Incident Investigation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

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.

  Media

• 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?

  Select Fire Spill Injury Illness Near Miss Property Damage

  • Fire
  • Spill
  • Injury
  • Illness
  • Near Miss
  • Property Damage

• Date and time of incident

  Date

• Date and time injured employee began work

  Date

• Affected Employee and Position:

• Location of near miss/injury incident:

• Employment Status of Injured Person

  Permanent

  Temporary

  Contractor

  Visitor

• Severity

  Select Near miss First Aid Medical Only Restricted Work Lost Time Fatality

  • Near miss
  • First Aid
  • Medical Only
  • Restricted Work
  • Lost Time
  • Fatality

• Nature of Injury

  Select Amputation/avulsion Fracture/dislocation/crush Cut/scrape/puncture Sting/bite Bruise/contusion Irritation Hernia/rupture Sprain/strain Burn-chemical Burn-thermal or electrical Suffocate/drown/asphyxiated Concussion/unconscious Poisoning-acute Ergonomic issue (sprain, strain)

  • Amputation/avulsion
  • Fracture/dislocation/crush
  • Cut/scrape/puncture
  • Sting/bite
  • Bruise/contusion
  • Irritation
  • Hernia/rupture
  • Sprain/strain
  • Burn-chemical
  • Burn-thermal or electrical
  • Suffocate/drown/asphyxiated
  • Concussion/unconscious
  • Poisoning-acute
  • Ergonomic issue (sprain, strain)

• Body Parts Affected

  Select Head Eye(s) Ear(s) Face Neck Shoulder Chest Back, Spine Abdomen Groin Hip Upper Arm Elbow Forearm Wrist Hand Fingers(s) Thigh Knee Shin, calf Ankle Foot Toe(s) Circulatory Respiratory

  • Head
  • Eye(s)
  • Ear(s)
  • Face
  • Neck
  • Shoulder
  • Chest
  • Back, Spine
  • Abdomen
  • Groin
  • Hip
  • Upper Arm
  • Elbow
  • Forearm
  • Wrist
  • Hand
  • Fingers(s)
  • Thigh
  • Knee
  • Shin, calf
  • Ankle
  • Foot
  • Toe(s)
  • Circulatory
  • Respiratory

• Injury Type

  Select Fall from elevation Fall, same level Slip or trip without fall Struck against object Struck by object Caught in, under, or between Overexertion Public or contracted transportation Motor vehicle Drowning, buried

  • Fall from elevation
  • Fall, same level
  • Slip or trip without fall
  • Struck against object
  • Struck by object
  • Caught in, under, or between
  • Overexertion
  • Public or contracted transportation
  • Motor vehicle
  • Drowning, buried

• Injury Type (Contact by):

  Select Chemical(s) Electricity Temperature Extremes Noise Other physical agents Animal, insect

  • Chemical(s)
  • Electricity
  • Temperature Extremes
  • Noise
  • Other physical agents
  • Animal, insect

• Injury Company/Involved Equipment

  Select Fired vessel-boiler, incinerator Chemical Process

  • Fired vessel-boiler, incinerator
  • Chemical Process

• Stationary Powered Equipment

  Select Gas or liquid handling Solids handling Mechanical power transmission Portable equipment Hoist, cranes, lifting equipment Power presses, brakes, shears Powered saws Drills, screw machines, boring bar Fastening equipment

  • Gas or liquid handling
  • Solids handling
  • Mechanical power transmission
  • Portable equipment
  • Hoist, cranes, lifting equipment
  • Power presses, brakes, shears
  • Powered saws
  • Drills, screw machines, boring bar
  • Fastening equipment

• Vehicles

  Manual carts, pallet jacks

  Fork truck/roll grab

  Walk behind

  Company Vehicle (trucks)

• Miscellaneous

  Select Piping hoses, valves & fittings Drums, boxes, pails, cylinders Ladders, scissor lift, scaffolding Floor, stairs, working surfaces Tools-hand (knives, wrenches) Electrical distribution systems Office Equipment Lab equipment Machine/maintenance shop Unknown Other

  • Piping hoses, valves & fittings
  • Drums, boxes, pails, cylinders
  • Ladders, scissor lift, scaffolding
  • Floor, stairs, working surfaces
  • Tools-hand (knives, wrenches)
  • Electrical distribution systems
  • Office Equipment
  • Lab equipment
  • Machine/maintenance shop
  • Unknown
  • Other

• Procedures

  Select Failure to follow written procedures or rules Confined space procedure not followed Hot work procedure not followed lockout/Tagout procedure not followed Written procedures not available Incomplete/outdated procedures Other

  • Failure to follow written procedures or rules
  • Confined space procedure not followed
  • Hot work procedure not followed
  • lockout/Tagout procedure not followed
  • Written procedures not available
  • Incomplete/outdated procedures
  • Other

• Personal Protective Equipment

  Select Failure to use appropriate PPE Appropriate PPE not specified Appropriate PPE not available Employee improperly trained on PPE PPE not used properly

  • Failure to use appropriate PPE
  • Appropriate PPE not specified
  • Appropriate PPE not available
  • Employee improperly trained on PPE
  • PPE not used properly

• Ergonomic Considerations

  Select Static work Direct pressure Duration Position Type of grip Force Vibration Tool design/Weight Repetition Physical characteristics

  • Static work
  • Direct pressure
  • Duration
  • Position
  • Type of grip
  • Force
  • Vibration
  • Tool design/Weight
  • Repetition
  • Physical characteristics

• Was on-site first aid treatment given?

