Law Department notice on WTC document preservation, Oct 2001

NYC 9/11 Public Portal Document

WRS INFRASTRUCTURE & ENVIRONMENT, INC. INJURY/ILLNESS/INCIDENT INVESTIGATION AND REPORT (OSHA 301 Form Equivalent) Supenrisor Complete Both Pages/Forward to Branch and WRS H&S Manager within 48 hrs./Supervisor's Manager Review for Completeness

1. Case Number I 2. Soc. Sec. No. I 3. Name (Last name, first initial) 5. Date of Birth 6. Gender I 7. Date of Hire □ MDF 11. Time of Accident 12. Time Employee 8. Job or Site Name

13. Date of Accident ___J 14. Date Reported 9. Job Number

15. Number Of Others Began Work Involved In Accident

16. Occupation at Accident Time I 17. Regular Occupation 18. Number of Others Injured in Accident 19. Nature of Injuries (Bruise, Strain, etc.) 20. Injured Body Part (left index finger)

21. Names of Others Involved In Accident 22. Names of Others Injured in Accident

23. Chemicals Involved in Accident I 24. Exact Location of Accident 25. On WRS Premises? I (Sketch on Back) □ Yes ONo 26. Activity Injured was doing at time of accident or Illness (operating backhoe, unloading drums, etc.) -Try to Identify Job In three words -use no more than 30 spaces I I I I I I I I I I I I I 1 I I I I I I I I I I I I I I I I 27. What Occurred (Use single line descriptive sentences to tell the story of what occurred)

28. Check Type of Accident (Check one) □ a. Struck by □ c. Contacted by □ e. Trapped in □ g Caught between □! Different level fall □ k. Exposure □ b. Struck against □ d. Contact with □ f. Caught on □ h Same level fall O J Strain/overexertion □ I. Other 29. Accident Agent (Limit io 21 spaces)(i.e., equipment machine, hand tool) 30. Contact Agent (IMt to 22 spaces)0.e.. machine part or material I I I I I I I I I I I I I I I I I I I I I contacting) I I I I I I I I I I I I I I I I I I I I I 31. UNSAFE ACTIONS - What did employee do or tell to do that 32. UNSAFE CONDITIONS - What condition of tools, equipment caused or contributed to accident? (Check no more than 2 give details or Job site caused or contributed to accident? (Check no mme than 2 onrm&rse) give details on reverse) □ a. Operating without authority □ i. Failure to make inoperative □ a.inadequate guard/Safety device □ h. Close dearance/oongesHon □ b. Failure to make secure □ J. Riding hazardous equipment □ b. Hazardous personal attire □ i. Hazardous arrange/storage □ a Operating unsafe speed □ k. Took unsafe position □ c. Inadequate warning system □ J. Defective tools/equipment □ d. Failure to watn/signal □ I. Horseplay, distractive □ d. Fire or Explosion hazard □ k. Atmospheric condition □ e. Nullified safety device □ m. No protective equip, worn □ e. Unsecured against movement □ I. Illumination/nolse □ f. Used defective equipment □ n. Unsafe Job procedure □ f. Poor housek^ing □ m. Other unsafe condition □ g. Used equipment unsafely □ o. No unsafe action □ g. Protruding object □ n. No unsafe condition □ h. Used wrong tool □ p. Other 33. What caused or Influenced unsafe actions you identified 34. What caused or Influenced unsafe condition you identified above? (Answer only if item 32 applies. Check no more than 2) above? (Answer only if Item 33 applies. Check no more than 2) □ a. Unaware of Job hazards □ h. Influence of emotions □ a. Caused by employee □ h. Preventive maintenance failure □ b. Inattention to hazard □ I. Influence of fatigue □ b. Defective from normal use □ i. Defective tools/equlpment □ c. Unaware of safe method □ J. Influence of Intoxicant/drugs □ c. Defective via abuse/misuse □ J. Exposure to corrosion □ d. Low level Job skill □ k. Defective vision □ d. Safety inspection failure □ k. Extreme temperature □ e. Tried to gain or save time □ I. Influence of illness □ e. Housekeeping/cleaning failure □ I. Caused by other employees □ f. Tried to avoid extra effort □ m. Other personal factors □ f. Faulty deslgn/constructlon □ m. Other source cause □ g. Tried to avoid discomfort □ n. Unknown personal factors □ g. Inadequate Illumination □ n. Unknown source cause 35. What action has been taken WarirX box) or Is planned /Marfr P box) to prevent recurrence: (Mark no more than S) X P X P X P □ □a. Reinsfruction of employee □ □ h. Action to improve enforcement □ □ o. Improve design/construction □ □ b.Reprimand/wamlng of employees involved □ □I. Order JSA done on Job □ □ p. Eliminate congestion □ □ c. Penally discipline of employe Involved □ □J. OrderJSArevision □ □q. Use safer Materials/supplies □ □.Preventhro Instruction of others who do Job □ □ k. Install safety guard against □ Dr. Improveillumination/ventilation □ De. Job reassignment of employee □ DI. Require protective equipment □ □s. Mandatory pre-Job instructions □ □ f. Improved inspection procedure □ □ m. repair/replace equipment □ □t Conectlon other than above □ □ g. Improved cleanup procedure □ □ n. Improve storage/arrangement □ □ u. No action required 36. Immediate Supervisor (Last name first, first initial) 37. Employee's Signature

38. Investigated by (Names and positions) Date 39. Reviewed and approved by (Name and portion) Date

Parti. Accident Description and Direct Cause Analysis IB as as 5/

-001 WRS Infrastructure and Environment, Inc. 27

NYC-WTC_000145104