PMD Cracker Project: Accident / Incident Investigation Form Form
PMD Cracker Project: Accident / Incident Investigation Form Form
PMD Cracker Project: Accident / Incident Investigation Form Form
Name
Near Miss
First Aid
PMD Cracker Doctor Case Social Security Number Sex M F
Estimated Down Time Date Lost Time Began Work Days Lost
579615181.xls
The Causes
Direct Personnel Causes Direct Environmental Causes
What did a person-the victim or someone else-do, or fail to do, that What defective or otherwise unsafe condition(s) of tools, machinery,
contributed directly to this accident? Be specific, for example: equipment, product, working surface, structures, or work area
"Operated machinery without authority", "Used pipe wrench for contributed directly to this accident? Be specific, for example:
a hammer; Brushed fillings away with finger rather than a brush." "Hand - railing missing". "Badly worn brake linings", "Cracked
fork on lift truck."
The Correction
Corrective Action Taken
Check those actions taken to prevent recurrence. Fill in the appropriate box for corrective actions decided upon or planned by not yet
initiated or completed.
1. Reinstructed of those involved 8. Action to improve clean-up 15. Correction of necessary congestion
2. Reprimand of those involved 9. STA done 16. Improved personal protective equipment
3. Discipline of those involved 10. Revision of STA 17. Order regular pre-job instructions
4. Reinstruction of others doing the job 11. Equipment repair or replacement 18. Order use of safer materials
5. Temporary reassignment of person 12. Action to improve design 19. Check with manufacturer
6. Permanent reassignment of person 13. Action to improve construction 20. Inform all departmental supervision
7. Action to improve inspection 14. Installation of guard or safety device 21. Other than above
In all disabling and medical treatment injuries, describe details of your corrective action:
Signatures: