Attachment 0015 TE 1.2-04 -- USACE Accident Investigation Report.pdf

a. ACTIVITY AT TIME OF ACCIDENT

a. SEVERITY OF ILLNESS/INJURY

b. TYPE OF CONSTRUCTION EQUIPMENT

g. HAZARDOUS/TOXIC WASTE

ACTIVITY

b. TIME OF ACCIDENT (Military Time)

GOVERNMENT

ENG FORM 3394, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 1 of 13 Pages

REPORT NO.

1. ACCIDENT CLASSIFICATION

UNITED STATES ARMY CORPS OF ENGINEERS

ACCIDENT INVESTIGATION REPORT

For use of this form, see Help Menu and USACE Supplement to AR 385-40 The proponent agency is CESO

CIVILIAN

REQUIREMENT

CONTROL SYMBOL:

CEEC-S-8 (R2)

(For safety staff only)

EROC CODE

PERSONNEL CLASSIFICATION INJURY/ILLNESS/FATAL PROPERTY DAMAGE MOTOR VEHICLE INVOLVED DIVING

MILITARY

CONTRACTOR

PUBLIC FATAL OTHER

FIRE INVOLVED OTHER

OTHERFIRE INVOLVED

2. PERSONAL DATA

a. NAME (Last, First MI.) b. AGE c. SEX

MALE FEMALE

d. SOCIAL SECURITY NUMBER e. GRADE

f. JOB SERIES/TITLE g. DUTY STATUS AT TIME OF ACCIDENT

ON DUTY TDY

OFF DUTY

h. EMPLOYMENT STATUS AT TIME OF ACCIDENT

ARMY ACTIVE

PERMANENT

TEMPORARY

OTHER (Specify)

ARMY RESERVE

FOREIGN NATIONAL

STUDENT

VOLUNTEER

SEASONAL

3. GENERAL INFORMATION

a. DATE OF ACCIDENT

(YYYYMMDD)

hrs.

c. EXACT LOCATION OF ACCIDENT

e. CONTRACT NUMBER

CIVIL WORKS MILITARY

OTHER (Specify)

f. TYPE OF CONTRACT

CONSTRUCTION

A/E

SERVICE

DREDGE

OTHER (Specify)

DERP

OTHER (Specify)IRP

SUPERFUND

d. CONTRACTOR'S NAME

(1) PRIME

(2) SUBCONTRACTOR

4. CONSTRUCTION ACTIVITIES ONLY (Fill in line and corresponding code number in box from list - see help menu)

b. ESTIMATED

DAYS LOST

a. CONSTRUCTION ACTIVITY (CODE)

(CODE)

5. INJURY/ILLNESS INFORMATION (Include name on line and corresponding code number in box for items e, f & g - see help menu)

(CODE)

c. ESTIMATED DAYS

HOSPITALIZED

d. ESTIMATED DAYS

RESTRICTED DUTY

e. BODY PART AFFECTED

PRIMARY

SECONDARY

(CODE)

(CODE)

f. NATURE OF ILLNESS / INJURY (CODE)

g. TYPE AND SOURCE OF INJURY/ILLNESS

TYPE

SOURCE

(CODE)

(CODE)

6. PUBLIC FATALITY (Fill in line and correspondence code number in box - see help menu)

(CODE) b. PERSONAL FLOTATION DEVICE USED?

YES NO N/A

Print Form E-mailTE-1.2 - 03 USACE Accident Investigation Report

a. ACTIVITY AT TIME OF ACCIDENTa. ACTIVITY AT TIME OF ACCIDENT

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 2 of 13

7. MOTOR VEHICLE ACCIDENT

a. TYPE OF VEHICLE b. TYPE OF COLLISION c. SEAT BELTS USED NOT USED NOT APPLICABLE

(1) FRONT SEAT

(2) REAR SEAT

SIDE SWIPE

BROADSIDE

HEAD ON

ROLL OVER

REAR END

BACKING

OTHER (Specify)

PICKUP/VAN

TRUCK

AUTOMOBILE

OTHER (Specify)

8. PROPERTY MATERIAL INVOLVED

a. NAME OF ITEM b. OWNERSHIP c. AMOUNT OF DAMAGE

(1)

(2)

(3)

9. VESSEL/FLOATING PLANT ACCIDENT (Fill in line and correspondence code number in box from list - see help menu)

(CODE)

(CODE)

10. ACCIDENT DESCRIPTION (Use additional paper, if necessary, see attached page 4.)

11. CAUSAL FACTOR(s) (Read instructions before completing)

a. (Explain YES answers in item 13) YES NO

DESIGN: Was design of facility, workplace or equipment a factor?

INSPECTION/MAINTENANCE: Were inspection & maintenance procedures a factor?

PERSON'S PHYSICAL CONDITION: In your opinion, was the physical condition of the person a factor?

OPERATING PROCEDURES: Were operating procedures a factor?

JOB PRACTICES: Were any job safety/health practices not followed when the accident occurred?

HUMAN FACTORS: Did any human factors such as, size or strength of person, etc., contribute to accident?

ENVIRONMENTAL FACTORS: Did heat, cold, dust, sun, glare, etc., contribute to the accident?

CHEMICAL AND PHYSICAL AGENT FACTORS: Did exposure to chemical agents, such as dust, fumes, mists, vapors or physical agents, such as, noise, radiation, etc., contribute to accident?

OFFICE FACTORS: Did office setting such as, lifting office furniture, carrying, stooping, etc., contribute to the accident?

SUPPORT FACTORS: Were inappropriate tools/resources provided to properly perform the activity/task?

PERSONAL PROTECTIVE EQUIPMENT: Did the improper selection, use or maintenance of personal protective equipment contribute to the accident?

