Attachment_IX_-_TSA_Form_2401_OSH_Incident_Investigation_Report.pdf

SIS Incident Number: ______________

INSTRUCTIONS: Use this form to record investigations of incidents including fatalities, injuries, illnesses, and damage to motor vehicles, property, equipment or facilities.

• Investigations must begin within 24 hours of notification of the incident.

• For injuries or illnesses that are considered to be recordable to the Occupational Safety and Health Administration

(OSHA), the investigation must be completed and recorded in the Safety Information System (SIS) within 7 calendar days after the notice of injury or illness is received.

• Document investigations of employee reports of unsafe or unhealthful working conditions in section C of TSA Form 2400 Employee Report of Unsafe/Unhealthful Working Conditions.

SECTION A: INCIDENT SUMMARY, DESCRIPTION, AND WITNESS(ES)

1. Incident Date and Time: / / : AM PM 2. Assigned to:

Check here if time cannot be determined:

3. Incident Type:

FATALITY: Reported to DSHO Date Reported: / / INJURY/ILLNESS: Injury Illness/Exposure 3 or more employees hospitalized MOTOR VEHICLE: TSA Vehicle Non-TSA Vehicle Both PROPERTY DAMAGE ONLY: Facility Equipment Property

4. Reported by: 5. Serious Incident contact: Local OSHA TSOC Other

6. TSA Controlled Area: Yes No 7. Incident Severity: A B C D E

8. Organization (3-character airport code or Organizational code):

9. Specific Location:

10. Supervisor Name: 11. On Site: Yes No 12. Notified: Yes No

13. Emergency Response: Airport EMS Community 911 No Response Other:

Section A1: Description

14. Complete Description of Incident:

15. Describe the Cause of Incident:

Section A2: Witnesses

16. Identify any witnesses to the incident that you interviewed, or who provided statements.

Name Address Street, City, State, Zip Phone Interviewed by Emp

OSH Incident Investigation Report

Previous editions of this form are obsolete.

TSA Form 2401, 02/11 rev. [File: 2400.5.1]

SIS Incident Number: ___________________

Section A3: Additional Information

No. of People Involved: No. of Motor Vehicles Involved: Amount of Property and Equipment Involved:

SECTION B: INVOLVED PERSONS (When more than one person is involved in this incident, complete TSA Form 2401A, Supplement to OSH Incident Investigation Report for each additional person involved in this incident)

Section B1: Demographics Check here if this involved person is with the National Deployment Office.

(Shaded areas are not required fields as they will auto-populate in SIS.)

17. Person ID: 18. Name: 19. Date of Birth: / / 20. Gender: M F

21. Hire Date: / / 22. Employment: Federal Contractor Volunteer Other

23. Work Shift: FT Conv. FT Comp. FT Conv. Split Shift FT Comp. Split Shift PT PT Split Shift

24. Home Address: 25. Work Address:

Street City State Zip Street City State Zip

Phone No. Email Address Phone No. Email Address

26. Job Title: 26a. Contract Name: 26b. Start Date: / /

27. Supervisor Name: 28. Supv. Phone: 29. Supv. Email:

Section B2: Summary of Involved Person

30. Tasks Performed at Time of Incident:

31. Experience in Task: 0-3 months 3-12 months 1-3 years 3-5 years 5 or more years Unknown

32. Time Work Began on Date of Incident: / / : AM PM 33. Incident Occurred: On Duty Off Duty

34. What was the employee doing just before the incident occurred: (Describe activity, tools, equipment, or material the employee was using.)

35. What happened: (Describe how the injury occurred. Be clear, concise, and limit to one or two sentences)

36. Employee Statement Provided: Yes No 36a. Statement Date: / / (Attach Employee Statement to this report) Section B3: Controls

37. Required PPE: 37a. PPE Available for Task: Yes No 37b. In Use: Yes No Section B4: Injury/Illness

38. Outcome: Traumatic Injury Occupational Disease or Illness No Injury 38a. Illness Onset Date: / /

39. Severity of Injury:

Fatality Lost Time Restricted Duty or Job Transfer First Aid Medical Treatment Beyond First Aid No Injury

40. Caused by Work Activity: Yes No 41. Poisoning: Yes No 42. Loss of Consciousness: Yes No

43. Needle Stick/Sharps Involved: Yes No 43a. If yes, Disposition of Needle or Sharp: _________________________

44. Privacy Case: Yes No 44a. Reason for Privacy Case Consideration: __________________________ NOTE: For Nos. 45 – 49, refer to Appendices B, C, D, E, and F, respectively.

45. Cause of Injury: 46. Event Type: 47. Source of Injury: 48. Nature of Injury: 49. Body Part:

Section B5: Medical Treatment (Contact your local Workers’ Compensation Coordinator to assist with this information.)

50. First Aid Administered: Yes No 50a. First Aid Treatment Received: ______________________________

51. Medical Treatment Beyond First Aid: Yes No 51a. Date: / / 52. Details:

53. Emergency Room: Yes No 54. Hospitalized Overnight as In-patient: Yes, # of Days No 53a. Physician or Emergency Room Information: 54a. Hospital Information:

Name Street Name Street

City State Zip City State Zip SECTION B6: Lost Days

56. Record any Lost Work Days (LWD), Restricted Work Days (RWD), or Transfer Work Days (TWD) Lost, Restricted or Transfer Start Date End Date Estimated? Comments

LWD RWD TWD / / / / Estimated LWD RWD TWD / / / / Estimated LWD RWD TWD / / / / Estimated

SECTION C: MOTOR VEHICLE DAMAGE Check here if there were no motor vehicles involved in this incident.

57. Vehicle #

58. Type:

Automobile

Delivery Truck Van

Bus Pickup or SUV

Dump Truck Motorcycle

Semi /Tractor Trailer Other Light Vehicle

Other Heavy Vehicle

59. TSA Damage ($): 60. Non-TSA Damage ($): 61. Total Damage ($):

Description: Provide the following additional information for all persons involved in this motor vehicle incident Person # Relation to Vehicle Seatbelt Available Seatbelt In Use OSHA Recordable Injury

Driver Passenger Pedestrian Yes No Yes No Yes No Driver Passenger Pedestrian Yes No Yes No Yes No Driver Passenger Pedestrian Yes No Yes No Yes No

SECTION D: PROPERTY AND EQUIPMENT DAMAGE Check here if property and equipment were not involved in this incident.

