Accident Investigation Forms (Revised) - Accident/Incident Prevention Techniques - page 511

AccIdent dAtA, PoWered hAulAge 1 of 2

.(1). Type.of.equipment:.. _______________________________________________________________
.(2). Manufacturer:.______________________________________.Model:.______________________________________
. . Serial.Number:.__________________________________________________.Age:..______________________
.(3). Approval/permissibility.numbers:.____________________________.Agency:..______________________
.(4). Condition.of.equipment:._________.Good. _________.Poor. If.poor,.describe:
. . ________________________________________________________________________________
. . ________________________________________________________________________________
.(5). Last.scheduled.maintenance:.______________________.(Attach.copy.of.maintenance.records,.if.available.)
. . Last.unscheduled.repair:.__________________________.(Attach.copy.of.repair.records,.if.available.)
.(6). Was.maintenance.factor.involved.in.the.accident?. □ .Yes. □ .No
. . If.so,.describe:.. ___________________________________________________________________
.(7). Last.inspection:.__________________.By._________________________________.Title.. _________________
.(8). Modiication.related.to.accident.(from.manufacturer's.coniguration):

□ .Yes. □ .No. Describe.modiication.and.by.whom.done:.. _______________________________
. . ________________________________________________________________________________
.(9). Was.modiication.unique.to.this.operation?. □ .Yes. □ .No
. . Was.modiication.unique.to.this.piece.of.equipment?. □ .Yes. □ .No
(10). Was.equipment.failure.involved.in.the.accident?. □ .Yes. □ .No. If.so,.explain:..______________
. . ________________________________________________________________________________
(11). Primary.power.type:._________.Electric.

_________.Pneumatic. _________.Hydraulic

. . _________.Diesel/gas
(12). Was.equipment.operating.at.design.power?. □ .Yes. □ .No
. . If.over.power/pressure,.note.amount:..__________________________________________________
(13). Was.equipment.operating.within.design.load?. □ .Yes. □ .No. If.not,.how.much.was.it.

overloaded?._________.lb
(14). Was.equipment.provided.with.“emergency.shut-off”.control?. □ .Yes. □ .No

. . Was.it.used?. □ .Yes. □ .No. Did.it.work.properly?. □ .Yes. □ .No

. . If.not,.explain:.. ___________________________________________________________________