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HomeMy WebLinkAboutDocumentation_Safety_Tab 4A_10/9/1997 WATER DEPARTMENT SUPERVISOR'S ACCIDENT INVESTIGATION REPORT Employee Name 14'ti0/21 rie.% Date of Accident ) g 7 - 99 Location of Accident t4.Pf7 L PLAIOr Time.of Accident /off.30 P ' Occupation of Employee�[ t17" Ok Injury CCU 04) l'114xp Witness PogY6 Reviewed by Management Employee's description of accident. kO CA-Me, u1P ©ti RA-WE W C--- Jv fl1€ P ts' - 40, Ds, 4-14ar.- Parr What acts, failures to act and/or conditions contributed most directly to this accident? it) LIP no W Ta ko- Aiv Ately (t-r1.1- cy-r 1 ( 1;110eA,, �r � What are the reasons for the existence of these acts and/or conditions? 1- d1il Iq1ev Lf P'i 1s b5s(C aF `7` R149144. P 2 «_ G1 4 , C',2 � fr Pi ii C n)6l-n7371)r What is the plan of action to prevent recurrence? 1A'�6 E PL CMG L 7h ?_ L✓t ry & iv it.bea-ii01,- 02 U L ex) Pao& /90 %Ua'L rz.s6 . Supervisor's Comments: _ArS 0-u4,C frd4/.Elt W;TAP PL mob J r 2C C-1 H11 7a axe. Investigated by: 1-a(A ( S F 3ItiDiV Reviewed by: 01_rIS/ Pr Date: 1 3O ^ Date: 2- i9`77