LLF Incident Analysis Report

• Case Number

• DEPT/Location
  Address

• Personnel

• Conducted on

  Date

• Prepared by

• This form is to be completed by the Manager and employees involved in an incident. An incident is defined as any unplanned event that contributes to or could have contributed to a Near miss, injury or property damage. The form should be submitted to the EHS manager within 24 hrs from the day of the incident.

• Identify parties involved with the incident.

  Select Employee - hourly Employee - Salary Visitor Contractor General Public N/A Unknown

  • Employee - hourly
  • Employee - Salary
  • Visitor
  • Contractor
  • General Public
  • N/A
  • Unknown

Date, Time and Location of Incident

• DATE & TIME OF INCIDENT

  Date

• Department

  Select Bin Complex Building and Grounds Corn Mill Elevator Extruder Main Office Maintenance Masa Packaging Sanitation Securitty Shipping

  • Bin Complex
  • Building and Grounds
  • Corn Mill
  • Elevator
  • Extruder
  • Main Office
  • Maintenance
  • Masa
  • Packaging
  • Sanitation
  • Securitty
  • Shipping
• SPECIFIC LOCATION OF INCIDENT
  Address

CONTACTS

• Manager

• Phone Number

• Was there more than one employee involved?

  YES

  NO

• List all Employees involved and their demographic information

Employee(s) involved

• Employee's Name

• Employee's Occupation

  Select Operator Sanitation Tech Sanitation Maintenance Lead Maintenance Ship/Receiving Operator Manager/Supervisor Office/Admin Security

  • Operator
  • Sanitation Tech
  • Sanitation
  • Maintenance Lead
  • Maintenance
  • Ship/Receiving Operator
  • Manager/Supervisor
  • Office/Admin
  • Security
• Employee's address, city, state, zip
  Address

• Employee's Phone

• Male/Female

  Male

  Female

• Date of hire

  Date

• Serious Incidents include: Head Injuries (loss of consciousness), Heart Attacks, Amputations, Fractures in two or more bones, Serious Burns (3rd degree), Hospitalizations,
  
  Significant Property Damage is considered when damages are anticipated to exceed $100,000.

Classification

• Severity of Incident

  Select Serious - OSHA report within 8 hrs Lost Time Restricted Duty Medical Treatment Medical Treatment - not recordable First Aid (Report only) Near Miss Significant Property Damage Minor Property Damage

  • Serious - OSHA report within 8 hrs
  • Lost Time
  • Restricted Duty
  • Medical Treatment
  • Medical Treatment - not recordable
  • First Aid (Report only)
  • Near Miss
  • Significant Property Damage
  • Minor Property Damage

• Estimated days of restricted duty (if known)

• Date of next medical appointment

  Date

• Describe seriousness of incident. If the incident is an OSHA reportable case, the incident details must be called into the OSHA 800 line.

• Date and Time OSHA notified

  Date

• Date and Time Broker notified (for Significant Property Damage).

  Date

• List medical treatment received and future medical care (if known)

• Drug/Alcohol screen completed

Incident Description

• Date and Time incident was reported

  Date

• Reported to:

• Type of Incident

  Select Sprain/Strain Contusion/Bruise Burn - minor (First/Second) Cut/Laceration Foreign Body Cumulative Chemical Exposure Fracture - minor Amputation Burns - Major (Second/Third) Fracture - major No Injury

  • Sprain/Strain
  • Contusion/Bruise
  • Burn - minor (First/Second)
  • Cut/Laceration
  • Foreign Body
  • Cumulative
  • Chemical Exposure
  • Fracture - minor
  • Amputation
  • Burns - Major (Second/Third)
  • Fracture - major
  • No Injury

• Nature of Incident

  Select Slip/Fall Struck by/Against Overexertion Electrical Caught Between Temperature Repetitive Motion Inhalation Ingestion Absorption Unknown Other Property Damage

  • Slip/Fall
  • Struck by/Against
  • Overexertion
  • Electrical
  • Caught Between
  • Temperature
  • Repetitive Motion
  • Inhalation
  • Ingestion
  • Absorption
  • Unknown
  • Other
  • Property Damage

• Initial incident reported to Senior Management:

  Date

Employee(s) Statement

• Were two or more employees involved?

  Yes

  No

  N/A

• Summarize or attach employee(s) statements

Employee statements

• Type or hand write Employee's statement. Please describe what activities were performed when the incident occurred.

• Employee's signature

  Sign

• Date and time of statement

  Date

• Type or hand write Employee's statement. Please describe what activities were performed when the incident occurred.

Brief Description

• Summary of Incident

SEQUENCE OF EVENTS

• What was (were) employee(s) doing at the time of the incident?