  Yes

  No

• 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.

  Yes

  No

  N/A

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

• Date:

  Date

• Start Time:

  Date

• End Time:

  Date

• 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?

  Select 1642 SOLVENT -04R08UNTA1642- 7.2 LBS-GAL 1042 EA SOLVENT -04R08HYTA1042- 7.5 LBS-GAL 1497 EXT/PAPER - Foil -04R17CR0A1497- 8.06 LBS-GAL 1512 LAC -04R09SNPA1512- 8.4 LBS-GAL 1675 SOLVENT -04R08UNTA1675- 7 LBS-GAL 1899 LAM WHITE -04R17CRQC1899- 1855 GPF EXT -04R17CROC1855- 7.4 LBS-GAL FOIL WHITE -04R17CRQA2047- 1308 SOLVENT -04R08UNTA1308- 6.8 LBS-GAL DB ADH (PB6370) -04R06PSKD1257- 1104 SOLVENT -04R08UNTC1104- 6.7 LBS-GAL

  • 1642 SOLVENT -04R08UNTA1642- 7.2 LBS-GAL
  • 1042 EA SOLVENT -04R08HYTA1042- 7.5 LBS-GAL
  • 1497 EXT/PAPER - Foil -04R17CR0A1497- 8.06 LBS-GAL
  • 1512 LAC -04R09SNPA1512- 8.4 LBS-GAL
  • 1675 SOLVENT -04R08UNTA1675- 7 LBS-GAL
  • 1899 LAM WHITE -04R17CRQC1899-
  • 1855 GPF EXT -04R17CROC1855- 7.4 LBS-GAL
  • FOIL WHITE -04R17CRQA2047-
  • 1308 SOLVENT -04R08UNTA1308- 6.8 LBS-GAL
  • DB ADH (PB6370) -04R06PSKD1257-
  • 1104 SOLVENT -04R08UNTC1104- 6.7 LBS-GAL

• ~ 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:

  Date

• 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:

  Date

• 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:

  Date

• 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

  Select 1642 SOLVENT -04R08UNTA1642- 7.2 LBS-GAL 1042 EA SOLVENT -04R08HYTA1042- 7.5 LBS-GAL 1497 EXT/PAPER - Foil -04R17CR0A1497- 8.06 LBS-GAL 1512 LAC -04R09SNPA1512- 8.4 LBS-GAL 1675 SOLVENT -04R08UNTA1675- 7 LBS-GAL 1899 LAM WHITE -04R17CRQC1899- 1855 GPF EXT -04R17CROC1855- 7.4 LBS-GAL FOIL WHITE -04R17CRQA2047- 1308 SOLVENT -04R08UNTA1308- 6.8 LBS-GAL DB ADH (PB6370) -04R06PSKD1257- 1104 SOLVENT -04R08UNTC1104- 6.7 LBS-GAL

  • 1642 SOLVENT -04R08UNTA1642- 7.2 LBS-GAL
  • 1042 EA SOLVENT -04R08HYTA1042- 7.5 LBS-GAL
  • 1497 EXT/PAPER - Foil -04R17CR0A1497- 8.06 LBS-GAL
  • 1512 LAC -04R09SNPA1512- 8.4 LBS-GAL
  • 1675 SOLVENT -04R08UNTA1675- 7 LBS-GAL
  • 1899 LAM WHITE -04R17CRQC1899-
  • 1855 GPF EXT -04R17CROC1855- 7.4 LBS-GAL
  • FOIL WHITE -04R17CRQA2047-
  • 1308 SOLVENT -04R08UNTA1308- 6.8 LBS-GAL
  • DB ADH (PB6370) -04R06PSKD1257-
  • 1104 SOLVENT -04R08UNTC1104- 6.7 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:

  Date

• Temp:

M40 Multi Gas Monitor

• CO:

• H2S:

• O2:

• LEL:

• Time:

  Date

• Temp

M40 Multi Gas Monitor

• CO:

• H2S:

• O2:

• LEL:

• Time:

  Date

• Temp:

M40 Multi Gas Monitor

• CO:

• H2S:

• O2:

• LEL:

• Time:

  Date

• 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?

  Yes

  No

  N/A

• Comment:

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

  Yes

  No

  N/A

• Comment:

• Additional Comments:

• Date and Time:

  Date

• Witness Statement

  Yes

  No

• Witness name?

• Telephone Number

• Occupation

• Date and time of injury

  Date

• 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?

  Yes

  No

• What could have been done?

• Did anything appear suspicious about the incident?

  Yes

  No

• 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

  Sign

• Preparers Signature

  Sign