62. Property, Equipment, or Facility Type: Facility Non-Motorized Vehicle Equipment Other

63. Manufacturer: 64. Make: 65. Model:

66. Description of Damage:

67. TSA Damage ($): 68. Non-TSA Damage ($): 69. Total Damage ($):

SECTION E: CAUSAL/CONTRIBUTORY FACTORS Check here if no factors contributed to this incident.

(Create separate sheet if additional space is needed.)

70. Causal or Contributory Factors Group Type Assessment Description SECTION F: DISPOSITION OF INCIDENT Check here if no corrective action is necessary.

71. Recommended corrective actions that are either implemented locally or require collaboration with other entities.

Recommendation Estimated Cost ($) Date Implemented Actual

Cost ($) Implemented By Date

/ / Yes No / / / / Yes No / / / / Yes No / /

72. Is an Inspection Needed: Yes No 73. Date Requested: / / 74. Requested by:

75. Type of Inspection: 76. Status of Request: Pending Approved Denied

77. Reason for Denial of Inspection:

78. Status: Check most appropriate incident status based on the investigation.

Closed – Non Recordable Closed Provisionally Closed – Recordable (Future Lost Time Estimated)

79. Investigation Summary:

SECTION G: CERTIFICATION AND SIGNATURE

80. Report Prepared by: 81. Title:

82. Signature: 83. Date Prepared: / /

84. Reviewed by: 85. Date Reviewed: / /

PRIVACY ACT STATEMNT: Authority: 20 U.S.C. § 1904; 49 U.S.C. § 114; E.O. 12196. Principal Purpose(s): To report, track and study work-related injuries, illnesses and mishaps. Routine Use(s): This information may be shared with third-parties during the course of an investigation into any matter associated with an occupationally-related accident, injury or illness, to the extent necessary to obtain information pertinent to the investigation, or for routine uses identified in the Transportation Security Administration system of records notice, DHS/TSA 020, Safety Information System.

Disclosure: Voluntary.

Instructions for Completing TSA Form 2401 – OSH Incident Investigation Report Purpose: This form is used to document investigations of TSA incidents including fatalities, injuries, illnesses, and damage to motor vehicles, property, equipment or facilities. It will also be used to serve as an Initial Written Notification to be forwarded to the TSA Headquarters Occupational Safety, Health, and Environment (OSHE) in the event of a serious incident.

Completed by: The person investigating the incident. Staff Directors, Directors in Security Operations, and Managers and Supervisors must ensure that investigations of incidents must begin within 24 hours from date of notice and that this form is completed for each work-related incident resulting in injury, illness, fatality, or damage to property, equipment, or facility.

Special Instructions: Within 8 hours after the death of any employee from a work-related incident or the in-patient hospitalization of 3 or more employees as a result of a work-related incident, the responsible individual appointed by the DOSHO must telephone or visit the OSHA Area Office nearest to the site of the incident and either your local Coordination Center or the Transportation Security Operations - Freedom Center. If reports cannot be made during normal OSHA business hours, then make reports through the OSHA telephone hotline at 1-800-321-OSHA (6742).

Recordkeeping: This form must be completed and signed by the person investigating the incident. Information contained in this form for injuries and illnesses must be entered into the Safety Information System (SIS) and a recordability assessment made no later than seven

(7) calendar days after notification of an incident is received. The signed paper copy of this form must be kept on file in the local establishment file plan for five (5) years following the end of the calendar year that these records cover. The electronic copy of this form is maintained in SIS, the official TSA System of Record.

Completing Section A – Incident Summary, Description, and Witness(es)

# Item Name Instruction

1. Incident Date and Time: Enter the date and time that the incident occurred. Place a check mark in the appropriate box if a time cannot be determined for this incident.

2. Assigned to: Enter the organizational unit responsible for investigating the incident and abating hazards.

3. Incident Type: Place a checkmark next to the most appropriate incident type. If a motor vehicle or property damage incident also resulted in an injury or illness, then check the injury/illness type as well. Place a checkmark in the appropriate responses to the right that correlate to the incident type. For a notice of unsafe or unhealthful working condition, use TSA Form 2400 to record investigation.

4. Reported by: Enter the name of the person reporting the incident that is being investigated.

5. Serious Incident: If this is considered a serious incident as defined in TSA Management Directive 2400.1, place a checkmark next to all organizations contacted as a result.

6. TSA Controlled Area: Indicate whether or not the incident occurred in a TSA owned or controlled area. TSA Controlled Area is defined as an area where corrective actions can be made without intervention or support from a non- TSA entity such as a worksite authority or an air carrier. GSA Leased space is a TSA Controlled Area.

7. Incident Severity: Place a checkmark to the left of the appropriate severity classification code based on the most severe injury, illness, or property, equipment, facility damage associated with the incident. Use Appendix A ‘Incident Severity Codes Grouped by Incident Type’ to find the appropriate code.

8. Organization: Enter the 3-character airport code or the 11-character organizational code for the facility where the incident occurred.

9. Specific Location: Describe as completely as possible the specific location where the incident occurred.

10. Supervisor Name: Enter the name of the supervisor responsible for the area where the incident occurred. Note: This may be different than the supervisor who is managing an involved person.

11. On Site Indicate whether or not the supervisor responsible for the area where the incident occurred was on-site at the incident location when the incident occurred.

12. Notified: Indicate whether or not the supervisor responsible for the area where the incident occurred was notified of the incident.

13. Emergency Response: Place a checkmark next to the appropriate emergency response provider who was called to the incident scene. Note: If ‘Other,’ please describe the type of emergency response contacted.

14. Complete Description of Incident:

Describe the event sequentially, beginning with the initiating events, and include details such as the object or substance directly contributing to the incident, and the nature and severity of any injury, illness, motor vehicle, or property damage resulting from the incident.

15. Describe the Cause of Incident:

Describe the underlying causes found during an investigation that most likely contributed to the incident; e.g., a power failure.

16. Witnesses: Enter the number of witnesses that you interviewed, or who provided statements. Record the names and pertinent information in the appropriate areas. Attached any witness statements to this form.