• SEQUENCE OF EVENTS

• Add diagrams/drawings and measurements to support analysis

  Drawing

• Supporting photographs

  Media

INDICATION OF INJURIES

• WERE EMPLOYEE(s) INJURED?

  YES

  NO

• SELECT BODY PART(s).

  Select Head Face Neck Mid back Lumber region Eyes Chest/ribs Adbomen Shoulder Upper Arm Elbow Forearm Wrist Hand Finger(s) Hip Thigh Knee Calf Ankle Foot Toe(s)

  • Head
  • Face
  • Neck
  • Mid back
  • Lumber region
  • Eyes
  • Chest/ribs
  • Adbomen
  • Shoulder
  • Upper Arm
  • Elbow
  • Forearm
  • Wrist
  • Hand
  • Finger(s)
  • Hip
  • Thigh
  • Knee
  • Calf
  • Ankle
  • Foot
  • Toe(s)

• SIDE

  Select Left Righ Center

  • Left
  • Righ
  • Center

• DETAILS OF INJURY?

• If Medical Treatment received, who provided the care?

• Date/Time of medical treatment

  Date

• PHOTOGRAPHS OF INJURY

  Media

INDICATION OF DAMAGE TO PROPERTY

• WAS THERE ANY DAMAGE TO PROPERTY?

  YES

  NO

• RECORD DETAILS AND EXTENT OF DAMAGE

• PHOTOGRAPHS OF DAMAGE

  Media

• List estimated costs of property damages.

WITNESSES

• WERE THERE ANY WITNESSES?

  Yes

  No

  N/A

• Name of witness

• Position

• Did the witness directly observe the incident?

  Yes

  No

  N/A

• Summary of Witnesses Statement

OBSERVATIONS/CONTRIBUTING FACTORS

• CONTRIBUTING FACTORS

  Select Inadequate guarding Exposure to electricity Equipment Failure Inadequate lighting Exposure to chemicals/hazardous substances Exposure to sound/noise Congested Work areas/poor housekeeping Fire/Explosion Temperature extreme (hot/cold) Inadequate/lack of training Use of incorrect tools/equipment Incorrect manual handling equipment Lack of PPE Inspection not performed Line of fire/Work positioning Safety Rule Infraction Lack of Permit (Confined Space, Hot work) Inadequate/lack of work procedures Lack of supervision No Risk Assessments No safety equipment Recurring/repeat Incident Work Schedule Other

  • Inadequate guarding
  • Exposure to electricity
  • Equipment Failure
  • Inadequate lighting
  • Exposure to chemicals/hazardous substances
  • Exposure to sound/noise
  • Congested Work areas/poor housekeeping
  • Fire/Explosion
  • Temperature extreme (hot/cold)
  • Inadequate/lack of training
  • Use of incorrect tools/equipment
  • Incorrect manual handling equipment
  • Lack of PPE
  • Inspection not performed
  • Line of fire/Work positioning
  • Safety Rule Infraction
  • Lack of Permit (Confined Space, Hot work)
  • Inadequate/lack of work procedures
  • Lack of supervision
  • No Risk Assessments
  • No safety equipment
  • Recurring/repeat Incident
  • Work Schedule
  • Other

• Additional supporting factors

• List tools, equipment, materials or chemicals used at the time of the incident.

RECOMMENDATIONS (include any corrective, preventive actions)

• Corrective Action Categories

  Select Work Order required Install interlock or guard Develop Preventive Maintenance Request engineering/consulting Improve Master Cleaning Schedule Improve lighting PPE assessment Improve Material Handling/Ergonomics Disciplinary Actions Training Job Safety Assessment Write/review/improve SOP

  • Work Order required
  • Install interlock or guard
  • Develop Preventive Maintenance
  • Request engineering/consulting
  • Improve Master Cleaning Schedule
  • Improve lighting
  • PPE assessment
  • Improve Material Handling/Ergonomics
  • Disciplinary Actions
  • Training
  • Job Safety Assessment
  • Write/review/improve SOP

• List each corrective action plan associated with each corrective action category.

Corrective Action Plans

• Corrective Action

• Person(s) assigned to CAP

• Additional people/resources involved to complete CAP

• Describe Corrective Action Plans (CAP)

• Anticipated Date to complete

  Date

• Estimated direct costs to complete

• Add photo

  Media

REPORT COMPLETED BY

• ANALYSIS COMPLETED BY:

  Sign

• DATE OF REPORT

  Date

• OPERATIONS REVIEW

  Sign

• DATE OF REVIEW

  Date

• CEO REVIEW

  Sign

• DATE OF CEO REVIEW

  Date