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Intelex v5.2.O.O.57.51120 Page 1 of 1 <br /> Main I Tasks I Recent Setup [I IE *Help Logout <br /> INTELEXM 19 ® Location F Maintenance - Facilities - Ripon V <br /> My Dashboard Site Re Module Safety Incident V <br /> Tasks Map <br /> Safety Incident: Safety Incident Report Exit <br /> n <br /> Location Maintenance- Facilities - Ripon <br /> Record No. 07334 <br /> Status Approval <br /> Category Environmental Release <br /> Injury Status Near Miss <br /> Department Facility Maintenance <br /> Employee activity at time of incident Walking - Dn Concrete <br /> Shift Swingshift <br /> Give department specific location Refrigeration area "B" <br /> Date of Incident Saturday, November 21,Time employee began 15:00 <br /> 2020 work: 24 Hour Clock (HH:MM) <br /> Time of Incident 16:00 Effected Employee's 000000 <br /> 24 Hour Clock(HH:MM)Ultipro # <br /> Occupation Salaried <br /> Ultipro# of Witness (If applicable) Gender: Male � Female <br /> Employee's Supervisor McPherson, Mark <br /> Nature of Injury/Illness Respiratory - Fumes or part of Body Injured N/A <br /> Vapor <br /> Source Chemicals Injury Classification N/A <br /> EE was walking around checking line up for bottling when he noticed and <br /> smell of ammonia in the air. EE called facility maintenance supervisor. <br /> Facility maintenance supervisor got ahold of refrigeration tech, and asked <br /> Description (F) them to come in to investigated source of ammonia smell. Refrigeration <br /> tech found the recirculation pump in area "B" was leaking ammonia. EE <br /> locked and tagged out recirculation unit and then pumped down the <br /> recirculation tank. <br /> If treatment was given away from the N/A <br /> worksite, where was it given?: <br /> Was employee Treated in an No <br /> Emergency Room? <br /> What was the employee doing just EE was supervising bottling operations. <br /> before the incident occurred? <br /> I <br /> How did the injury occur? inhalation of ammonia vapor <br /> What object or substance directly Ammonia vapor cause slight irritation to respiratory system. <br /> harmed the employee? <br /> Equipment/Machine/Tools/HazardousAmmonia leak on recirculation pump <br /> Materials <br /> Root Cause failed seal on recirculation pump <br /> Action Taken-Ensure Corrective MTRP, recirculation pump was rebuilt and new seal was installed <br /> Actions are entered below for tracking <br /> i <br /> INVESTIGATED AND PREPARED BY: Jeff Atkinson <br /> (list names of all investigating team) <br /> V <br /> https://clients.intelex.com/thewinegroup/Master—l.asp 12/2/2020 <br />