incident report sample 2003

7/25/2019 Incident Report Sample 2003

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INCIDENT REPORT SAMPLENorthwestern UniversityVice President for ResearchUniversity Safety CommitteesOffice for Research Safety

The Incident Report Form is located at http://research.northwestern.edu/research/ors/forms/.

Hint: Save this file to your computer, complete your section, email a copy to the next person for theirpart, and when all information has been entered, printed, and signed by the Principal Investigator, return

it to Tech, N!"# $

I. Report by person involved

Name: __Josephine Doe____________ Department: ___Chemistry_________Date repared: Decem!er "#$ "##%__

&ow lon' at this (o!) _* w+s______osition/Title ,e.'.$ -rad tudent$ Technician$ ostdoc0 ___-raduate tudent___

1ocation of Incident: ___Tech -"""_________Date/time of incident: _Decem!er 23$ "##%_ / %:*# am_____

rincipal In4esti'ator/uper4isor: ___Fran+ No!el_________________________

A. Describe how the incident occrred.2. 56plain the operation in which you were in4ol4ed. 7hat were you doin' !efore the incident occurred) 7hat

was your 'oal) 7hat were you doin' at the time the incident occurred) 7hat were the conditions of your wor+)

Is this a routine operation)

I was washin' a 4olumetric flas+. I added a mi6ture of acid ,hydrochloric and nitric0 to the flas+$ aprocedure typical in our la!. I was holdin' the flas+ and swirlin' the acid alon' the inner walls.

". Descri!e the incident in detail. 7hat happened)

8 reaction occurred inside the flas+. I had capped it to pre4ent spilla'e. 8 pressure !uildup !lew the cap

off the flas+ and sprayed acid on my face. In shoc+$ I dropped the flas+ on the !ench and it shattered$

spillin' acid on the surface.

*. Descri!e the se9uence of e4ents that followed the incident. &ow did you respond)

I ran to the eyewash at the sin+ and rinsed my face for appro6. 2 minutes$ holdin' my eyes open with my

hands. I called ; and re9uested emer'ency assistance. aramedics arri4ed a!out 2# minutes after that.


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Incident Report ample ;pdated #3/"##=

C. %"s there "ny property loss or d"("*e$ Ple"se el"bor"te.

The fask was broken. The acid permanently stained the work surace. Acid wassprayed as ar as 20 eet rom the spill site. ORS cleaned the acid contamination.The lab was closed the next mornin ater the spill because no one could work inthe area while ORS decontaminated it.

D. S")ety Rles "nd Procedres.2. 7as the use of personal protecti4e e9uipment ,50 necessary durin' the 'i4en operation) 7as the 5 worn)7hat did it consist of)

! was wearin a lab coat and nitrile lo"es but no eye protection. ! should ha"ebeen wearin saety lasses.

". 7hat type of trainin' did you recei4e prior to en'a'in' in this operation) 7as the trainin' ade9uate) 7hat

did it consist of)

I recei4ed >R 'eneral safety trainin' when I entered the pro'ram my first year. No trainin' since then.8lso$ no trainin' in my la! as to specific procedures. I !elie4e I should ha4e annual refresher trainin'.

*. 8re there any specific safety rules which apply to this procedure) 7ere they followed) 8re they ade9uate)

#o speci$c rules established or cleanin o lassware. There are rules reardin%%&. Saety lasses are re'uired and ! will wear them rom now on.

ther comments.

! was workin alone in the lab. ! won(t do that aain since ! could ha"e used helpin locatin the eyewash.

E. Causal Factors2. 7hat do you percei4e to !e the causal factors !ehind this incident) This could include: inade9uate mana'ement

o4ersi'ht? lac+ of appropriate safety policy? proper e9uipment not used$ re9uired$ or supplied? etc.

)ack o a standardi*ed procedure. An ad"erse reaction between the acid andcontaminants was ne"er addressed in trainin so ! didn(t reali*e it could occur andhow to ade'uately handle the situation.

". 7hat are your recommendations for pre4entin' recurrence)

+etter awareness ,trainin- about the reactions that can occur between chemicals.

II. Other Individ"ls Involved+%itnesses where "pplic"ble

2. Name: __None____________________ osition_____________________ _

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A. Description of Incident Where were you and what were you doing whenthe incident occurred? What did you see?

B. Additional comments or oser!ations.

". Name: __________________________ osition_____________________ _

A. Description of Incident Where were you and what were you doing whenthe incident occurred? What did you see?

B. Additional comments or oser!ations.

III. Report by Princip"l Investi*"tor+Spervisor

A. "ow and when did you learn of the incident?

I recei4ed a phone call from the student the ne6t day.

!. Contribtin*+Miti*"tin* ,"ctors - %h"t do yo perceive to be the c"s"l )"ctors behind this

incident$ This cold inclde in"de'"te ("n"*e(ent oversi*ht l"c/ o) "ppropri"te s")ety policy

i(proper procedre proper e'ip(ent not sed0 re'ired0 or spplied etc.

There was a reaction !etween the acid and an or'anic contaminant in the 'lassware. The flas+ should not ha4e een

capped. The cappin' caused a pressure !uildup to occur in the 4essel. The student did not consider the possi!ility

since we had not discussed 'lassware cleanin' procedures.

C. I((edi"te corrective "ction t"/en.

The use of acids for cleanin' 'lassware will !e closely e4aluated to determine when a less haAardous cleanin' a'ent

can !e used. To limit the potential for reaction$ we will ensure that any 'ross or'anic contamination is remo4ed !y

thorou'h rinsin' and scrapin' !efore use of acid. 8cid will !e restricted to cleanin' of trace contamination. 7hen la!

personnel clean with acids$ re'ular 4entin' will !e performed to pre4ent pressure !uildup. 8lso$ the procedure will !edone in a chemical fume hood$ utiliAin' the horiAontal sash as a physical !arrier a'ainst sprays and splashes.

