 minutes / Pump Stroke_104SA_ETHYL ALCOHOL (ETHANOL)_9-44%_1000 ppm_3300 ppm_55deg F_19%_3.3%

    ~ 1.5 minutes / Pump Stroke_151U_N-PROPYL ACETATE_9.25%_200 ppm_1700 ppm_55 deg F_8.0%_1.7%

  • ~ 1.5 minutes / Pump Stroke_111U_ETHYL ACETATE_10-30%_400 ppm_2000 ppm_24 deg F_11.5%_2.0%

    ~ 1.5minutes / Pump Stroke_151U_N-PROPYL ACETATE_5-10%_200 ppm_1700 ppm_55 deg F_8%_1.7%

    ~ N-PROPYL ALCOHOL (N-PROPANOL)_3.7%_200 ppm_800 ppm_72 deg F_13.7%_2.2%

  • ~ 1.5 minutes / Pump Stroke_151_ISOPROPYL ACETATE_40%_200 ppm_1700 ppm_55 deg F_8%_1.7%

    ~ 2 minutes / Pump Stroke_104SA_ETHYL ALCOHOL (ETHANOL)_30%_1000 ppm_3300 ppm_55deg F_19%_3.3%

    ~ 1.5 minutes / Pump Stroke_150U_N-PROPYL ACETATE_30%_100 ppm_800ppm_72 deg F_13.7%_2.2%

  • ~ 1.5 minutes / Pump Stroke_111U_ISOPROPYL ACETATE_10-30%_250 ppm_1800 ppm_36 deg F_8.0%_1.8%

    ~ 1.5 minutes / Pump Stroke_151U_N-PROPYL ACETATE_10-30%_200 ppm_1700 ppm_55 deg F_8%_1.7%

    ~ NITROCELLULOSE_10-30%

    1.5 minutes / Pump Stroke_150U_ISOPROPYL ALCOHOL_3-7%_400 ppm_2000 ppm_53% F_12.7%_2.0%

  • ~ 2 minutes / Pump Stroke_104SA_ETHYL ALCOHOL (ETHANOL)_9-43%_1000 ppm_3300 ppm_55 deg F_19.0%_3.3%

    ~ 1.5minutes / Pump Stroke_151U_N-PROPYL ACETATE_9-25%_200 ppm_1700 ppm_55 deg F_8%_1.7%

    ~ 1.5 minutes / Pump Stroke_150U_ISOPROPYL ALCOHOL_9-33%_400 ppm_2000 ppm_53 deg F_12.7_2.0%

    ~ ALIPHATIC HYDROCARBON MIXTURE_9-13%

  • ~ 1.5 minutes / 1 Pump Stroke_111U_ETHYL ACETATE_99%_400 ppm_2000 ppm_24 deg_11.5%_2.0%

  • ~ 2 minutes / Pump Stroke_104SA_ETHYL ALCOHOL (ETHANOL)_85%_1000 ppm_3300 ppm_55 deg F_19.0%_3.3%

    ~ 1.5minutes / Pump Stroke_150U_ISOPROPYL ALCOHOL_14%_400 ppm_2000 ppm_53 deg F_12.7%_2.0%

    ~ 1.5 minutes / Pump Stroke_151U_N-PROPYL ACETATE_1%_200 ppm_1700 ppm_55 deg F_8.0%_1.7%

  • Review MSDS For Hazards and Exposure Limits:

Selected PPE

  • Tryhem Suit

  • Boot Covers

  • Nitrile Gloves

  • Goggles

  • Face Shield

Air Monitoring - Initial Readings

  • Time:

  • Temperature:

M40 Multi Gas Monitor

  • CO:

  • H2S:

  • O2:

  • LEL:

Sensydine Gas Detector

  • Ethyl Acetate ppm:

  • Reading:

  • Ethyl Alcohol ppm:

  • Reading:

  • Isopropyl Acetate ppm:

  • Reading:

  • Isopropyl Alcohol ppm:

  • Reading:

  • N-Propyl Acetate ppm:

  • Reading:

  • N-Propyl Alcohol ppm:

  • Reading:

  • Toluene ppm:

  • Reading:

  • Nitrocellulose ppm:

  • Reading:

  • Clean

  • Exhaust

  • Call Outside HAZMAT

Exhaust

  • Ventilation Blower

  • Intrinsically Safe Fan

  • Foam Extinguisher

  • How Was The Spill Exhausted?

