0 State of California Department of Industrial Relations Division of Occupational Health and Sal'er 3419 Broadway Street. Suite H-S American Canyon, CA 94503 FIELD NOTES: I 05.5 I 95-036- 1 5 Establishment Name: Blue Apron Inc. Site Address 23151 Regatta Blvd. Building C60. Richmond, CA 94804 Mailing Address :3151 Regatta Blvd. Building C60, Richmond. CA 94804 April 13l 2015 Mr. Ronald Aruejo Associate Safety Engineer arrived at the site located at 3151 Regatta Blvd, Richmond, CA 94804 on 04/13/15 at approximately 10:45 A.M. Drove along Regatta Blvd. but cannot locate the site address. Called an off duty employee (previous complainant) and asked for direction. Drove to thejobsite at around 11:30 AM. Conducted an opening conference with Ms. Samantha Bruck, HR Manager, Mr. Raj Atisivan, Asst. General Manager and Mr. Trevor Hargreaves, Assistant General Manager. Credentials were presented along with an explanation or the purpose and scope of the inspection. Ms. Samantha Emck gave permission to Mr. Aruejo to take photographs and interview employees. Mr. Aruejo was accompanied by Ms. Samantha Bruclc Mr. Raj Atisivan and Mr. Trevor Hargreaves, during the inspection. Issued a Document Request completed for safety documentation that was not readily available. During the investigation, Ms. Samantha Buck, HR Manager informed the Division that an employee, Ms. Toiya Adams was seriously injured when the forklift was operating rolled on ils side pinning EEl's lefi leg between the floor and the broken side mirror of the forklifi. picked up a broken table in front of the loading area using the forks of the forklift and was on her way to deposit said broken table in the yard when the incident happened. There were no witnesses to EEl's accident. Per Ms. Samantha Bruck, 13131 is a warehouse Associate. During the walk around, Ms. Samantha 13ka showed the Division the forklift that used by during her accident. The forklifi is a propane gas driven forklifi of Nissan make with a chassis model #4 900985. It was observed that a pre-inspeetion checklist was performed but does not indicate who performed the pre-inspection check. The tires were also observed to be bald and worn out. A portion of the yard were forklifis will have to traverse regularly. Ms. Samantha Bruck also admitted that the forklifi is operated on a three dule. ht Interview three employees, All three employees showed etr eertt motion to operate a pa eI jaC a capacity 0 45 0 art a crown stand forklifi with a capacity of 4000. All three employees also arirnined that they have been assigned to operate the Nissan forklift at the yard. All three employees confirmed that they did not undergo an actual driving lest nor are they certified to operate the Nissan forklifi. EE2, E153 and EE4 also stated that there is a depression at the yard that always causes the forklifi to become unbalanced. Left the facility at 2:30 PM. April 14, 1015 lnterw'ewed injured employee. Toiya Adams (IE) at her residence. Per EEI, on 04/06/15 had to bring out two bales of card boards and to stack it at the back of the yard. however have to move a broken table that was blocking the loading area. then lifled up Ihe broken metal table using a fork of the forklifi. lifled the fork above her level and Iumed around the forklifi and drove towards a depository area. staled that as soon as the forklifi passed by the depressed are at the yard. the forklifi started to tilt on the driver's side. As soon as she made a right turn, the forklifl rolled over to its side. EEl's lefi foot was pinned in between the floor of the forklifi and the broken side mirror. sustained a deep laceration on the lower lefl leg, split lefl ankle and pressured heel. Sent an email ro Bruck, Alisivan and Hargreaves for additional doc. Request, April 15,2015 Called Eruck and Raj and discussed additional request, Resent emails to Bruck, -alled the Division and provided information relating lo the accident of Tciya Adams. Witness List Ms. Samantha Bruck, HR Manager, Blue Apron inc, Richmond, CA Mr. Raj Atisivan, AssL General Manager, Blue Apron Inc, Richmond, CA Mr. Trever Hargreaves, Asst. Geneml Manager. Blue Apron Inc.. Richmond. CA Mr. Ronald Amejo, Associate Safety Engineer, DOSHV RIDS. American Canyon, CA State of California Department of Industrial Relations Division of Occupational Safety and Health - Field Documentation Worksheet Establishment Name: Page of Tor San-0&0 in'weoL m: 1100:36th medk' ML tow Wk mlcodeo a 31104?1 . .. Jae??0 Claw Tare ?rth. .?C?xfgar (Dr {Ah/lain, (Anglia.? 