DRUGS/ALCOHOL: In your opinion, was drugs or alcohol a factor to the accident?

b. WAS A WRITTEN JOB/ACTIVITY HAZARD ANALYSIS COMPLETED FOR TASK BEING PERFORMED AT TIME OF ACCIDENT? (If yes, attach a copy.)

12. TRAINING

a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK?

YES NO

b. TYPE OF TRAINING

CLASSROOM ON JOB

c. DATE OF MOST RECENT FORMAL

TRAINING (YYYYMMDD)

13. FULLY EXPLAIN WHAT ALLOWED OR CAUSED THE ACCIDENT; INCLUDE DIRECT AND INDIRECT CAUSES (See instruction for definition of direct and indirect causes.) (Use additional paper, if necessary)

a. DIRECT CAUSE(s) (Attach additional sheets as needed, See page 4)

b. INDIRECT CAUSE(s) (Attach additional sheets as needed, See page 5)

TE-1.2 - 03 USACE Accident Investigation Report

CONCUR

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 3 of 13 Pages

14. ACTION(s) TAKEN, ANTICIPATED OR RECOMMENDED TO ELIMINATE CAUSE(s)

DESCRIBE FULLY (Attach additional sheets as necessary, See page 5)

15. DATES FOR ACTIONS IDENTIFIED IN BLOCK 14.

a. BEGINNING (YYYYMMDD) b. ANTICIPATED COMPLETION (YYYYMMDD)

16. MANAGEMENT REVIEW (1st)

c. DATE SIGNED

(YYYYMMDD)

e. CORPS SIGNATURE, SUPERVISOR COMPLETING REPORT

e. CONTRACTOR SIGNATURE, SUPERVISOR COMPLETING REPORTc. DATE SIGNED

(YYYYMMDD)

d. TITLE OF SUPERVISOR COMPLETING REPORT

d. TITLE OF SUPERVISOR COMPLETING REPORT

f. ORGANIZATION IDENTIFIER (Division, Branch, Section, etc.,) g. OFFICE SYMBOL

a. b. c. COMMENTSNONCONCUR

TITLEDATE (YYYYMMDD) SIGNATURE

CONCUR

17. MANAGEMENT REVIEW (2nd - Chief Operations, Construction, Engineering, etc.,)

a. b. c. COMMENTSNONCONCUR

TITLEDATE (YYYYMMDD) SIGNATURE

CONCUR

18. SAFETY AND OCCUPATIONAL HEALTH OFFICE REVIEW

a. b. c. ADDITIONAL ACTIONS/COMMENTSNONCONCUR

TITLEDATE (YYYYMMDD) SIGNATURE

19. COMMAND APPROVAL

COMMENTS

DATE (YYYYMMDD) COMMANDER SIGNATURE

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 4 of 13 Pages

10. ACCIDENT DESCRIPTION (Continuation)

13a. DIRECT CAUSE(s) (Continuation)

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 5 of 13 Pages

13b. INDIRECT CAUSE(s) (Continuation)

14. ACTION(s) TAKEN, ANTICIPATED, OR RECOMMENDED TO ELIMINATE CAUSE(s) (Continuation)

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 6 of 13 Pages

GENERAL. Complete a separate report for each person who was injured, caused, or contributed to the accident (excluding uninjured personnel and witnesses).

Use of this form for reporting USACE employee first-aid type injuries not submitted to the Office of Workers' Compensation Programs (OWCP) shall be at the discretion of the FOA commander. Please type or print legibly. Appropriate items shall be marked with an "X" in box(es). If additional space is needed, provide the information on a separate sheet and attach to the completed form. Ensure that these instructions are forwarded with the completed report to the designated management reviewers indicated in sections 16 and 17.

INSTRUCTIONS FOR SECTION 1 - ACCIDENT CLASSIFICATION

(Mark All Boxes That Are Applicable)

a. GOVERNMENT. Mark "CIVILIAN" box if accident involved government civilian employee; mark "MILITARY" box if accident involved U.S. military personnel.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in any government civilian employee injury, illness, or fatality that requires the submission of OWCP Forms CA-1 (injury), CA-2 (illness) or CA-6 (fatality) to OWCP; mark if accident resulted in military personnel lost-time or fatal injury or illness.

(2) PROPERTY DAMAGE - Mark the appropriate box if accident resulted in any damage of $1000 or more to government property (including motor vehicles).

(3) VEHICLE INVOLVED - Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are marked.

(4) DIVING ACTIVITY - Mark if the accident involved an in-house USACE diving activity.

b. CONTRACTOR.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in any contractor lost-time injury/illness or fatality.

(2) PROPERTY DAMAGE - Mark the appropriate box if accident resulted in any damage of $1000 or more to contractor property (including motor vehicles).

(3) VEHICLE INVOLVED - Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are marked.

(4) DIVING ACTIVITY - Mark if the accident involved a USACE Contractor diving activity.

c. PUBLIC.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in public fatality or permanent total disability. (The "OTHER" box will be marked when requested by the FOA to report an unusual non-fatal public accident that could result in claims against the government or as otherwise directed by the FOA Commander).

(2) VOID SPACE - Make no entry.

(3) VEHICLE INVOLVED - Mark if accident resulted in a fatality to a member of the public and involved a motor vehicle, regardless of whether "INJURY/lLLNESS/ FATALlTY" is marked.

(4) VOID SPACE - Make no entry.