A3. Additional Information. Enter the total number of Involved Persons, Motor Vehicles, and Property and Equipment in the appropriate areas. If more than one involved person, copy page 2 of this form for each additional person. If more than one motor vehicle, property, or equipment is involved, copy page 3 of this form for each additional item.

Completing Section B – INVOLVED PERSONS (Create separate sheet for each TSA Employee or TSA contractor involved in this incident) Confidentiality Requirements THIS FORM CONTAINS INFORMATION RELATING TO EMPLOYEE HEALTH AND MUST BE USED IN A MANNER THAT PROTECTS THE CONFIDENTIALITY OF EMPLOYEES TO THE MAXIMUM EXTENT POSSIBLE WHILE THE INFORMATION IS BEING USED FOR OCCUPATIONAL SAFETY AND HEALTH PURPOSES. THIS FORM SHOULD BE MAINTAINED IN A SECURED OFFICE OR FILE TO PREVENT UNWARRANTED RELEASE OF EMPLOYEE PERSONAL INFORMATION (FOR EXAMPLE, NAME, ADDRESS, SOCIAL SECURITY NUMBER, AND MEDICAL INFORMATION) THAT IS PROTECTED BY OSHA AND the PRIVACY ACT. TSA SUPERVISORS, MANAGERS, AND OCCUPATIONAL SAFETY AND HEALTH STAFF MUST FAMILIARIZE THEMSELVES WITH “PRIVACY CONCERN CASE” REQUIREMENTS IN 29 CFR 1904.29 BEFORE COMPLETING PART 1904 FORMS. SINCE THIS FORM INCORPORATES ALL DATA ELEMENTS IN OSHA FORM 301, INJURY AND ILLNESS INCIDENT REPORT, THE SAME “PRIVACY CONCERN CASE” RESTRICTIONS APPLY. EMPLOYEES MAY REQUEST ACCESS TO THEIR OWN RECORDS IN ACCORDANCE WITH 29 CFR 1904.35 or the DHS Freedom of Information Act and Privacy Act regulations at 6 CFR Part 5. GOVERNMENT REPRESENTATIVES MAY REQUEST PART 1904 RECORDS IN ACCORDANCE WITH 29

CFR 1904.40 AND TSA MD 2400.5.

If the involved person was a TSO with the National Deployment Force when the incident occurred, place a check mark in the appropriate box contained in B1. Demographics.

# Item Name Instruction

17. Person ID: Enter a sequential 3-digit number to identify each involved person for this incident, beginning with

001. Use a separate Involved Persons page for each person involved in this incident.

18 Name: Enter the name of the involved person in First, Middle, and Last name sequence.

19. Date of Birth: Enter the Date of Birth of the involved person. (Auto-populated by SIS)

20. Gender: Place a checkmark next to the appropriate response. (Auto-populated by SIS)

21. Hire Date: Enter the date that the involved person was hired by TSA. If a contractor, enter the date that the contract began. (Auto-populated by SIS)

22. Employment: Place a checkmark next to the appropriate employment held by the involved person. For any other type of employment, check ‘Other’ and provide an employment description.

23. Work Shift: Place a checkmark next to the appropriate type of work shift the involved person was working at the time of incident. Note: FT = Full Time, Conv = Conventional, Comp = Compressed

24. Home Address: Enter the current home address, telephone number and email address for the involved person. (Auto-populated by SIS)

25. Work Address: Enter the current work address, telephone number and email address for the involved person. (Auto-populated by SIS)

26. Job Title: Enter the correct occupational title for the position held by this involved person.

26a. Contract Name: If the involved person is a contractor, enter the contract name. (For use only with personal service contractor incidents.)

26b. Start Date: If the involved person is a contractor, enter the contract award date.

27. Supervisor Name: Enter the name of the supervisor managing the involved person.

28. Supv. Phone: Enter the telephone number of the supervisor managing the involved person.

29. Supv. Email: Enter the work email address for the supervisor managing the involved person.

30. Tasks Performed at

Time of Incident:

Describe in detail, the tasks that this involved person was performing at the time the incident occurred.

31. Experience in Task: Place a checkmark next to the most appropriate response. Note: Experience in Task should reflect the length of time that the involved person has performed the task in which the incident occurred, and not necessarily the length of time employed by TSA.

32. Time Work Began on Date of Incident:

Enter the time that the involved person began their work shift on the date of incident. Required for OSHA 301, Report of Work-Related Injury or Illness, and OSHA 300, Log of Work Related Injuries or Illnesses.

33. Incident Occurred: Place a checkmark in the appropriate selection to indicate whether the incident occurred on duty or off duty.

34. What was the employee doing just before the incident occurred:

Describe in detail the tasks or actions taken by the employee just before the incident occurred. Note:

This is not the same as item 30, Tasks Performed at Time of Incident, and should only reflect the activities leading up to the incident. Required for OSHA 301, Report of Work-Related Injury or Illness, and OSHA 300, Log of Work Related Injuries or Illnesses.

35. What happened: Describe in your own words, the details of the incident as they relate to the involved person. Include ‘who,’ ‘what,’ ‘when,’ ‘where,’ and ‘how’ in this description. Required for OSHA 301, Report of Work-Related Injury or Illness, and OSHA 300, Log of Work Related Injuries or Illnesses.

36. Employee Statement Provided:

Place a checkmark in the appropriate response to whether the employee provided a statement of incident. If yes, then enter the statement date in item 36a.

37. PPE Required for Task: Identify any Personal Protective Equipment (PPE) that must be used by the involved person for the task being performed. Indicate whether the PPE was available at the time the task was performed in item 37a, and indicate in item 37b whether the PPE was in use at the time of the incident.

38. Outcome: Place a checkmark next to the response that best describes the outcome of this incident as it relates to this involved person. A Traumatic injury occurs within one work shift and is identifiable as to a time and place of occurrence. An Occupational Disease or Illness usually presents symptoms over a period of time greater than one work shift. If no injury exists, such as in a motor vehicle or property damage incident without injury, then check ‘No Injury.’ When Occupational Disease or Illness is selected, enter the first date of onset in item 38a.

Completing Section B – INVOLVED PERSONS (Continued) # Item Name Instruction

39. Severity of Injury: Place a checkmark next to the highest level of severity experienced by this involved person. For example, you would check the Lost Time checkbox instead of the restricted duty checkbox for an injured employee who is currently on restricted duty but lost two work days at the onset of the injury.

