Accident Investigation Forms (Revised) - Accident/Incident Prevention Techniques - page 513

AccIdent dAtA, hoIstIng 1 of 2

.(1). Type.of.hoist:..____________________________________________________________________
.(2). Manufacturer:.___________________________.Model:._____________________________.Age:.. ___________
.(3). Last.inspected:.__________________________.By:.. __________________________________________
.(4). Rated.capacity:._________.lb. Size.of.rope:._________.strands.×._________.wires
. . Diameter.of.rope:._________.in.. Date.rope.placed.in.service:.. ______________________________
.(5). Angle.of.lift:.._____________________________________________________________________
.(6). Type.of.emergency.braking:.._________________________________________________________
.(7). Was.hoist.overloaded?. □ .Yes. □ .No. If.so,.by.how.much._________.lb
.(8). Were.all.guards.in.place?. □ .Yes. □ .No. If.not,.describe.unguarded.areas:.._________________
. . ________________________________________________________________________________
.(9). Was.a.maintenance.problem.involved?. □ .Yes. □ .No. If.so,.describe:.._____________________
. . ________________________________________________________________________________
(10). Was.there.a.mechanical/physical.failure?. □ .Yes. □ .No. If.so,.collect.sample.of.failed.parts.
for analysis..If.rope.failure.involved,.test.must.be.completed.for.strength..Check._________.when.
completed.
(11). Did.the.design.of.the.hoist.contribute.to.the.accident?. □ .Yes. □ .No.
. . If.so,.explain:..____________________________________________________________________
. . ________________________________________________________________________________
(12). Was.there.a.trained.hoist.person.on.duty?. □ .Yes. □ .No

. . Name:.______________________________________.Date.of.last.training.. __________________________

. . Last.physical.exam:.. _______________________.Was.he.operating.the.hoist.at.the.time.of.the.accident?.

□ .Yes. □ .No
. . If.not,.identify.the.person.operating.hoist:.______________________________________________
. . ________________________________________________________________________________
. . Experience.of.person.operating.hoist:.._________________________________________________
(13). Was.the.hoist.person.alone?. □ .Yes. □ .No. If.not,.identify.person(s).with.operator:..
. . ________________________________________________________________________________
(14). Were.communications.being.maintained.at.time.of.accident?. □ .Yes. □ .No. If.not,.explain:.

. . ________________________________________________________________________________