INSTRUCTIONS FOR SECTION 2 - PERSONAL DATA

a. NAME - (MANDATORY FOR GOVERNMENT ACCIDENTS. OPTIONAL AT THE DISCRETION OF THE FOA COMMANDER FOR CONTRACTOR AND PUBLIC ACCIDENTS). Enter last name, first name, middle initial of person involved.

b. AGE - Enter age.

c. SEX - Mark appropriate box.

d. SOCIAL SECURITY NUMBER - (FOR GOVERNMENT PERSONNEL ONLY) Enter the social security number (or other personal identification number if no social security number issued).

e. GRADE - (FOR GOVERNMENT PERSONNEL ONLY) Enter pay grade. Example: 0-6; E-7; WG-8; WS-12; GS-11; etc.

f. JOB SERIES/TlTLE - For government civilian employees enter the pay plan, full series number, and job title, e.g., GS-O810/Civil Engineer. For military personnel enter the primary military occupational specialty (PMOS), e.g., 15A30 or 11G50. For contractor employees enter the job title assigned to the injured person, e.g., carpenter, laborer, surveyor, etc.

g. DUTY STATUS - Mark the appropriate box.

(1) ON DUTY - Person was at duty station during duty hours or person was away from duty station during duty hours but on official business at time of the accident.

(2) TDY - Person was on official business, away from the duty station and with travel orders at time of accident. Line-of-duty investigation required.

(3) OFF DUTY - Person was not on official business at time of accident.

h. EMPLOYMENT STATUS - (FOR GOVERNMENT PERSONNEL ONLY) Mark the most appropriate box. If "OTHER" is marked, specify the employment status of the person.

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 7 of 13 Pages

INSTRUCTION FOR SECTION 3 - GENERAL INFORMATION

a. DATE OF ACCIDENT - Enter the month, day, and year of accident.

b. TIME OF ACCIDENT - Enter the local time of accident in military time. Example: 1430 hrs (not 2:30 p.m.).

c. EXACT LOCATION OF ACCIDENT - Enter facts needed to locate the accident scene, (installation/project name, building number, street, direction and distance from closest landmark, etc.).

d. CONTRACTOR NAME

(1) PRIME - Enter the exact name (title of firm) of the prime contractor.

(2) SUBCONTRACTOR - Enter the name of any subcontractor involved in the accident.

e. CONTRACT NUMBER - Mark the appropriate box to identify if contract is civil works, military, or other: if "OTHER" is marked, specify contract appropriation on line provided. Enter complete contract number of prime contract, e.g., DACW 09-85-C-0100.

f. TYPE OF CONTRACT - Mark appropriate box. A/E means architect/engineer. If "OTHER" is marked, specify type of contract on line provided.

g. HAZARDOUS/TOXIC WASTE ACTIVITY (HTW) - Mark the box to identify the HTW activity being performed at the time of the accident. For Superfund, DERP, and Installation Restoration Program (IRP) HTW activities include accidents that occurred during inventory, predesign, design, and construction. For the purpose of accident reporting, DERP Formerly Used DoD Site (FUDS) activities and IRP activities will be treated separately. For Civil Works O&M HTW activities mark the "OTHER" box.

INSTRUCTIONS FOR SECTION 4 - CONSTRUCTION ACTIVITIES

a. CONSTRUCTION ACTIVITY - Select the most appropriate construction activity being performed at time of accident from the list below. Enter the activity name and place the corresponding code number identified in the box.

CONSTRUCTION ACTIVITY LIST

1. MOBILIZATION

2. SITE PREPARATION

3. EXCAVATION/TRENCHING

4. GRADING (EARTHWORK)

5. PIPING/UTILITIES

6. FOUNDATION

7. FORMING

8. CONCRETE PLACEMENT

9. STEEL ERECTION

10. ROOFING

11. FRAMING

12. MASONRY

13. CARPENTRY

14. ELECTRICAL

15. SCAFFOLDING/ACCESS

16. MECHANICAL

17. PAINTING

18. EOUIPMENT/MAINTENANCE

19. TUNNELING

20. WAREHOUSING/STORAGE

21. PAVING

22. FENCING

23. SIGNING

24. LANDSCAPING/IRRIGATION

25. INSULATION

26. DEMOLITION

b. TYPE OF CONSTRUCTION EQUIPMENT - Select the equipment involved in the accident from the list below. Enter the name and place the corresponding code number identified in the box. If equipment is not included below, use code 24, "OTHER", and write in specific type of equipment.

CONSTRUCTION EQUIPMENT

1. GRADER

2. DRAGLINE

3. CRANE (ON VESSEL/BARGE)

4. CRANE (TRACKED)

5. CRANE (RUBBER TIRE)

6. CRANE (VEHICLE MOUNTED)

7. CRANE (TOWER)

8. SHOVEL

9. SCRAPER

10. PUMP TRUCK (CONCRETE)

11. TRUCK (CONCRETE/TRANSIT MIXER)

12. DUMP TRUCK (HIGHWAY)

13. DUMP TRUCK (OFF HIGHWAY)

14. TRUCK (OTHER)

15. FORKLIFT

16. BACKHOE

17. FRONT-END LOADER

18. PILE DRIVER

19. TRACTOR (UTILITY)

20. MANLIFT

21. DOZER

22. DRILL RIG

23. COMPACTOR/VIBRATORY ROLLER

24. OTHER

INSTRUCTIONS FOR SECTION 5 - INJURY/ILLNESS INFORMATION

a. SEVERITY OF INJURY/ILLNESS - Reference paragraph 2-10 of USACE Supplement 1 to AR 385-40 and enter code and description from list below.