‘No Injury’ responses in this item should correlate with ‘No Injury’ in Item 37 Outcome.

40. Caused by Work Activity:

Indicate whether or not the injury or illness experienced by this involved person was caused by work activity. This data field correlates to the ‘Work Environment Exceptions’ outlined in 29 CFR 1904.5(b) (2) and should only be marked as ‘not caused by work activity’ when one of these nine reasons exists or when OWCP denies the employee’s workers’ compensation claim.

41. Poisoning: Indicate whether or not poisoning was a causal factor to the injury or illness of this involved person.

42. Loss of Consciousness: Indicate whether the involved person lost consciousness as a result of the incident.

43. Needle Stick/Sharps

Involved:

Indicate whether the involved person was stuck either by a needle or a sharp device. If ‘Yes,’ then record the disposition of that needle or sharp in item 43a.

44. Privacy Case: Indicate whether the involved person’s personal information must be omitted from the TSA Form 2401, OSHA 301 Incident Report, or the OSHA 300 Log as prescribed in 29 CFR 1904.29(b). If ‘Yes,’ then enter the reason(s) in item 44a.

45. Cause of Injury: Enter the appropriate injury type code as outlined in Appendix B ‘Causes of Injury Codes.’

46. Event Type: Enter the appropriate cause of injury code as outlined in Appendix C ‘Event Type Codes.’

47. Source of Injury: Enter the appropriate sources of injury code as outlined in Appendix D ‘Sources of Injury Codes.’

48. Nature of Injury: Enter the appropriate nature of injury code as outlined in Appendix E ‘Natures of Injury Codes.’

49. Body Part: Enter the appropriate anatomical location code as outlined in Appendix F ‘Body Part Codes.’

50. First Aid Administered: Indicate whether first aid medical treatment was provided to this involved person as defined in 29

CFR 1904.7(b) (5) (ii). If response is ‘Yes,’ describe the first aid treatment in item 50a.

51. Medical Treatment

Beyond First Aid:

Indicate whether medical treatment went beyond what is defined as ‘First Aid.’ If response is ‘Yes,’ then enter the date of first medical examination in item 51a, Date, and the health care provider information in item 53a, Physician or Emergency Room Information.

52. Details: If medical treatment was administered beyond first aid, enter details about that medical visit.

53. Emergency Room: Indicate whether the involved person was treated at an emergency room. If response is ‘Yes,’ record the name of the emergency room in item 53a, Physician or Emergency Room Information.

54 Hospitalized Overnight as Inpatient:

Indicate whether the involved person was admitted to a hospital as an in-patient with an overnight stay. If ‘Yes,’ then enter the number of days that the involved person stayed in the hospital, and enter the hospital information in item 54a.

56. Lost, Restricted or Transfer:

Record any lost days, restricted duty days, and/or transfer duty date ranges incurred by this involved person. If lost, restricted, or transfer days are continuing past the date that the investigation report is completed, place a checkmark in the ‘Estimated’ box and enter any comments you may have.

Completing Section C – MOTOR VEHICLE DAMAGE If no motor vehicles were involved in the incident, place a checkmark in the appropriate box in the header of this section and continue to Section D – Property and Equipment Damage

# Item Name Instruction

57. Vehicle Number: Enter the vehicle number for this involved vehicle. Use 001 for the first vehicle, 002 for the second, and so on.

58. Type: Place a checkmark in the appropriate box to best describe the involved vehicle. If none of the listed types apply, place a checkmark in the ‘Other Light Vehicle’ or ‘Other Heavy Vehicle’ box, as appropriate.

59. TSA Damage: If this involved motor vehicle is a TSA motor vehicle, enter the total cost of damage to the TSA motor vehicle. This would include GSA-leased vehicles.

60. Non-TSA Damage: If this involved motor vehicle is a non-TSA motor vehicle (private or commercial vehicle), enter the total cost of damage to non-TSA motor vehicle.

61. Total Damage: Enter total damage for all involved motor vehicles.

You must then assign any involved persons to the involved motor vehicle that they were driving in, riding in, or struck by. Enter the Person ID as contained in Item 17. Indicate their placement in the vehicle, and record seatbelt use where appropriate. Finally, indicate whether the involved person’s injury was deemed recordable under OSHA recordkeeping guidelines.

Completing Section D – PROPERTY AND EQUIPMENT DAMAGE If no property or equipment was damaged or involved in the incident, place a checkmark in the appropriate box in the header of this section and continue to Section E – Causal/Contributory Factors

# Item Name Instruction

62. Property or Equipment

Type:

Place a checkmark in the appropriate box to best describe the property or equipment type. If none of the listed types apply, place a checkmark in the ‘Other’ box and enter a description of the actual property or equipment damaged.

63. Manufacturer: Enter the name of the manufacturer of the property or equipment that is damaged as a result of the incident. For facilities, enter the leasing company or owner of the facility.

64. Make: Enter the Make of the property or equipment that is damaged; leave blank for facility damage.

65. Model: Enter the model name or model number of the property or equipment that is damaged. Leave this blank for facility damage.

66. Damage Description: Describe fully, the damage to the property, equipment, or facility.

67. TSA Damage Amount: If this involved property or equipment is owned by TSA, enter the total cost of damage to the TSA property or equipment.

68. Non-TSA Damage

Amount:

If this involved non-TSA property or equipment, enter the total cost of damage to non-TSA property or equipment.

69. Total Damage Amount: Enter total damage for all involved properties and equipment.

Completing Section E – CAUSAL/CONTRIBUTORY FACTORS

# Item Name Instruction

70. Causal or Contributory

Factors:

Enter any factors that may have contributed or caused this incident to occur. Use the ‘Group’ column to outline the high-level factors and the ‘Type’ column to further define the factor. Enter either ‘Causal’ or ‘Contributory’ in the ‘Assessment’ column. Enter any additional information in the ‘Comment’ data field. Use Appendix G as a guide for this section.

Completing Section F – DISPOSITION OF INCIDENT # Item Name Instruction

71. Corrective Actions: Enter recommendations for corrective actions in the ‘Recommendation’ column. Identify the estimated cost to implement the recommendation, when known in the ‘Est. Cost’ column. If the recommendation has already been implemented, check ‘Yes’ in the ‘Implemented?’ column, otherwise check ‘No’. If implemented, enter the actual cost of implementation in the ‘Act. Cost’ column. Enter the person or entity that implemented the recommendation in the ‘By:’ column and the date of implementation in the ‘Date’ column.

