Injury/Illness Report

Department Where Accident Occurred:Maintenance___________________________________

Date of Accident:_____________________________Time:1:30 A.M.___________________

Name of Injured:Fred L.Wilson__________________________________________________

Age:40__ Years of Service10__ Time in this job:10 yrs.______________________________

Job Title:Electrician________________________ Time shift began:11 P.M.______________

Description of incident which resulted in injury or illness: On the above date and time, Mr. Wilson was severely shocked and burned when an electrician helper, Charles Hanks, energized a circuit that Mr. Wilson was in the process of repairing in the Chemical Laboratory.
 

Results of incident (Describe extent of injury or illness, including part of body affected and nature of treatment): Mr. Wison received 2nd degree burns to his right hand and shoulder.  The injuries required hospital treatment and expect lost time of 10 days.
 

Basic Cause (The single factor which if it had not occurred, would have kept this accident from happening): Working on an electrical circuit which had not been properly locked out and tagged.
 

Contributory Causes (Other key factors which contributed to the accident's occurrence, but may not have been direct cause): Improper procedures and poor communications been the employees working on this job.  Mr. Wilson explained he thought the job would only take a minute and didn't feel it was necessary to lockout panel.  Mr. Hanks, who was working with Wilson, thought Wilson had finished the job and forgot to turn on the power.  When he, Hanks, turned on the power he heard a scream and quickly turned off the power again.

Corrective measures taken or recommended: Mr. Wilson and Hanks were reinstructed on proper lockout/tagout procedures.  Both men will receive formal disciplinary action for violation of written lockout/tagout procedures.
 

Additional comments or observations: It should be noted that Mr. Wilson was involved in a similar incident three months earlier.  That accident did not result in an injury, but he was given reinstruction on proper lockout/tagout procedures and was given a verbal warning for violation of a safety procedure.

Investigated by: T. L. Harris____________________________________ Date:____________

Reviewed by:_Larry Jones_____________________________________ Date:____________