SABRE - Southbridge Accident/Incident Report and Investigation

• Document No.

• Audit Title

• Sabre - Southbridge

• Conducted on

  Date

• Prepared by

• Personnel

Accident/Incident Report and Investigation

To be completed by Area Supervisor or Manager

• Department

  Select Production Maintenance Shipping Receiving Inventory Administrative Pride & Polish EH&S Quality Beam Line Finishing Galvanizer Kettle Pre-Treat Racking Tool Room IT Department

  • Production
  • Maintenance
  • Shipping
  • Receiving
  • Inventory
  • Administrative
  • Pride & Polish
  • EH&S
  • Quality
  • Beam Line
  • Finishing
  • Galvanizer
  • Kettle
  • Pre-Treat
  • Racking
  • Tool Room
  • IT Department

• Supervisor:

  Select Jesus Hernandez Rick Rocha Chris Piazza Tabrina Albertson Todd Jasa Lloyd Myers Mike Libke Leah Neff Jorge Vasquez Ryan Dice Ben Wolverton Jeremy Gunnels Mike Thompson James Hathaway Rick Siders Bob Schmeckpeper Jeff Krafton Paula Peterson Bob Hubbel Brian Newberg Other

  • Jesus Hernandez
  • Rick Rocha
  • Chris Piazza
  • Tabrina Albertson
  • Todd Jasa
  • Lloyd Myers
  • Mike Libke
  • Leah Neff
  • Jorge Vasquez
  • Ryan Dice
  • Ben Wolverton
  • Jeremy Gunnels
  • Mike Thompson
  • James Hathaway
  • Rick Siders
  • Bob Schmeckpeper
  • Jeff Krafton
  • Paula Peterson
  • Bob Hubbel
  • Brian Newberg
  • Other

• Location of Incident:

  Select Bay 1 Bay 1 Arms Bay 2 Bay 3 Bay 6 Bay 6 Arms Bay 4 Bay 5 Bay 7 Bay 8 Peddinghaus Messer Alltra Bay 2 Longseamers Maintenance Blast Bldg. Paint Bldg. Shipping Yard Inventory Yard Parking Lot - general Yard - West of Bldg C

  • Bay 1
  • Bay 1 Arms
  • Bay 2
  • Bay 3
  • Bay 6
  • Bay 6 Arms
  • Bay 4
  • Bay 5
  • Bay 7
  • Bay 8
  • Peddinghaus
  • Messer
  • Alltra
  • Bay 2 Longseamers
  • Maintenance
  • Blast Bldg.
  • Paint Bldg.
  • Shipping Yard
  • Inventory Yard
  • Parking Lot - general
  • Yard - West of Bldg C

• 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:

• Telephone (best way to contact)

• 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

• Enter additional injury description:

• Occupation:

  Select Welder Welder Fitter Material Handeler Quality Control Lead Plate Locator Long Seam Operator Machine Operator Pride and Polish Mechanic Maintenance Technician Supervisor Manager EH&S Specialist Special Projects Inventory Control Administrative Shuttle Lift Operator Shipping Spec. Parts Coordinator Mule Driver Computer Technician

  • Welder
  • Welder Fitter
  • Material Handeler
  • Quality Control
  • Lead
  • Plate Locator
  • Long Seam Operator
  • Machine Operator
  • Pride and Polish
  • Mechanic
  • Maintenance Technician
  • Supervisor
  • Manager
  • EH&S Specialist
  • Special Projects
  • Inventory Control
  • Administrative
  • Shuttle Lift Operator
  • Shipping Spec.
  • Parts Coordinator
  • Mule Driver
  • Computer Technician

• 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

• Enter additional information if needed:

• 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

• Enter additional information if needed:

• Add media

  Media

INCIDENT DESCRIPTION:

• Describe How the Event Occured:

• Was First Aid Provided?

  Select Yes No

  • Yes
  • No

• If yes, by whom?

• Type of treatment?

Witness Statement:

• Name of Witness:

• Describe What the Witness Saw:

• Witness Signature:

  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

• Other if needed:

• 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 if needed:

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

• Other if needed:

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 Acids or Caustics Hazardous Chemicals Moving hoisted load Sharp edges Heavy pinch point / roll-over High noise Hazardous Light

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

SUPERVISOR'S CORRECTIVE ACTIONS:

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

• Signature of Supervisor:

  Sign

• Select date

  Date

• Signature of Employee:

  Sign

• Select date

  Date

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

• Name and signature of Safety Representative

  Sign

• Select date

  Date

• Incident Classification

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

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