NOI NO INJURY

FAT FATALITY

PTL PERMANENT TOTAL DISABILITY

PPR PERMANENT PARTIAL DISABILITY

LWD LOST WORKDAY CASE INVOLVING DAYS AWAY FROM WORK

NLW RECORDABLE CASE WITHOUT LOST WORKDAYS

RFA RECORDABLE FIRST AID CASE

NRI NON-RECORDABLE INJURY

b. ESTIMATED DAYS LOST - Enter the estimated number of workdays the person will lose from work.

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 8 of 13 Pages

c. ESTIMATED DAYS HOSPITALIZED - Enter the estimated number of workdays the person will be hospitalized.

d. ESTIMATED DAYS RESTRICTED DUTY - Enter the estimated number of workdays the person, as a result of the accident, will not be able to perform all of their regular duties.

e. BODY PART AFFECTED - Select the most appropriate primary and when applicable, secondary body part affected from the list below. Enter body part name on line and place the corresponding code letters identifying that body part in the box.

GENERAL BODY AREA CODE BODY PART NAME

ARM/WRIST AB ARM AND WRIST

AS ARM OR WRIST

TRUNK, EXTERNAL B1 SINGLE BREAST

MUSCULATURE B2 BOTH BREASTS

B3 SINGLE TESTICLE

B4 BOTH TESTICLES

BA ABDOMEN

BC CHEST

BL LOWER BACK

BP PENIS

BS SIDE

BU UPPER BACK

BW WAIST

BZ TRUNK OTHER

HEAD, INTERNAL C1 SINGLE EAR INTERNAL

C2 BOTH EARS INTERNAL

C3 SINGLE EYE INTERNAL

C4 BOTH EYES INTERNAL

CB BRAIN

CC CRANIAL BONES

CD TEETH

CJ JAW

CL THROAT, LARYNX

CM MOUTH

CN NOSE

CR THROAT, OTHER

CT TONGUE

CZ HEAD OTHER INTERNAL

ELBOW EB BOTH ELBOWS

ES SINGLE ELBOW

FINGER F1 FIRST FINGER

F2 BOTH FIRST FINGERS

F3 SECOND FINGER

F4 BOTH SECOND FINGERS

F5 THIRD FINGER

F6 BOTH THIRD FINGERS

F7 FOURTH FINGER

F8 BOTH FOURTH FINGERS

TOE G1 GREAT TOE

G2 BOTH GREAT TOES

G3 TOE OTHER

G4 TOES OTHER

HEAD, EXTERNAL H1 EYE EXTERNAL

H2 BOTH EYES EXTERNAL

H3 EAR EXTERNAL

H4 BOTH EARS EXTERNAL

HC CHIN

HF FACE

HK NECK/THROAT

HM MOUTH/LIPS

HN NOSE

HS SCALP

KNEE KB BOTH KNEES

KS KNEE

LEG, HIP, ANKLE, LB BOTH LEGS/HIPS/ ANKLES/

BUTTOCKS

BUTTOCK LS SINGLE LEG/HIP/ ANKLE/BUTTOCK

HAND MB BOTH HANDS

MS SINGLE HAND

FOOT PB BOTH FEET

PS SINGLE FOOT

TRUNK, BONES R1 SINGLE COLLAR BONE

R2 BOTH COLLAR BONES

R3 SHOULDER BLADE

R4 BOTH SHOULDER BLADES

RB RIB

RS STERNUM (BREAST BONE)

RV VERTEBRAE (SPINE; DISC)

RZ TRUNK BONES OTHER

SHOULDER SB BOTH SHOULDERS

SS SINGLE SHOULDER

THUMB TB BOTH THUMBS

TS SINGLE THUMB

TRUNK, INTERNAL V1 LUNG, SINGLE

ORGANS V2 LUNGS, BOTH

V3 KIDNEY, SINGLE

V4 KIDNEYS, BOTH

VH HEART

VL LIVER

VR REPRODUCTIVE ORGANS

VS STOMACH

VV INTESTINES

VZ TRUNK, INTERNAL; OTHER

f. NATURE OF INJURY/ILLNESS - Select the most appropriate nature of injury/illness from the list below. This nature of injury/illness shall correspond to the primary body part selected in 5e, above. Enter the nature of injury/illness name on the line and place the corresponding CODE letters in the box provided.

* The injury or condition selected below must be caused by a specific incident or event which occurred during a single work day or shift.

GENERAL NATURE

CATEGORY CODE NATURE OF INJURY NAME

*TRAUMATIC INJURY OR TA AMPUTATION

DISABILITY TB BACK STRAIN

TC CONTUSION; BRUISE; ABRASION

TD DISLOCATION

TF FRACTURE

TH HERNIA

GENERAL NATURE

CATEGORY CODE NATURE OF INJURY NAME

TK CONCUSSION

TL LACERATION, CUT

TP PUNCTURE

TS STRAIN, MULTIPLE

TU BURN, SCALD, SUNBURN

TI TRAUMATIC SKIN DISEASES/

CONDITIONS INCLUDING DERMATITIS

TR TRAUMATIC RESPIRATORY DISEASE

TQ TRAUMATIC FOOD POISONING

TW TRAUMATIC TUBERCULOSIS

TX TRAUMATIC VIROLOGICAL/INFECTIVE/

PARASITIC DISEASE

T1 TRAUMATIC CEREBRAL VASCULAR

CONDITION/STROKE

T2 TRAUMATIC HEARING LOSS

T3 TRAUMATIC HEART CONDITION

T4 TRAUMATIC MENTAL DISORDER,

STRESS; NERVOUS CONDITION

T8 TRAUMATIC INJURY - OTHER (EXCEPT

DISEASE, ILLNESS)

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 9 of 13 Pages

** A nontraumatic physiological harm or loss of capacity produced by systemic infection; continued or repeated stress or strain; exposure to toxins, poisons, fumes, etc.; or other continued and repeated exposures to conditions of the work environment over a long period of time. For practical purposes, an occupational illness/disease or disability is any reported condition which does not meet the definition of traumatic injury or disability as described above.