72. Inspection needed: Check ‘Yes’ if further inspection is required from an independent entity, otherwise check ‘No.’ In SIS, record a request for inspection as an additional recommendation.

73. Date Requested: Enter the date that the MSC OSH Specialist was notified that an inspection was requested.

74. Requested by: Enter the full name of the person who made the request to the MSC OSH Specialist.

75. Type of Inspection: Document the type of inspection that is requested, (i.e., noise study, air quality sampling, etc.).

76. Status of Request: Indicate the stats of the inspection request at the time TSA Form 2401 is completed by the investigator.

77. Reason for Denial of

Inspection:

If the request for inspection is denied, either by the MSC OSH Specialist or TSA HQ OSHE, indicate the reason provided here.

78. Status: Enter the most appropriate disposition status for the incident.

79. Investigation Summary: Summarize the investigation process and any findings of importance to support the determination of causal factors and recommendations for corrective actions. Enter into the Investigation Segment— Conclusion data field in SIS.

Completing Section G – CERTIFICATION AND SIGNATURE # Item Name Instruction

80. Report Prepared by: Print or type the full name of the person preparing the investigation report. This should be the person leading the investigation.

81. Title: Enter the title of the person preparing the investigation report.

82. Signature: The lead person conducting the investigation must sign the report in this area no later than 7 working days after first notification of the incident.

83. Date Prepared: Enter the date that the investigation report was completed.

84. Reviewed by: Print or type the full name of the CDSO or DOSHO reviewing the investigation report.

85. Date Reviewed: Enter the date that the investigation report was reviewed.

APPENDIX A – INCIDENT SEVERITY CODES GROUPED BY INCIDENT TYPE

INJURY and ILLNESSES Severity

Class Severity Title Severity Description

A Fatality When a work-related traumatic injury or occupational disease or illness results in death.

A Injury - Permanent Total

Disability When work-related traumatic injury results in a permanent total disability, (Maximum Medical Improvement (MMI)). DO NOT code an incident with this severity classification when lost time is incurred, but full or partial recovery and a return to duty is expected.

A Illness - Permanent Total Disability

When a work-related occupational disease or illness results in a permanent total disability, (Maximum Medical Improvement (MMI)). DO NOT code an incident with this severity classification when lost time is incurred, but full or partial recovery, and a return to duty is expected.

B Injury - 3 or More Employees Hospitalized

When a work-related traumatic injury results in in-patient hospitalization of three or more employees. In-patient hospitalization requires admittance to a hospital and does not include waiting time in an emergency room, or held for observation or diagnostic testing.

B Illness - 3 or More Employees Hospitalized

When a work-related occupational disease or illness results in in-patient hospitalization of three or more employees as a result of a work-related incident. In-patient hospitalization requires admittance to a hospital and does not include waiting time in an emergency room, or held for observation or diagnostic testing.

B Injury - Partial Disability When a work-related traumatic injury results in a permanent partial disability, (Maximum Medical Improvement (MMI)). DO NOT code an incident with this severity classification when restricted duty is incurred but a return to full duty is expected.

B Illness - Partial Disability When an occupational disease or illness that results in a permanent partial disability, (Maximum Medical Improvement (MMI)).

DO NOT code an incident with this severity classification when restricted duty is incurred but a return to full duty is expected.

C Injury - Lost Work Days Incurred

When a work-related traumatic injury results in a temporary disability and a return to either restricted or full duty is expected.

C Illness - Lost Work Days Incurred

When a work-related occupational disease or illness results in a temporary disability and a return to either restricted or full duty is expected.

D Injury - OSHA Recordable, Restricted Duty Incurred

When a work-related traumatic injury results in temporary work restrictions and a return to full duty is expected.

D Illness - OSHA Recordable, Restricted Duty Incurred

When a work-related occupational disease or illness results in temporary work restrictions and a return to full duty is expected.

D Injury - OSHA Recordable, No Lost Work Days

When a work-related traumatic injury does not result in permanent or temporary disability; or restricted duty, but is otherwise considered as OSHA recordable, (i.e., medical treatment beyond first aid, prescription drugs, etc.).

D Illness - OSHA Recordable, No Lost Work Days

When a work-related occupational disease or illness does not result in permanent or temporary disability or restricted duty, but is otherwise considered to be OSHA recordable, (i.e., medical treatment beyond first aid, prescription drugs administered, etc.).

E Injury - OSHA First Aid Only When a work-related traumatic injury is not considered to be OSHA recordable because only first aid medical treatment or diagnostic testing was performed or a work environment exception exists.

E Injury - OSHA First Aid Only When a work-related occupational disease or illness is not considered to be OSHA recordable because only first aid medical treatment or diagnostic testing was performed or a work environment exception exists.

MOTOR VEHICLE, PROPERTY, EQUIPMENT, OR FACILITY DAMAGE

Severity

Class Severity Title Severity Description

A Equipment Damage > $99,999 When motor vehicle, property, or equipment damage is valued at $100,000 or more. NOTE: When combined with an Injury/Illness incident type, record the highest level of severity from all applicable severity classifications.

A Facility Damage > $99,999 When TSA owned/leased facility damage is valued at $100,000 or more. NOTE: When combined with an Injury/Illness incident type, record the highest level of severity from all applicable severity classifications.

B Equipment Damage $10,000 - $99,999

When motor vehicle, property, or equipment damage is valued between $10,000 and $99,999.99. NOTE: When combined with an Injury/Illness incident type, record the highest level of severity from all applicable severity classifications.

B Facility Damage $10,000 - $99,999

When TSA owned/leased facility damage is valued between $10,000 and $99,999.99. NOTE: When combined with an Injury/Illness incident type, record the highest level of severity from all applicable severity classifications.

C Equipment Damage $500.01 -

$9,999.99 When motor vehicle, property, or equipment damage is valued between $500 and $9,999.99. NOTE: When combined with an Injury/Illness incident type, record the highest level of severity from all applicable severity classifications.

