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Accident Analysis The Supervisor of the injured shall investigate the accident at once and complete all items below. 1. Accident Cause A. Check one or more causes that contributed to accident. ( I a Design of Plant Facilities, or Equipment I I j Incorrect or Lack of Personal Protective Equipment I l b Job Planning or Instruction Inadequate 1 1 k Inadequate Training I I c Rules or Procedures Not Followed or Inadequate ( ) I Chemical Exposure, Personal Hygiene I I d Incorrect Body Position in Relation to Work I I m Improper Vehicle Operation I a e Incorrect Tools or Mechanical Aids Used I I n Environmental Factors, Weather ( I f Guarding or Protective Devices Not Provided or Ineffective I I o Animal, Reptile or Insect I 1 g Plant Equipment Operated Incorrectly ( I p Inattentive to Details of Job 1 1 It Housekeeping Congested, Incorrect Storage I I q Action of Fellow Employee I ) i Maintenance, Inspection Not Adequate I I r Other B. Indicate Primary Accident Cause (enter appropriate letter) And Explain Reason Selected. II. Corrective Action A. Check one or more actions that will prevent a recurrence. — I I a Provide More Complete Job Instruction I I g Reinforce Employee Training I I b Review Job Planning, Regulate Job Pace I I h Provide Personal Protective Equipment ( I c Update or Revise Procedures I I i Modify Plant or Equipment I ) d Enforce Work Rules, Revise Standards I I j Contact Third Party to Effect Correction I l e Provide Safe Equipment I l k Other I I f Provide Proper Tools, Equipment B. Indicate Primary Corrective Action (enter appropriate letter) And Explain Reason Selected. III. Follow-Up Action A. What Fallow-Up is Required? B. Completion Date for Corrective Action Responsibility of IV. Reviewed by Prepared by Date (Second Level Supervisor) Supervisor Name Monty Day Year Supervisor Social Security No. 60 42 .1w Rmetln 5-USA