GENERAL NATURE

CATEGORY CODE NATURE OF INJURY NAME

**NON-TRAUMATIC ILLNESS/DISEASE OR DISABILITY

RESPIRATORY DISEASE RA ASBESTOSIS

RB BRONCHITIS

RE EMPHYSEMA

RP PNEUMOCONIOSIS

RS SILICOSIS

R9 RESPIRATORY DISEASE, OTHER

VIROLOGICAL, INFECTIVE

& PARASITIC DISEASES

VB BRUCELLOSIS

VC COCCIDIOMYCOSIS

VF FOOD POISONING

VH HEPATITIS

VM MALARIA

VS STAPHYLOCOCCUS

VT TUBERCULOSIS

V9 VIROLOGICAL/INFECTIVE/

PARASITIC - OTHER

DISABILITY, DA ARTHRITIS, BURSITIS

OCCUPATIONAL DB BACK STRAIN, BACK SPRAIN

DC CEREBRAL VASCULAR CONDITION;

STROKE

DD ENDEMIC DISEASE (OTHER THAN

CODE TYPES R&S)

DE EFFECT OF ENVIRONMENTAL

CONDITION

DH HEARING LOSS

DK HEART CONDITION

DM MENTAL DISORDER, EMOTIONAL

STRESS, NERVOUS CONDITION

DR RADIATION

DS STRAIN, MULTIPLE

DU ULCER

DV OTHER VASCULAR CONDITIONS

D9 DISABILITY, OTHER

SKIN DISEASE OR

CONDITION

SB BIOLOGICAL

SC CHEMICAL

S9 DERMATITIS, UNCLASSIFIED

g. TYPE AND SOURCE OF INJURY/ILLNESS (CAUSE) - Type and Source Codes are used to describe what caused the incident. The Type Code stands for an ACTION and the Source Code for an OBJECT or SUBSTANCE. Together, they form a brief description of how the incident occurred. Where there are two different sources, code the initiating source of the incident (see example 1, below). Examples:

(1) An employee tripped on carpet and struck his head on a desk. TYPE: 210 (fell on same level) SOURCE: 0110 (walking/working surface).

NOTE: This example would NOT be coded 120 (struck against) and 0140 (furniture).

(2) A Park Ranger contracted dermatitis from contact with poison ivy/oak.

TYPE: 510 (contact) SOURCE: 0920 (plant)

(3) A lock and dam mechanic punctured his finger with a metal sliver while grinding a turbine blade.

TYPE: 410 (punctured by) SOURCE: 0830 (metal)

(4) An employee was driving a government vehicle when it was struck by another vehicle.

TYPE: 800 (traveling in) SOURCE: 0421 (government-owned vehicle, as driver)

NOTE: The Type Code 800, "Traveling In" is different from the other type codes in that its function is not to identify factors contributing to the injury or fatality, but rather to collect data on the type of vehicle the employee was operating or traveling in at the time of the incident.

Select the most appropriate TYPE and SOURCE identifier from the list below and enter the name on the line and the corresponding code in the appropriate box.

CODE TYPE OF INJURY NAME

STRUCK

0110 STRUCK BY

0111 STRUCK BY FALLING OBJECT

0120 STRUCK AGAINST

FELL, SLIPPED, TRIPPED

0210 FELL ON SAME LEVEL

0220 FELL ON DIFFERENT LEVEL

0230 SLIPPED, TRIPPED (NO FALL)

CAUGHT

0310 CAUGHT ON

0320 CAUGHT IN

0330 CAUGHT BETWEEN

PUNCTURED, LACERATED

0410 PUNCTURED BY

0420 CUT BY

0430 STUNG BY

0440 BITTEN BY

CONTACTED

0510 CONTACTED WITH (INJURED PERSON MOVING)

0520 CONTACTED BY (OBJECT WAS MOVING)

EXERTED

0610 LIFTED, STRAINED BY (SINGLE ACTION)

0620 STRESSED BY (REPEATED ACTION)

EXPOSED

0710 INHALED

0720 INGESTED

0730 ABSORBED

0740 EXPOSED TO

0800 TRAVELING IN

CODE SOURCE OF INJURY NAME

0100 BUILDING OR WORKING AREA

0110 WALKING/WORKING SURFACE (FLOOR, STREET,

SIDEWALKS, ETC.)