C Facility Damage $500.01 - $9,999.99

When TSA owned/leased facility damage is valued between $500 and $9,999.99. NOTE: When combined with an Injury/Illness incident type, record the highest level of severity from all applicable severity classifications.

D Equipment Damage < $500 When motor vehicle, property, or equipment damage is valued at less than $500.00. NOTE: When combined with an Injury/Illness incident type, record the highest level of severity from all applicable severity classifications.

D Facility Damage < $500 When TSA owned/leased facility damage is valued at less than $500.00. NOTE: When combined with an Injury/Illness incident type, record the highest level of severity from all applicable severity classifications.

APPENDIX B – CAUSE OF INJURY CODES

CAUSE OF INJURY

COD

E CAUSE OF INJURY

COD

E Accidental shooting 96 Handling cable, rope, nets, chains, etc. 36 Aircraft 02 Handling electrical equipment 45 Animals, insects 95 Handling fire extinguishers 48 Anthrax 1A Handling hand trucks, dollies 34 Carbon dioxide 21 Handling magazines, paper 46 Carbon monoxide 16 Handling or using ladders 41 Cave-ins 88 Handling or using scaffolds 42 Changing tires 50 Handling pallets and hatch boards 44 Cranking motors 49 Handling stone, clay, glass, cement 39 Dog bites 98 Handling tool boxes 47 Drowning 89 Handling trash 40 Electricity 12 Handling unpackaged fabric containers 30 Elevator 04 Handling unpackaged fabrication metals 26 Enemy action 97 Handling unpackaged furniture, office equipment 33 Explosion 10 Handling unpackaged lumber, dunnage 32 Fall from chair, stool, rest bar, bench 69 Handling unpackaged machinery 28 Fall from desk, table, or workbench 70 Handling unpackaged misc. mail containers 31 Fall from hill, slope 75 Handling unpackaged tools, instruments 29 Fall from ladder 68 Handling unpackaged vehicular equipment 27 Fall from piled, stacked cargo 74 Handling wire 38 Fall from ramp, runway, gangplank 76 Jumping to or from places 83 Fall from scaffold, staging, platform 67 Machinery 87 Fall from stopped vehicle 79 Objects from machinery 62 Fall getting on/off elevator 80 Oil 17 Fall inside moving vehicle 81 Other dust, gas, or chemical 23 Fall into hold, hatch, manhole, chute 71 Other falling objects 63 Fall off dock 77 Other falls 82 Fall off machinery 78 Other manual handling and equipment 51 Fall on deck 72 Packaged material handling, weight stated 24 Fall on road, highway, or street 73 Packaged material handling; weight not stated 25 Fall/slip on floor, work surface, aisleway 64 Paint, paint fumes, lead 15 Fall/slip on stairway, steps 65 Poison ivy, oak, sumac 94 Fall/slip on walkways, curbs, porches 66 Pressure equipment 09 Falling cargo, stacked or piled 59 Railroad and street cars 01 Falling desk or chair 52 Silica 22 Falling file case, or objects from 61 Slip on or in, not falling 91 Falling hand truck, dolly, etc. 54 Slip, twist, trip, not falling 92 Falling objects, ladder 55 Solvents 19 Falling objects, scaffold 56 Strike against material equipment 84 Falling objects, shelving 58 Unclassified 99 Falling objects, wall/ceiling radiator 60 Using gangways or platforms 43 Falling objects, window/window ledge 57 Using windows or doors 37 Falling workbench, table 53 Vehicle: driver 05 Fiberglass 20 Vehicle: passenger 06 Fire/smoke 11 Vehicle: pedestrian 07 Flash burn 13 Violence 90 Flying particles 85 Watercraft 03 Galvo fume poisoning 14 Weather exposure 93 Hand tools 86 Working on/around vehicles 08 Handling bombs, shells, cannons, guns 35 Zinc 18

APPENDIX C – EVENT TYPE CODES

CODE EVENT TYPE DESCRIPTION

100 STRUCK

110 Struck by

111 Struck by falling object 120 Struck against

200 FELL, SLIPPED, TRIPPED

210 Fell on same level 220 Fell on different level

230 Slipped, tripped (no fall)

300 CAUGHT

310 Caught on

320 Caught in 330 Caught between

400 PUNCTURED, LACERATED

410 Punctured by

420 Cut by 430 Stung by 440 Bitten by

500 CONTACT

510 Contact with (motion of person)

511 Rubbed, Abraded 520 Contact by (motion of object)

600 EXERTION

610 Lifted, strained by (single action) 620 Stressed by (repeated action)

700 EXPOSURE

710 Inhalation

720 Ingestion 730 Absorption

800 TRAVELING IN

999 UNCLASSIFIED/INSUFFICIENT DATA

APPENDIX D – SOURCE OF INJURY CODES

COD

E SOURCE DESCRIPTION

COD

E SOURCE DESCRIPTION

0100 BUILDING OR WORKING AREA 0620 Fibers 0110 Walking/working surface 0621 Asbestos 0120 Stairs, steps 0630 Gases 0130 Ladder 0631 Carbon monoxide 0140 Furniture, furnishings, office equipment 0640 Mist, steam, vapor, fume 0150 Boiler, pressure vessel 0650 Particles (unidentified) 0160 Equipment layout (ergonomic) 0700 CHEMICAL, PLASTIC, ETC.

0170 Windows, doors 0710 Chemical, dry 0180 Electric, electricity 0711 Corrosive 0200 ENVIRONMENTAL CONDITION 0712 Toxic 0210 Temperature extreme (indoor) 0713 Explosive 0220 Weather (ice, rain, heat, etc.) 0714 Flammable 0230 Fire, flame, smoke (not tobacco) 0720 Chemical, liquid 0240 Noise 0721 Corrosive 0250 Radiation 0722 Toxic 0260 Ventilation 0723 Explosive 0271 Tobacco smoke 0724 Flammable 0280 Stress (emotional) 0730 Plastic 0290 Confined space 0740 Water 0300 MACHINE OR TOOL 0750 Medicine 0310 Hand tool (powered) 0800 INANIMATE OBJECT 0320 Hand tool (non-powered) 0810 Box, barrel, container, etc.

