ENVIRONMENT, HEALTH, AND SAFETY

RE-3200

Page 1 of 3

TITLE: EHS INCIDENT INVESTIGATION REPORT Accident Near Miss/Close Call

3. Location (bldg./room #, outside, etc.)

Revision No: 01 Effective Date: 01.10.12

Incident
4. Date reported

PARTICULARS OF INCIDENT
1. Date of Incident: 06.08.12 2. Time :

THE PERSON
6. Name & employee number: 9. Work Phone #:

04.PM
7. Affiliation (SAIC, NCI, etc.): 8. Supervisor: 10. FME employee? Yes No

11 . Injury type if any (cut, burn, chemical exposure, slip/trip/fall, etc.):

DAMAGED PROPERTY
12 . Property/ material damaged: 14 . Object/substance inflicting damage: 13. Nature of damage:

THE INCIDENT
15 . Description Describe what happened (draw the scene on an additional sheet if necessary, question any witnesses, describe tools used, equipment, chemicals & concentrations, take photos, list what was done post incident, i.e. first aid, clean up etc.)

16 . Was potentially infectious material or recombinant DNA involved? If yes, please describe: 17 . PPE worn or not worn; was it compromised (e.g. gloves torn): 18 . First Aid measures taken: 19. HOW BAD COULD IT HAVE BEEN? Very serious Serious Minor Analysis 21 . What could have prevented this accident (narrative):

Yes

No

20. Chance of similar events happening? Occasionall Frequently y

Rarely

What were the Immediate causes of the accident (see next page of form for categories)?

What are the basic causes that led to the immediate causes above (i.e. the root cause) (see page 2)?

ENVIRONMENT, HEALTH, AND SAFETY

RESPONSE RECORD NUMBER 11-

Page 2 of 3

TITLE: EHS INCIDENT INVESTIGATION REPORT

Revision No: 02 Effective Date: 10/09

22. Corrective Actions What action has or will be taken to prevent a recurrence? By whom Follow-up date Completed date

23. Is there an SOP, safetygram, standard, or regulation applicable?

Yes

No

If yes reference:

If additional space is needed please attach a separate sheet. 1. Operating equipment without authority 2. Failure to warn CHECK ALL APPLICABLE EVENTS : 1. Struck against 2. Struck by Object (physical) 3. Fall from elevation Heat 4. Fall on same level Cold 5. Caught in Radiation 6. Caught on Caustics/acid 7. Caught between Toxic/Noxious substances 9. Abnormal operation Biological agents 10. Animal Bite Noise CH EC KL IST AN D 8. CONTACT WITH Electricity EV EN T 5. Making safety devices inoperative 6. Using defective equipment 7. Failure to use personal protective equipment (PPE) properly 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 11. Overstress, overpressure, overexertion, ergonomic stress 12. Equipment failure 13. slip (not fall) CHECK ALL APPLICABLE IMMEDIATE/DIRECT CAUSES: CA US E Improper loading Improper placement Improper lifting Taking a risky position Servicing equipment in operation Horseplay Using equipment improperly Failure to follow procedure Failure to identify hazard/risk Failure to pay attention Inexperience / lack of training Rushing / hurried job 3. Failure to secure 4. Operating at improper speed

24. Incident investigated by (supervisor):

SUBSTANDARD BEHAVIORS

42. SUBSTANDARD CONDITIONS 21. Inadequate guards or barriers 22. Inadequate or improper protective equipment 23. Defective tools, equipment, or materials 24. Congestion or restricted action 25. Inadequate warning system 26. Fire and explosion hazards 27. Poor housekeeping/disorder 28. Noise exposure 29. Radiation exposure 30. Temperature extremes 31. Inadequate or excessive illumination 32. Inadequate ventilation 33. Presence of harmful materials 34. Inadequate instructions/procedures 35. Inadequate information/data 36. Inadequate preparation/planning 37. Inadequate support/assistance 38. Inadequate communications process 39. Road conditions 40. Weather conditions 41. Mind off task EHS Investigator Review: .

Other- Describe:

CHECK ALL APPLICABLE ROOT/BASIC CAUSES: PERSONAL FACTORS 1. Inadequate physical capability 2. Inad. Mental/psych. Capability 3. Physical/ physiological stress 4. Mental/ 5. 6. 7. 8. psychological stress Lack of knowledge Lack of training/skill Improper motivation Abuse or misuse JOB FACTORS Inad.Leader/supervisio 9. n Inadequate 10. engineering Inadequate 11. purchasing 12. Inad. maintenance 13. Inad. tools/equipment 14. Inad. work standard 15. Excessive wear/tear Inad. 16. Communications 17. Inadequate controls 18. Poor housekeeping 19. Other-Describe:

26. Date:

DATE :