0120 STAIRS, STEPS

0130 LADDER

0140 FURNITURE, FURNISHINGS, OFFICE EQUIPMENT

0150 BOILER, PRESSURE VESSEL

0160 EQUIPMENT LAYOUT (ERGONOMIC)

0170 WINDOWS, DOORS

0180 ELECTRICITY

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 10 of 13 Pages

0200 ENVIRONMENTAL CONDITION

0210 TEMPERATURE EXTREME (INDOOR)

0220 WEATHER (ICE, RAIN, HEAT, ETC.)

0230 FIRE, FLAME, SMOKE (NOT TOBACCO)

0240 NOISE

0250 RADIATION

0260 LIGHT

0270 VENTILATION

0271 TOBACCO SMOKE

0280 STRESS (EMOTIONAL)

0290 CONFINED SPACE

0300 MACHINE OR TOOL

0310 HAND TOOL (POWERED; SAW, GRINDER, ETC.)

0320 HAND TOOL (NONPOWERED)

0330 MECHANICAL POWER TRANSMISSION APPARATUS

0340 GUARD, SHIELD (FIXED, MOVEABLE, INTERLOCK)

0350 VIDEO DISPLAY TERMINAL

0360 PUMP, COMPRESSOR, AIR PRESSURE TOOL

0370 HEATING EQUIPMENT

0380 WELDING EQUIPMENT

0400 VEHICLE

0411 AS DRIVER OF PRIVATELY OWNED/RENTAL VEHICLE

0412 AS PASSENGER OF PRIVATELY OWNED/RENTAL VEHICLE

0421 DRIVER OF GOVERNMENT VEHICLE

0422 PASSENGER OF GOVERNMENT VEHICLE

0430 COMMON CARRIER (AIRLINE, BUS, ETC.)

0440 AIRCRAFT (NOT COMMERCIAL)

0450 BOAT, SHIP, BARGE

0500 MATERIAL HANDLING EQUIPMENT

0510 EARTHMOVER (TRACTOR, BACKHOE, ETC.)

0520 CONVEYOR (FOR MATERIAL AND EQUIPMENT)

0530 ELEVATOR, ESCALATOR, PERSONNEL HOIST

0540 HOIST, SLING CHAIN, JACK

0550 CRANE

0551 FORKLIFT

0560 HANDTRUCK, DOLLY

0600 DUST, VAPOR, ETC.

0610 DUST (SILICA, COAL, ETC.)

0620 FIBERS

0621 ASBESTOS

0630 GASES

0631 CARBON MONOXIDE

0640 MIST, STEAM, VAPOR, FUME

0641 WELDING FUMES

0650 PARTICLES (UNIDENTIFIED)

0700 CHEMICAL, PLASTIC, ETC.

0711 DRY CHEMICAL - CORROSIVE

0712 DRY CHEMICAL - TOXIC

0713 DRY CHEMICAL - EXPLOSIVE

0714 DRY CHEMICAL FLAMMABLE

0721 LIQUID CHEMICAL - CORROSIVE

0722 LIQUID CHEMICAL - TOXIC

0723 LIQUID CHEMICAL - EXPLOSIVE

0724 LIQUID CHEMICAL - FLAMMABLE

0730 PLASTIC

0740 WATER

0750 MEDICINE

0800 INAMINATE OBJECT

0810 BOX, BARREL, ETC.

0820 PAPER

0830 METAL ITEM, MINERAL

0831 NEEDLE

0840 GLASS

0850 SCRAP, TRASH

0860 WOOD

0870 FOOD

0880 CLOTHING, APPAREL, SHOES

0900 ANIMATE OBJECT

0911 DOG

0912 OTHER ANIMAL

0920 PLANT

0930 INSECT

0940 HUMAN (VIOLENCE)

0950 HUMAN (COMMUNICABLE DISEASE)

0960 BACTERIA, VIRUS (NOT HUMAN CONTACT)

1000 PERSONAL PROTECTIVE EQUIPMENT

1010 PROTECTIVE CLOTHING, SHOES, GLASSES,

GOGGLES

1020 RESPIRATOR, MASK

1021 DIVING EQUIPMENT

1030 SAFETY BELT, HARNESS

1040 PARACHUTE

INSTRUCTIONS FOR SECTION 6 - PUBLIC FATALITY

a. ACTIVITY AT TIME OF ACCIDENT - Select the activity being performed at the time of the accident from the list below. Enter the activity name on the line and the corresponding number in the box. If the activity performed is not identified on the list, select from the most appropriate primary activity area (water related, non-water related or other activity), the code number for "Other", and write in the activity being performed at the time of the accident.

WATER RELATED RECREATION

1. Sailing

2. Boating-powered

3. Boating-unpowered

4. Water skiing

5. Fishing from boat

6. Fishing from bank dock or pier

7. Fishing while wading

8. Swimming/supervised area

9. Swimming/designated area

10. Swimming/other area

11. Underwater activities (skin diving, scuba, etc.)

12. Wading

13. Attempted rescue

14. Hunting from boat

15. Other

NON-WATER RELATED RECREATION

16. Hiking and walking

17. Climbing (general)

18. Camping/picnicking authorized area

19. Camping/picnicking unauthorized area

20. Guided tours

21. Hunting

22. Playground equipment

23. Sports/summer (baseball, football, etc.)

24. Sports/winter (skiing, sledding, snowmobiling etc.)

25. Cycling (bicycle, motorcycle, scooter)

26. Gliding

27. Parachuting

28. Other non-water related

OTHER ACTIVITIES

29. Unlawful acts (fights, riots, vandalism, etc.)

30. Food preparation/serving

31. Food consumption

32. Housekeeping

33. Sleeping

34. Pedestrian struck by vehicle

35. Pedestrian other acts

36. Suicide

37. "Other" activities

b. PERSONAL FLOTATION DEVICE USED - If fatality was water-related was the victim wearing a person flotation device? Mark the appropriate box.

INSTRUCTIONS FOR SECTION 7 - MOTOR VEHICLE ACCIDENT

a. TYPE OF VEHICLE - Mark appropriate box for each vehicle involved. If more than one vehicle of the same type is involved, mark both halves of the appropriate box. USACE vehicle(s) involved shall be marked in left half of appropriate box.

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b. TYPE OF COLLISION - Mark appropriate box.

c. SEAT BELT - Mark appropriate box.

INSTRUCTIONS FOR SECTION 8 - PROPERTY/MATERIAL INVOLVED

a. NAME OF ITEM - Describe all property involved in accident. Property/material involved means material which is damaged or whose use or misuse contributed to the accident. Include the name, type, model; also include the National Stock Number (NSN) whenever applicable.

b. OWNERSHIP - Enter ownership for each item listed. (Enter one of the following: USACE; OTHER GOVERNMENT; CONTRACTOR; PRIVATE)

c. $ AMOUNT OF DAMAGE - Enter the total estimated dollar amount of damage (parts and labor), if any.

