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HomeMy WebLinkAboutDocumentation_Safety_Tab 4A_2/6/1998 -A- WATER DEPARTMENT SUPERVISOR'S ACCIDENT INVESTIGATION REPORT Employee Name k R) 7f itT Date of Accident J + a-7 - 99 Location of Accident WA-MI- PL4' )t Time of Accident f :30 N Occupation of Employee -e[,A-Or Okalfait. Injury CCU' DA) N11-x1,6 Witness poto6 Reviewed by Management Employee's description of accident. RAI0b &i*ie LAP ©,J F -wre WEe -I r P CpeuAGO � A Cam►—' oiJ kf -A)f . What acts, failures to act and/or conditions contributed most directly to this accident? PLUid r►t, uP ©>a vU fa.-1c3e Po --r' r IJ m /gym 12- 7724(R-707,ract (pi It)eAt poceor) What are the reasons�foorr the existence of these acts and/or conditions? 114� F/y(,v 'N_�c r c..26 (S J(G-A) ©F '7i Res—to _ What is the plan of action to prevent recurrence? 02 i CU L rate, f 7Y ) j Tot tJ,s5 Supervisor's Comments: rScu � �'�/�� Cc.) 77-1- PL P � Mob r/2C- ( 7-ea-� axe, Investigated by: 1-0(.A. 1 S !'Al 1, Reviewed by: Attime L Date: 1 3O ^ Date: 2- b'?7