Page 558 - Safety Memo

ACCIDENT / INCIDENT REPORT PAGE 1

A. DAMAGED PROPERTY (leave section blank if there was no property damage)

!
"

#"$
% "!

B. INJURED PERSON (leave section blank if there were no injuries)
& !

' ' !!
(
) " % ' ! &

ڧ ڧ ڧ ڧ
&
$ ڧ ڧ ڧ !

" $ % ' '
ڧ * +*
ڧ * +3 ڧ $
ڧ ڧ 3
ڧ ' 6 7
ڧ + ڧ +* ' ڧ 6

&
!!
( !

*
ڧ 3 '
ڧ 6
ڧ 8;
ڧ <
=
C. INCIDENT DESCRIPTION (attach photos if necessary)

D. ROOT CAUSE ANALYSIS (Check All that Apply)
+
!
! +
! ,

!

!
ڧ $

> 7 @ ڧ > 7 ' + ڧ 7
>
Q
'
ڧ *
X ڧ ' > 7 ڧ *

'
ڧ $

' ڧ < = ' ڧ < = ' '
'
ڧ
> ڧ Z
= ' ڧ X
ڧ > ڧ $ ' @ X ڧ $

> 7
ڧ

' ڧ $

ڧ $

X
ڧ [

' X ڧ $

@
ڧ $
ڧ \ ' ' ڧ $

7 > '
% ڧ $ ' @
X
ڧ $

'
ڧ *

' ڧ $ ' @ %
ڧ $

ڧ 7
ڧ $ ' @
ڧ * X ڧ Z X ڧ $ ' @ > 7
ڧ <
ڧ $ ' @ = ' ' ڧ $ ' @ @
ڧ ڧ
X + @
ڧ ]
'
ڧ ] ڧ $

ڧ ] '
ڧ ]

ڧ $ ' @

ڧ
'
ڧ ڧ ڧ

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