Accident Investigation Forms (Revised) - Accident/Incident Prevention Techniques - page 515

AccIdent dAtA, mAchInery 1 of 2

.(1). Type.of.machinery:.. _______________________________________________________________
.(2). Manufacturer:.______________________________________.Model:.______________________________________
. . Serial.Number:.__________________________________________________.Age:..______________________
.(3). Power.source:. Electric._________. Propane._________. Diesel._________. Gasoline._________

. . Air._________. Hydraulic._________. Other._________. Motor.Driven.H.P.._________

. . Component.driven.H.P.._________
.(4). Approval/Permissibility:.Number:._____________________________.Agency:.._____________________
.(5). Modiied.(from.manufacturer's.coniguration)?. □ .Yes. □ .No
. . If.so,.describe:.. ___________________________________________________________________
. . ________________________________________________________________________________
.(6). Was.modiication.unique.to.mine?. □ .Yes. □ .No
. . Was.modiication.unique.to.this.place.of.equipment?. □ .Yes. □ .No
.(7). Were.all.guards.in.place?. □ .Yes. □ .No. If.not,.explain:.. _______________________________
. . ________________________________________________________________________________
. . ________________________________________________________________________________
.(8). Note.condition.and.estimate.the.readability.of.gauges.related.directly.in.the.accident.sequence:..
. . ________________________________________________________________________________
.(9). Last.inspection.date:.________________________.By:.. _______________________________________
. . Title:._________.Report:.._____________________________________________________________
(10). Was.a.material.failure.involved.in.the.accident?. □ .Yes. □ .No
. . If.so,.describe:.. ___________________________________________________________________
(11). Was.maintenance.involved.in.the.failure?. □ .Yes. □ .No. If.so,.how?
. . ________________________________________________________________________________
. . ________________________________________________________________________________
. . Attach.maintenance.records.if.available.
(12). Are.operation.instructions/warnings.related.to.accident.visible.on.the.machine. □ .Yes. □ .No
. . Describe:.. _______________________________________________________________________
. . ________________________________________________________________________________
(13). Determine.if.equipment.was.operated.in.an.overpowered.manner.(too.high.air.pressure,.etc.)
. . □ .Yes. □ .No

. . How.much?.. _____________________________________________________________________