13039, - Signature: Ronald Aruejo Date: Region 2 District 2 ldent L5223 Optional Inspection (07/01/95) 0 Documentation Worksheet-Contin nation Establishment Name Blue Apron Inc. I Region 1 District - 5 CSHO Optional Report Date/Time L5223 036 15 Severity Extent Likelihood . Total Ad].Factors 1n Notebook 40% Comments: AVD/Citatlon Text T8 CCR ?3273)(b) Working Area. Permanent roadways, walkways, and material storage areas in yards shall be maintained free of dangerous depressions, obstructions, and debris. MIDLAIIQH Prior to and during the course of the investigation, including, but not limited to, on 04/13/2015, the employer did not ensure that materials storage areas in the yard were maintained free of dangerous depressions. On 04/06/15, an employee was injured when a Nissan Forklift driven across a depressed area in the yard tipped over and pinned the employee?s left leg. 22. Elemental Analysis - List numerically each of the cited Title 8 CCR section in the Elements column. In the column, specify each item of evidence found during the inspection which substantiates the descriptive element hazards, operation. equipment, location and/or measurements). Under WW specify the classi?cation of the evidence described under Evidence Summary (see legend at bottom of page). Elements E?denseiummam Imam! Existence Permanent roadways, walkways, and material storage areas in yards shall be maintained free of dangerous depressions, obstructions, and debris. On 04/13/15, the Division conducted an inspection at the employer?s yard located at 3151 Regatta Blvd. Building C60, Richmond, CA 94804. Ms. Samantha Bruck, HR Manager informed the Division that an employee was injured when the forklift operated by the employee rolled over and pinned employee?s le? foot. During the walk around, it was observed that a portion of the yard where the forklift traverses had a depression deep enough to cause a forklift to lose its center of gravity when passing over said depression. Coupled with the ground depression, it was also observed that the tires of the forklift were worn out/bald which could affect the balance of said forklift. Ms. Samantha Bruck committed to have the ground repaired at the earliest and to replace the tire. D0. EA, E08, 005. 0W5. OB, PH. Video lB Ins ection Number I 1 05 5 1 95 Page 1 0 Documentation Two employees--(lass) and Mr. -- (EE6) nformed lhe Ihal they operated the Ntssan Forklifi at the yard for moving supplies. Bolh EES and EE6 forklifi seams Io lip over/rollover every lime they passed over the depression at the yard. Both EES and EEG also slated that the tires are worn out/bald causing lhe forklifl to have] not "fully balanced". Mse Toiya Adams (EEI) also stated that on 04/06/15 was assigned io operate the Nissan forklifi at the employer's yard. loaded a broken tahls at the loading area using one fork of the (main. While traveling at tlte yard to deposit the broken table. Il'ie became uncontrollable and smed to lean on the righl side as soon as il passed over the depressed ma. The rotitlin eventually tipped over/rolled over on its lefi side upon making a right Iufllt As a result, 5131 sustained a deep laceration at her lower lefl leg, split lefi ankle and pressured lefi heel. On 04/27/15. the employer provided the Division a copy the video footage mken prior lo the accident of The video footage showed that the forklifi had a big hump afler passing the depressed area hi the yard causing lhe forklifi lo lose its center of gravity then iinally rolled over on its side afier making a right iunt, On the employer informed the Division Illal a request for the repair or the depressed area at the yard was already placed on order. - onservation Employer Admissinn (EA), Employer oral Statement (E05), Other Oral Statement [005). Employer Written Statement (EWS), Other Written Statement (ows), Photograph (rli), Business Record Document Sample Measurement (SM), Monitoring Measurement (MM), Equipment/Pans/Machinery (EPM), other: please specify nuns tntat mommy Emulnyees Dnrallan E. Warehousehrsneiare 25 i i EE- 25 i EEZ WautwuseAswclaIr 25 i i Additional Witness Documentation - 5e: employees suned statements that an aotadent nr exposure ottuts, what! are the likely tunseduenoesl (what type manner/illnesses it