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FORM Other
RWC Supervisor General Foreman
Project Nam No.
Estimated Down Time Date Lost Time Began Work Days Lost
M F
Date of Birth
Service Date
General Foreman
Exposure
Other (Explain)
Severity Potential
Rare
ATTACHMENT A
The Causes
1. Unaware of job hazards 8. Influence of emotions 1. Worn out from normal use 11. Faulty construction
2. Inattentive to hazards 9. Influence of fatigue 2. Abuse or misuse by users 12. Inadequate illumination
3. Unaware of safe method 10. Influence of illness 3. Required inspection not done 13. Lubrication failure
4. Low level of job skill 11. Influence of intoxicants 4. Inspection not required 14. Exposure to corrosion
5. Tried to gain or save time 12. Defective vision/hearing 5. Clean-up failure 15. Exposure to vibration
6. Tried to avoid extra effort 13. Unable to determine 6. Clean-up not required 16. Exposure to temp. extrem
7. Acted to avoid discomfort 14. Other (explain) 7. Clean-up not done 17. Tampering
8. Inadequate ventilation 18. Supervisor failed to corre
9. Congestion - lack of space 19. Unable to determine
10. Unsafe design 20. Other (explain)
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:
Conduct training on Refinery Instruction 503 with all employees, Reinforce following procedures and
specifications, Implement plan not to use plate on hydro-test without approval from professional
engineer with specifications, Develop a plan to notify engineering when deviations from ewo's are required,
Communicate to all employees to use all resources such as; engineering, co. rep's, QC, Safety, etc.
Person responsible for Corrective Action Target Date Date Completed
Signatures:
Supervisor _________________________________________________
436608645.xls
ATTACHMENT A
The Causes
Faulty construction
Inadequate illumination
Lubrication failure
Exposure to corrosion
Exposure to vibration
Exposure to temp. extreme
Tampering
Supervisor failed to correct
Unable to determine
Other (explain)
(Check One)
The Correction
Date Completed
Date
436608645.xls