INSTRUCTIONS FOR SECTION 9 - VESSEL/FLOATING PLANT ACCIDENT

a. TYPE OF VESSEL/FLOATING PLANT - Select the most appropriate vessel/floating plant from list below. Enter name and place corresponding number in box.

If item is not listed below, enter item number for "OTHER" and write in specific type of vessel floating plant.

VESSEL/FLOATING PLANTS

1. ROW BOAT

2. SAIL BOAT

3. MOTOR BOAT

4. BARGE

5. DREDGE/HOPPER

6. DREDGE/SIDE CASTING

7. DREDGE/DIPPER

8. DREDGE/CLAMSHELL, BUCKET

9. DREDGE/PIPE LINE

10. DREDGE/DUST PAN

11. TUG BOAT

12. OTHER

b. COLLISION/MISHAP - Select from the list below the object(s) that contributed to the accident or were damaged in the accident.

COLLISION/MISHAP

1. COLLISION W/OTHER VESSEL

2. UPPER GUIDE WALL

3. UPPER LOCK GATES

4. LOCK WALL

5. LOWER LOCK GATES

6. LOWER GUIDE WALL

7. HAULAGE UNIT

8. BREAKING TOW

9. TOW BREAKING UP

10. SWEPT DOWN 0N DAM

11. BUOY/DOLPHIN/CELL

12. WHARF OR DOCK

13. OTHER

INSTRUCTIONS FOR SECTION 10 - ACCIDENT DESCRIPTION

DESCRIBE ACCIDENT - Fully describe the accident. Give the sequence of events that describe what happened leading up to and including the accident. Fully identify personnel and equipment involved and their role(s) in the accident. Ensure that relationships between personnel and equipment are clearly specified.

Continue on blank sheets if necessary and attach to this report.

INSTRUCTIONS FOR SECTION 11 - CAUSAL FACTORS

a. Review thoroughly. Answer each question by marking the appropriate block. If any answer is yes, explain in item 13 below. Consider, as a minimum, the following:

(1) DESIGN - Did inadequacies associated with the building or work site play a role? Would an improved design or layout of the equipment or facilities reduce the likelihood of similar accidents? Were the tools or other equipment designed and intended for the task at hand?

(2) INSPECTION/MAINTENANCE - Did inadequately or improperly maintained equipment, tools, workplace, etc. create or worsen any hazards that contributed to the accident? Would better equipment, facility, work site or work activity inspections have helped avoid the accident?

(3) PERSON'S PHYSICAL CONDITION - Do you feel that the accident would probably not have occurred if the employee was in "good" physical condition? If the person involved in the accident had been in better physical condition, would the accident have been less severe or avoided altogether? Was over exertion a factor?

(4) OPERATING PROCEDURES - Did a lack of or inadequacy within established operating procedures contribute to the accident? Did any aspect of the procedures introduce any hazard to, or increase the risk associated with the work process? Would establishment or improvement of operating procedures reduce the likelihood of similar accidents?

(5) JOB PRACTICES - Were any of the provisions of the Safety and Health Requirements Manual (EM 385-1-1) violated? Was the task being accomplished in a manner which was not in compliance with an established job hazard analysis or activity hazard analysis? Did any established job practice (including EM 385-1-1) fail to adequately address the task or work process? Would better job practices improve the safety of the task?

(6) HUMAN FACTORS - Was the person under undue stress (either internal or external to the job)? Did the task tend toward overloading the capabilities of the person; i.e., did the job require tracking and reacting to many external inputs such as displays, alarms, or signals? Did the arrangement of the workplace tend to interfere with efficient task performance? Did the task require reach, strength, endurance, agility, etc., at or beyond the capabilities of the employee? Was the work environment ill-adapted to the person? Did the person need more training, experience, or practice in doing the task? Was the person inadequately rested to perform safely?

(7) ENVIRONMENTAL FACTORS - Did any factors such as moisture, humidity, rain, snow, sleet, hail, ice, fog, cold, heat, sun, temperature changes, wind, tides, floods, currents, dust, mud, glare, pressure changes, lightning, etc., play a part in the accident?

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 12 of 13 Pages

(8) CHEMICAL AND PHYSICAL AGENT FACTORS - Did exposure to chemical agents (either single shift exposure or long-term exposure) such as dusts, fibers (asbestos, etc.), silica, gases (carbon monoxide, chlorine, etc.,), mists, steam, vapors, fumes, smoke, other particulates, liquid or dry chemicals that are corrosive, toxic, explosive or flammable, by products of combustion or physical agents such as noise, ionizing radiation, non-ionizing radiation (UV radiation created during welding, etc.) contribute to the accident/incident?

(9) OFFICE FACTORS - Did the fact that the accident occurred in an office setting or to an office worker have a bearing on its cause? For example, office workers tend to have less experience and training in performing tasks such as lifting office furniture. Did physical hazards within the office environment contribute to the hazard?

(10) SUPPORT FACTORS - Was the person using an improper tool for the job? Was inadequate time available or utilized to safely accomplish the task? Were less than adequate personnel resources (in terms of employee skills, number of workers, and adequate supervision) available to get the job done properly?

Was funding available, utilized, and adequate to provide proper tools, equipment, personnel, site preparation, etc.?

(11) PERSONAL PROTECTIVE EQUIPMENT - Did the person fail to use appropriate personal protective equipment (gloves, eye protection, hard-toed shoes, respirator, etc.) for the task or environment? Did protective equipment provided or worn fail to provide adequate protection from the hazard(s)? Did lack of or inadequate maintenance of protective gear contribute to the accident?