rumlauon desinned prevent? wast hind ran oer-tr net-ante violation exlm? ran death or Serious mum) Flilnre to ensure yards were tree or dangerous depression could result to minor to serious Injuries such as hrolren bone: to the upper and lower body, head trauma or even death should an employee is 'nned or crushed by a forklift that rolls over on its side due to depression: on the ground Page 2 IE lnspecilon Number loss 9 :2 Documentation Worksheet-Continuation Knowledge: ACTUAL MANAGEMENT KNOWLEDGE CONSTRUCTWE MANAGEMENT KNOWLEDGE (check all ofthe following which apply) Violation common practice at iobsite El Accident at iobsite previously from same violation K4 Proximity of supervisors to violation El Special duty to inspect (Competent Person at excavation) Violation readily visible to anyone passing by El Employer received complaints from other EE's Obligation anticipated: Foreseeable hazard(s) Asbestos With reasonable diligence employer could have known of the presence of the containing construction materials in older violation? Condition existed long enough for employer awareness El OTHER: El LACK OF EMPLOYER KNOWLEDGE REGULATORY: GENERAL: Posting requirement El Violation is related to safety and health of employees but not Reporting requirement expected to result in death or serious physical harm. El Recordkeeping requirement El Lacks evidence of employer knowledge No direct relationship to employee safety and health CONSIDERATION FOR SERIOUS CLASSIFICATION per AB 2774: What is the actual hazard (describe the speci?c hazardous condition) created by the violation? Failure to ensure that yards were maintained free of dangerous depression could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death sh0uld an employee is pinned or crushed by a forklift that rolls over on its side due to depressions on the ground. In what way can an employee actually sustain an injury as a result of that hazard? Failure to ensure that yards were maintained free of dangerous depression could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to depressions on the ground. is there a realistic probability of serous physical harm? Did a serious injury/accident occur as a result of the violation? Failure to ensure that yards were maintained free of dangerous depression could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to depressions on the ground. e, classify this citation as GENERAL. REF: Serious Physical Harm includes "serious injury? de?ned in BC CR ?342(o) and includes "loss of e??iciency" and hospitalization for any length of time for other than observation. Labor Code ?6432(a)- "any injury or illness speci?c or cumulative?, occurring in the place of employment or in connection therewith that results in 1) inpatient hospitalization for ?other than observation? 2) "Loss of any member of the body? 3) ?Serious degree of permanent disfiguremen t? 4) ?Impairment su?icient" to a?ect "the body or the function of an organ to become permanently and signi?cantly reduced in efficiency? Evaluation of ER's steps taken to discover, anticipate prevent the violation: Review of training provided to employees and supervisors as it pertains to preventing employee exposure to the hazard or similar hazards Review of procedures established to discover, control access to and correct the hazard or similar hazards Effectiveness of supervision provided to employees exposed or potentially expOSed to the hazard. Procedures for communicating to employees about the employer's health safety rules 81 programs Effectiveness of action taken to eliminate exposure as soon as violation was discovered Use the documentation continuation sheet to document evidence of any of the following: Prio Violations (Repeat) Intentional, Knowing, or Reckless Conduct (Will?il) - Willful Elements Worksheet must be attached. Failure to Abate. Page 3 IB Ins ection Number l1055195 9 0 Documentation Worksheet-Continuation Establishment Blue Apron Inc. CSHO lD Optional Report Likelihood Notebook Total Adi.Factors in Comments: MID/Citation Text T8 CCR ?3650(t)(7) Industrial Trucks. Drivers shall check the vehicle at the beginning of each shift, and if it is found to be unsafe, the matter shall be reported immediately to a foreman or mechanic, and the vehicle shall not be put in service again until it has been made safe. Attention shall be given to the proper functioning of tires, horn, lights, battery, controller, brakes, steering mechanism, cooling system, and the lift system for fork lifts (forks, chains, cable, and limit switches). ILQLAIIQN Prior to and during the course of the investigation, including, but not limited to, on 04/13/2015, the employer did not ensure that the sit down Nissan Forklift was checked at the beginning of each shift by its drivers. 