0330 Mechanical power transmission apparatus 0820 Paper 0340 Guard, shield (fixed, movable, deadman) 0830 Metal item, mineral 0350 Video display terminal 0831 Needle 0360 Pump, compressor, air pressure tool 0840 Glass 0370 Heating equipment 0850 Scrap, trash 0380 Welding equipment 0860 Wood 0400 VEHICLE 0870 Food 0410 Private vehicle (includes rental) 0880 Personal clothing, apparel, shoes 0411 As driver 0900 ANIMATE OBJECT 0412 As passenger 0910 Animal 0420 Government Vehicle 0911 Bite (dog) 0421 As driver 0912 Bite (other) 0422 As passenger 0913 Disease 0430 Common carrier (air, bus, cab, etc.) 0920 Plant 0440 Air (not commercial scheduled) 0930 Insect 0450 Boat, ship, barge 0940 Human (violence)

MATERIAL, HANDLING

EQUIPMENT 0950 Human (communicable disease)

0510 Earthmover (tractor, backhoe, etc.) 0960 Bacteria, virus (not contact) 0520 Conveyor (for material and equipment) 1000 PERSONAL PROTECTIVE EQUIPMENT 0530 Elevator, escalator, personnel hoist 1010 Protective clothing, shoes, glasses, goggles 0540 Hoist, sling chain, jack (for material and 1020 Respirator, mask 0550 Forklift, crane 1021 Diving equipment 0560 Hand trucks, dollies 1030 Safety belt, harness 0600 DUST, MIST, VAPOR, ETC. 1040 Parachute 0610 Dust (silica, coal, grain, cotton) 9999 UNCLASSIFIED/INSUFFICIENT DATA

APPENDIX E – NATURE OF INJURY CODES (Use only Traumatic Injury Codes for injuries, all others for occupational disease or illnesses.)

CATEGORY NATURE OF INJURY CODE CATEGORY NATURE OF INJURY CODE

Traumatic (T) Amputation TA Musculoskeletal and Connective Tissue (M) Carpal tunnel syndrome MC

Traumatic (T) Back strain TB Musculoskeletal and Connective Tissue (M) Chondromalacia MK

Traumatic (T) Burn, scald, sunburn TU Musculoskeletal and Connective Tissue (M)

Degenerative disc disease, spondylosis, spondylitis MD

Traumatic (T) Cerebral vascular condition;

stroke T1 Musculoskeletal and

Connective Tissue (M) Inflammatory disease (including bursitis, tendonitis) MI

Traumatic (T) Concussion TK Musculoskeletal and Connective Tissue (M) Not otherwise classified M9

Traumatic (T) Contusion, bruise, abrasion TC Occupational Disease - non-complex (O) Food poisoning OF

Traumatic (T) Crush injury TJ Occupational Disease - non-complex (O) Inguinal hernia OL

Traumatic (T) Dislocation TD Occupational Disease - non-complex (O) Pregnancy (Peace Corps only) OP

Traumatic (T) Exposure (e.g., frostbite, heat stroke, exhaustion) TE Occupational Disease - non-complex (O) Tooth or gum-related problems OG

Traumatic (T) Food poisoning TQ Other Disability Occupational (D) Hearing loss DH

Traumatic (T) Foreign body in eye TV Other Disability Occupational (D)

Mental disorder; emotional condition;

nervous condition DM

Traumatic (T) Fracture TF Other Disability Occupational (D)

Nerve injury, (e.g., paralysis after exposure to toxins) DN

Traumatic (T) Hearing loss T2 Other Disability Occupational (D) Radiation DR

Traumatic (T) Heart condition T3 Other Disability Occupational (D)

Tumors and other cancer-related conditions DT

Traumatic (T) Hernia (inguinal) TH Other Disability Occupational (D) Vision/sight loss DI

Traumatic (T) Insect bite TY Skin disease (S) Biological (e.g., poison ivy/oak) SB

Traumatic (T) Laceration, cut TL Skin disease (S) Chemical SC

Traumatic (T) Mental disorder, stress, nervous condition T4 Skin disease (S) Dermatitis, not otherwise classified S9

Traumatic (T) Puncture (not insect bite) TP Skin disease (S) Skin lesion (including blister, bunion, callus, and corn) SL

Traumatic (T) Respiratory disease TR Respiratory Diseases (R) Asbestosis RA

Traumatic (T) Skin diseases (e.g., dermatitis) TI Respiratory Diseases (R) Bronchitis, asthma RB Traumatic (T) Strain (not back) TS Respiratory Diseases (R) Emphysema RE

Traumatic (T) Tooth injury TT Respiratory Diseases (R) Not otherwise classified R9 Traumatic (T) Tuberculosis TW Respiratory Diseases (R) Pneumoconiosis (black lung) RP Traumatic (T) Unclassified T8 Respiratory Diseases (R) React to smoke, fumes, chemicals RR

Traumatic (T) Virological, infective, parasitic disease TX Respiratory Diseases (R) Silicosis RS

Cardiovascular,circulatory

(C) Angina CA Virological diseases (V) Acquired immune deficiency syndrome (AIDS) and HIV VA

Cardiovascular,circulatory

(C) Blood disorder CB Virological diseases (V) Brucellosis VB

Cardiovascular,circulatory

(C) Heart attack CM Virological diseases (V) Hepatitis VH

Cardiovascular,circulatory

(C) Hypertension CH Virological diseases (V) Lyme disease VL

Cardiovascular,circulatory

(C) Not otherwise classified C9 Virological diseases (V) Malaria VM

Cardiovascular,circulatory

(C) Phlebitis, varicose veins CP Virological diseases (V) Not otherwise classified V9

Cardiovascular,circulatory (C)

Stroke, cerebral vascular condition CS Virological diseases (V) Parasitic diseases VP

Gastrointestinal (G) Hiatal, umbilical, or ventral hernia GH Virological diseases (V) Rocky Mtn. spotted fever VR

Gastrointestinal (G) Not otherwise classified G9 Virological diseases (V) Staphylococcus VS

Gastrointestinal (G) Ulcer GU Virological diseases (V) Tuberculosis VT Musculoskeletal and Connective Tissue (M) Arthritis MA Virological diseases (V) Valley fever (Coccidioidomycosis) VC

Musculoskeletal and Connective Tissue (M) Back or neck strain, sprain MB

APPENDIX F - BODY PART CODES

SYSTEM BODY PART CODE SYSTEM BODY PART CODE

Body Systems Heart VH Trunk Abdomen BA Body Systems Kidney - Both V4 Trunk Breast - Single B1