Air Monitoring - After Exhausting

  • Time:

  • Temperature:

M40 Multi Gas Monitor

  • CO:

  • H2S:

  • O2:

  • LEL:

Sensydine Gas Detector

  • Ethyl Acetate ppm:

  • Reading:

  • Ethyl Alcohol ppm:

  • Reading:

  • Isopropyl Acetate ppm:

  • Reading:

  • Isopropyl alcohol ppm:

  • Reading:

  • N-Propyl Acetate ppm:

  • Reading:

  • N-Propyl Alcohol ppm:

  • Reading:

  • Toluene ppm:

  • Reading:

  • Nitrocellulose ppm:

  • Reading:

  • Clean

  • Call outside HAZMAT

Clean

  • Employees Cleaning Spill:

  • Time:

  • Temperature:

  • Good way Vacuum

  • Absorbent Pads

  • Spill Booms

  • Rags

  • LSS Spill Kit

  • Battery Acid Spill Kit

  • How Was Spill Contained and Cleaned?

  • lbs. Of Waste Cleaned:

  • LBS-GAL

  • A Waste

  • # of Barrels:

  • B Waste

  • # of Barrels:

  • C Waste

  • # of Barrels:

  • Location of Waste Drums:

Air Monitoring - Continuous

  • M40 readings should be recorded every 20 minutes. Toxicity should be checked and recorded every 1 hour with the Sensidyne Gas Tubes, unless conditions change that warrent immediate attention

  • 1 hour period

  • Air Monitoring
  • Time:

  • Temp:

M40 Multi Gas Monitor

  • CO:

  • H2S:

  • O2:

  • LEL:

  • Time:

  • Temp

M40 Multi Gas Monitor

  • CO:

  • H2S:

  • O2:

  • LEL:

  • Time:

  • Temp:

M40 Multi Gas Monitor

  • CO:

  • H2S:

  • O2:

  • LEL:

  • Time:

  • Temp:

Sensydine Gas Detector

  • Ethyl Acetate ppm:

  • Reading:

  • Ethyl Alcohol ppm:

  • Reading:

  • Isopropyl Acetate ppm:

  • Reading:

  • Isopropyl Alcohol ppm:

  • Reading:

  • N- Propyl Acetate ppm:

  • Reading:

  • N-Propyl Alcohol ppm:

  • Reading:

  • Toluene ppm:

  • Reading:

  • Nitrocellulose ppm:

  • Reading:

Review of Spill Area

  • Refer to ESOP-6012 EPCRA to determine if regulatory reporting is required)

  • Is there any indication that the spill leaked or penetrated into the soil?

  • Comment:

  • Is there any indication that the spill has leaked into the storm sewer?

  • Comment:

  • Additional Comments:

  • Date and Time:

  • Witness Statement

  • Witness name?

  • Telephone Number

  • Occupation

  • Date and time of injury

  • Location where injury occurred.

  • Description of what you saw.

  • Who or what caused the accident/injury?

  • In your opinion what body parts were injured?

  • Was there anything that could have been done to prevent injury?

  • What could have been done?

  • Did anything appear suspicious about the incident?

  • What was suspicious?

Root Cause

  • What was the root cause of this incident?

Immediate Corrective Actions:

  • Enter corrective actions taken to prevent immediate reoccurrence. Enter suggestions for future corrective actions.

Finalization

  • Employee Signature

  • Preparers Signature

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