(12) DRUGS/ALCOHOL - Is there any reason to believe the person's mental or physical capabilities, judgment, etc., were impaired or altered by the use of drugs or alcohol? Consider the effects of prescription medicine and over the counter medications as well as illicit drug use. Consider the effect of drug or alcohol induced "hangovers".

b. WRITTEN JOB/ACTIVITY HAZARD ANALYSIS - Was a written Job/Activity Hazard Analysis completed for the task being performed at the time of the accident? Mark the appropriate box. If one was performed, attach a copy of the analysis to the report.

INSTRUCTIONS FOR SECTION 12 - TRAINING

a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK? - For the purpose of this section "trained" means the person has been provided the necessary information (either formal and/or on-the-job (OJT) training) to competently perform the activity/task in a safe and healthful manner.

b. TYPE OF TRAINING - Mark the appropriate box that best indicates the type of training; (classroom or on-the-job) that the injured person received, before the accident happened.

c. DATE OF MOST RECENT TRAINING - Enter YYYYMMDD of the last formal training completed that covered the activity task being performed at the time of the accident.

INSTRUCTIONS FOR SECTION 13 - CAUSES

a. DIRECT CAUSES - The direct cause is that single factor, which most directly lead to the accident. See examples below.

b. INDIRECT CAUSES - Indirect causes are those factors which contributed to but did not directly initiate the occurrence of the accident.

Examples for section 13:

a. Employee was dismantling scaffold and fell 12 feet from unguarded opening.

Direct cause: failure to provide fall protection at elevation. Indirect causes: failure to enforce USACE safety requirements; improper training/motivation of employee (possibility that employee was not knowledgeable of USACE fall protection requirements or was lax in his attitude towards safety); failure to ensure provision of positive fall protection whenever elevated; failure to address fall protection during scaffold dismantling in phase hazard analysis.

b. Private citizen had stopped his vehicle at intersection for red light when vehicle was struck in rear by USACE vehicle. (Note: USACE vehicle was in proper/safe working condition).

Direct cause: failure of USACE driver to maintain control of and stop USACE vehicle within safe distance.

Indirect cause: failure of employee to pay attention to driving (defensive driving).

INSTRUCTIONS FOR SECTION 14 - ACTION TO ELIMINATE CAUSE(s)

DESCRIPTION - Fully describe all the actions taken, anticipated, and recommended to eliminate the cause(s) and prevent reoccurrence of similar accidents/ illnesses. Continue on blank sheets of paper if necessary to fully explain and attach to the completed report form.

INSTRUCTIONS FOR SECTION 15 - DATES FOR ACTION

a. BEGIN DATE - Enter the date YYYYMMDD when the corrective action(s) identified in section 14 will begin.

b. COMPLETE DATE - Enter the date YYYYMMDD when the corrective action(s) identified in section 14 will be completed.

c. DATE SIGNED - Enter YYYYMMDD that the report was signed by the responsible supervisor.

d.e.. TITLE AND SIGNATURE - Enter the title and signature of supervisor completing the accident report. For a GOVERNMENT employee accident/illness the immediate supervisor will complete and sign the report. For PUBLIC accidents the USACE Project Manager/Area Engineer responsible for the USACE property where the accident happened shall complete and sign the report. For CONTRACTOR accidents the Contractor's project manager shall complete and sign the report and provide to the USACE supervisor responsible for oversight of that contractor activity. This USACE supervisor shall also sign the report. Upon entering the information required in 15c., 15d., 15e., 15f. and 15g. below, the responsible USACE supervisor shall forward the report for management review as indicated in section 16.

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f. ORGANIZATION NAME - For GOVERNMENT employee accidents enter the USACE organization name (Division, Branch, Section, etc.) of the injured employee. For PUBLIC accidents enter the USACE organization name for the person identified in block 15d. For CONTRACTOR accidents enter the USACE organization name for the USACE office responsible for providing contract administration oversight.

g. OFFICE SYMBOL - Enter the latest complete USACE Office Symbol for the USACE organization identified in block 15f.

INSTRUCTIONS FOR SECTION 16 - MANAGEMENT REVIEW (1st)

1ST REVIEW - Each USACE FOA shall determine who will provide 1st management review. The responsible USACE supervisor in section 15d. shall forward the completed report to the USACE office designated as the 1st Reviewer by the FOA. Upon receipt, the Chief of the Office shall review the completed report, mark the appropriate box, provide substantive comments, sign, date, and forward to the FOA Staff Chief (2nd review) for review and comment.

INSTRUCTIONS FOR SECTION 17 - MANAGEMENT REVIEW (2nd)

2ND REVIEW - The FOA Staff Chief (i .e., FOA Chief of Construction, Operations, Engineering, Planning, etc.) shall mark the appropriate box, review the completed report, provide substantive comments, sign, date, and return to the FOA Safety and Occupational Health Office.

INSTRUCTIONS FOR SECTION 18 - SAFETY AND OCCUPATIONAL HEALTH REVIEW

3RD REVIEW - The FOA Safety and Occupational Health Office shall review the completed report, mark the appropriate box, ensure that any inadequacies, discrepancies, etc. are rectified by the responsible supervisor and management reviewers, provide substantive comments, sign, date and forward to the FOA Commander for review, comment, and signature.

INSTRUCTION FOR SECTION 19 - COMMAND APPROVAL

4TH REVIEW - The FOA Commander shall (to include the person designated Acting Commander in his absence) review the completed report, comment if required, sign, date, and forward the report to the FOA Safety and Occupational Health Office. Signature authority shall not be delegated.