Body Systems Kidney - Single V3 Trunk Breasts - Both B2 Body Systems Liver VL Trunk Chest BC

Body Systems Lung - Both V2 Trunk Clavical (Collar Bone) - Single R1 Body Systems Lung, Single V1 Trunk Clavicles (Collar Bones) - Both R2 Body Systems Reproductive Organs VR Trunk Lower Back BL

Body Systems Stomach VS Trunk Not Otherwise Classified BZ Body Systems Trunk, Internal Unclassified VZ Trunk Penis BP

Body Systems Trunk, Internal Unknown VI Trunk Rib RB Head and Neck Brain CB Trunk Scapula (Shoulder Blade) - Single R3

Head and Neck Chin HC Trunk Scapula (Shoulder Blades) - Both R4 Head and Neck Cranial Bones CC Trunk Shoulder - Single SS Head and Neck Ear (External) - Single H3 Trunk Shoulders - Both SB

Head and Neck Ear (Internal) - Single C1 Trunk Side BS Head and Neck Ears (External) - Both H4 Trunk Sternum (Breast Bone) RS

Head and Neck Ears (Internal) - Both C2 Trunk Testicle - Single B3 Head and Neck Eye (External) - Single H1 Trunk Testicles - Both B4 Head and Neck Eye (Internal) - Single C3 Trunk Trunk, Bones Unclassified RZ

Head and Neck Eyes (External) - Both H2 Trunk Undefined BX Head and Neck Eyes (Internal) - Both C4 Trunk Upper Back BU

Head and Neck Face HF Trunk Vertebrae (Spine; Disc) RV Head and Neck Jaw CJ Trunk Waist BW

Head and Neck Mouth CM Upper Extremities Arm and/or Wrist - Single AS Head and Neck Mouth/Lips HM Upper Extremities Arm(s), Multiple Sites AX Head and Neck Neck/Throat HK Upper Extremities Arm(s), Other AZ

Head and Neck Nose CN Upper Extremities Arms and/or Wrists - Both AB Head and Neck Not Otherwise Classified CZ Upper Extremities Elbow - Single ES

Head and Neck Scalp HS Upper Extremities Elbows - Both EB Head and Neck Teeth CD Upper Extremities Fingers, Unknown FB Head and Neck Throat; Larynx Cl Upper Extremities First Finger - Single F1

Head and Neck Throat; Other CR Upper Extremities First Fingers - Both F2 Head and Neck Tongue CT Upper Extremities Forearm - Single A3

Lower Extremities Feet - Both PB Upper Extremities Forearms - Both A4 Lower Extremities Foot - Single PS Upper Extremities Fourth Finger - Single F7

Lower Extremities Hips/Thighs - Both L1 Upper Extremities Fourth Fingers - Both F8 Lower Extremities Knee - Single KS Upper Extremities Hand - Single MS Lower Extremities Knees - Both KB Upper Extremities Hands - Both MB

Lower Extremities Leg(s), Multiple Sites LS Upper Extremities Second Finger - Single F3 Lower Extremities Leg(s), Other LX Upper Extremities Second Fingers - Both F4

Lower Extremities Leg/Hip/Ankle/Buttock - Single LB Upper Extremities Third Finger - Single F5

Lower Extremities Legs/Hips/Ankles/Buttocks - Both L4 Upper Extremities Third Fingers - Both F6

Lower Extremities Lower Leg/Ankle - Single L2 Upper Extremities Thumb - Single TS Lower Extremities Lower Leg/Ankles - Both L3 Upper Extremities Thumbs - Both TB Lower Extremities Toe Other - Single G3 Upper Extremities Upper Arm - Single A1

Lower Extremities Toe, Great - Single LZ Upper Extremities Upper Arms - Both A2 Lower Extremities Toes Other - Multiple G4 Upper Extremities Wrist - Single A5

Lower Extremities Toes, Great - Both G2 Upper Extremities Wrists - Both A6

APPENDIX G - CAUSAL/CONTRIBUTORY FACTORS

Group Type Group Type Animals / Insects Dog not muzzled Ergonomic Factors

(cont'd) Other - Specify in description field

Dog not restrained Repetitive motion Insect nest nearby Rough surfaces Other - Specify in description field Sharp projections Uncontrolled vermin Travel Distance

Vibration Environmental Air pressure (bends, decompression, altitude) Workstation layout / design deficiency

Brightness, glare Workstation too high Clear/dry, visibility unlimited Dark, dim Firearms Accidental discharge Dust, fumes, gasses, smoke, vapors Fog, condensation, frost Human Factors Alcohol use Uneven surfaces (Holes, rocky rough, rutted) Distraction Incline (gradual, steep) Drug Abuse Lightning, static electricity, ground Electrical cord not replaced Rain, sleet, hail, mist Employee has history of not following safe practices Noise, bank, static Failure to detect warning Other - Specify in description field Failure to yield right of way Radiation, laser, sunlight Fear/excitement Slippery (not due to precipitation) Following too closely Snow, ice Ground pin removed Storm, hurricane, tornado Guard removed Temperature/humidity (cold, heat) Improper backing Vibration (shimmy, sway, shake) Improper Use of Equipment Wind gust/turbulence In a hurry

Inattention Equipment Alarm failure Job hazard analysis conducted but not followed

Alarm not detected Lack of rest/sleep Alarm not present Misjudged clearance Bent/warped Other - Specify in description field Cold surfaces Overconfident in own/other's abilities Compressed/hit/punctured Poor/bad attitude Controls malfunctioned Prescription drug use Corroded/rusted/pitted Restricted vision Decayed/decomposed Safety feature disabled Design deficiency Task conducted under emergency conditions Electric current action Task performed alone, help needed Electrical shock Training course was not sufficient Equipment failure Froze (temperature) Management Policies ADA accommodations not provided Hot surfaces not insulated HazCom Program not adequate or not implemented Indicator failure Job hazard analyses not required or completed Indicator value inaccurate Lack of supervision Moving parts guard failure Not enforced Moving parts not guarded Other - Specify in description field Not suited for duty cycle Safety and Health Program not enforced Not suited for task / load Tasks requirements not communicated effectively Obstructed/pinched/clogged Other - Specify in description field Personal Protective

Equipment Other -…