D. Additional remediation e#orts to pre!ent future recurrence $ande%pected date of implementation&.

7e will schedule an inhouse trainin' class to re4iew the cleanin' procedures and other la! safety policies$ especially

the rules a!out wearin' of 5 and wor+in' alone.

E. Comments

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The student was wor+in' an 22hour day. Fati'ue may ha4e !een a factor. 7or+days will !e limited to 2# hours at the

most.

'rincipal In!estigator()uper!isor )ignature* ++++++++++++++++++++++++++++++++++++

a'e


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An incident reportneeds to include all the essential information about the accident or near-miss. The report-

writing processbegins with fact finding and ends with recommendations for preventing future accidents.

You may use a special incident reporting form, and it might be quite extensive. But writing any incident report

involves four basic steps, and those are the focus of todays post.

1. Find the Facts

To prepare for writing an accident report, you have to gather and record all the facts. !or example"

# $ate, time, and specific location of incident

# %ames, &ob titles, and department of employees involved and immediate supervisor's(

# %ames and accounts of witnesses

# )vents leading up to incident

# )xactly what employee was doing at the moment of the accident

# )nvironmentalconditions 'e.g. slippery floor, inadequate lighting, noise, etc.(

# *ircumstances 'including tas+s, equipment, tools, materials, ), etc.(

# pecificin&uries'including part's( of body in&ured and nature and extent of in&uries(

# Type of treatment for in&uries

# $amage to equipment, materials, etc.

2. Determine the Sequence

Based on the facts, you should be able to determine thesequence of events. n your report, describe this sequence

in detail, including"

# Events leading up to the incident./as the employee wal+ing, running, bending over, squatting, climbing,

lifting operating machinery, pushing a broom, turning a valve, using a tool, handling ha0ardous materials, etc.1

# Events involved in the incident./as the employee struc+ by an ob&ect or caught in2on2between ob&ects1

$id the wor+er fall on the same level or from a height1 $id the employee inhale ha0ardous vapors or get splashed

with a ha0ardous chemical1

# Events immediately following the incident./hat did the employee do" 3rab a +nee1 tart limping1 4old

his2her arm1 *omplain about bac+ pain1 ut a hand over a bleeding wound1 Also describe how other co-wor+ers

responded. $id they call for help, administer first aid, shut down equipment, move the victim, etc.1

The incident should be described on the report in sufficient detail that any reader can clearly picture what

happened. You might consider creating a diagram to show, in a simple and visually effective manner, the

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http://en.wikipedia.org/wiki/Incident_reporthttp://en.wikipedia.org/wiki/Incident_reporthttp://en.wikipedia.org/wiki/Writing_processhttp://en.wikipedia.org/wiki/Environmental_engineeringhttp://en.wikipedia.org/wiki/Personal_protective_equipmenthttp://en.wikipedia.org/wiki/Trauma_(medicine)http://en.wikipedia.org/wiki/Trauma_(medicine)http://en.wikipedia.org/wiki/Timehttp://en.wikipedia.org/wiki/Timehttp://en.wikipedia.org/wiki/Dangerous_goodshttp://en.wikipedia.org/wiki/Incident_reporthttp://en.wikipedia.org/wiki/Writing_processhttp://en.wikipedia.org/wiki/Environmental_engineeringhttp://en.wikipedia.org/wiki/Personal_protective_equipmenthttp://en.wikipedia.org/wiki/Trauma_(medicine)http://en.wikipedia.org/wiki/Timehttp://en.wikipedia.org/wiki/Dangerous_goods


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sequence of events related to the incident and include this in your incident report. You might also wish to include

photos of the accident scene, which may help readers follow the sequence of events.

3. Analye

Your report should include an in-depth analysis of the causes of the accident. *auses include"

# rimary cause 'e.g., a spill on the floor that caused aslip and fall(# econdary causes 'e.g., employee not wearing appropriate wor+ shoes or carrying a stac+ of material that

bloc+ed vision(

# 5ther contributing factors 'e.g., burned out light bulb in the area(.

!. "ecommend

6ecommendations for corrective action might include immediate corrective action as well as long-term corrective

actionssuch as"

# )mployeetraining on safe wor+ practices

# reventive maintenanceactivities that +eep equipment in good operating condition# )valuationof &ob procedures with a recommendation for changes

# *onducting a &ob ha0ard analysis to evaluate the tas+ for any other ha0ards and then train employees on these

ha0ards

# )ngineering changes that ma+e the tas+ safer or administrative changes that might include changing the way

the tas+ is performed

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http://en.wikipedia.org/wiki/Slip_and_fallhttp://en.wikipedia.org/wiki/Slip_and_fallhttp://en.wikipedia.org/wiki/Corrective_actionhttp://en.wikipedia.org/wiki/Corrective_actionhttp://en.wikipedia.org/wiki/Corrective_actionhttp://en.wikipedia.org/wiki/Employmenthttp://en.wikipedia.org/wiki/Preventive_maintenancehttp://en.wikipedia.org/wiki/Preventive_maintenancehttp://en.wikipedia.org/wiki/Evaluation_(workplace)http://en.wikipedia.org/wiki/Slip_and_fallhttp://en.wikipedia.org/wiki/Corrective_actionhttp://en.wikipedia.org/wiki/Corrective_actionhttp://en.wikipedia.org/wiki/Employmenthttp://en.wikipedia.org/wiki/Preventive_maintenancehttp://en.wikipedia.org/wiki/Evaluation_(workplace)

incident report sample 2003

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