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fia CBI INCIDENT REPORT CAUSAL ANALYSIS (IF APPLICABLE) Were ACTIONS adequate? Yes LJ No Were CONDITIONS adequate? Yes No If no,reasons actions not adequate If no,reasons not conditions not adequate LJ Following Procedures Protective Systems LJ Individual Guards/safety device utilization ❑ Group ❑ Guards/safety device functionality ❑ Supervision ❑ PPE utilization ❑ Operating equipment w/o authority ❑ PPE functionality ❑ Improper position/posture ❑ Warning systems effectiveness ❑ Overexertion—physical capabilities ❑ Warning systems functionality ❑ Work or motion at improper speed ❑ Isolation(LOTO) ❑ Improper loading ❑ Shortcuts Use of Tools or Equipment Tools,Equipment&Vehicles Use of tools Equipment/tools utilization ❑ Use of equipment ❑ Equipment/tools functionality ❑ Use of defective tools ❑ Equipment/tools preparation ❑ Use of defective equipment ❑ Defective vehicle ❑ Improper placement of tools/equipment ❑ Proper vehicle for purpose ❑ Operating equipment at improper speed ❑ Vehicle preparation ❑ Servicing of equipment in operation El Use of Protective Methods Work Exposure To: Prescribed PPE not used Fire or explosion ❑ PPE used improperly ❑ Noise ❑ Servicing energized equipment ❑ Energized electrical systems ❑ Lack of knowledge of job hazards ❑ Energized systems(non-electrical) ❑ Equipment/materials not secured ❑ Radiation ❑ Disabled guards/warning systems ❑ Temperature extremes ❑ Removed guards/warning devices ❑ Hazardous chemicals/substances ❑ PPE not available ❑ Mechanical hazards ❑ Clutter or debris ❑ Storms of acts of nature ❑ Slippery floors or walkways El Inattention/Lack of Awareness Workplace Environment Horseplay Congestion or restricted motion ❑ Acts of violence ❑ Lighting ❑ Failure to warn ❑ Ventilation ❑ Decisions/judgment ❑ Clearance ❑ Distracted by other concerns ❑ Layout(ergonomics) ❑ Inattention to footings/surroundings ❑ Routine activity(complacency) ❑ Use of drugs or alcohol ❑ Use of prescribed medications