22. Elemental Analysis - List numerically each which; of the cited Title 8 CCR section in the Elements column. In the We?: column, Specify each item of evidence found during the inspection which substantiates the descriptive element hazards. operation, equipment, location and/or measurements). Under Wage, specify the classi?cation of the evidence described under Evidence Summary (see legend at bottom of page]. Elements Issuer i!th Existence sumo Drivers shall check the vehicle at the On 04/13/15, the Division conducted an inspection at the DQEA. 505? beginning of each shift, and if it is employer?s yard located at 3151 Regatta Blvd. Building 005' ($1,303 found to be unsafe, the matter shall C60, Richmond, CA 94804. Ms. Samantha Bruck, HR be reported immediately to a Manager informed the Division that on 04/06/15, an foreman or mechanic, and the employee, Ms. Toiya Adams (EEI) was injured when the sit vehicle shall not be put in service down Nissan forklift (chassis N0. again until it has been made safe. operated by rolled over and pinned employee?s le? Attention shall be given to the foot. The Division was informed that is a Warehouse proper functioning of tires, horn, Associate, authorized by the employer to operate the said lights, battery, controller, brakes, forklift. steering mechanism, cooling system, and the lift system for fork lifts (forks, chains, cable, and limit switche Page 1 IB Ins ection Number [1 05 5 195' Dncumenlzn'un worksheet-Continuation Ms. Samantha showed a hinder of the Nissan rorklih containing the equipment check list (see checklist). Ms. Samantha Emck cannot however identify who performed the The said oheetdist was performed on 04/13/15. the dny or the Division's inspection. Ms, Samantha Emck present to the Division previous check performed on Nissan forklifi. Ms. Samantha Bruck admitted that the said forklifl was operated every day. Ms. Samantha Bruck presented three employees who were also working as Warehouse Associates and also authorized to operate the sit down Nissan fork Ii he three employees were identified as EEZ), I --EEJJ and EEZ, and E54 Informed the that they took a written examination in the safe operation of the crown Sland up forklifi and were evaluated by a forklifi authorized miner prior to being allowed to operate the stand crown inside the ware house. EEZ. EE3 and EEA all stated that they were assigned on several occasion to opemte the Nissan Forklifi at the yard. EEZ, EE3 and EE4 also slated that they are not certified In operate the Nissan Forklifl and were never provided actual driving test and evaluation their performance prior to being assigned to operate this forkliflt E52, and EEA all stated that they never performed any pre operation inspection prior to operating the Nissan forklifl, - onservau'on Employer Admission (EA), Employer Oral Statement (505), Other Oral Staoement (005). Employer Written Statement (EWS), nther Written Statement (ow5), Photograph (PH). Business Record Document (D0). Sample Measurement (SM), Monitoring Measurement (MM), Equipment/Parts/Machirtery (EPM). other: please specify. mm" mimics treanenq fig. WmhnuseAsitx'lam Addmonal Witness See employees signed statements, that an Ioddent or exposure were what are ate Ilhdy eaneequenoesr [what type ts regulatten denoted tn pmentt What totnd Mlnhuy/lflness an 0(qu oeuure violation death or Senor" harm result?) Failure to ensure that yards were tree atdangerorts depression tould result to minor to serious injuries aueh as hmtten bones to the upper and lower body, head traurnrr or even death shanld an employee is pinned or crushed by a furklifl that rolls over on its side due to depressions on the ground. Knowledge: )3 ln ictmn Number Page 2 3 Documentation Worksheet-Continuation ACTUAL MANAGEMENT KNOWLEDGE CONSTRUCTIVE MANAGEMENT KNOWLEDGE [check all of the following which apply) Violation common practice at jobsite Accident at jobsite previously from same violation Proximity of supervisors to violation Special duty to inspect [Competent Person at excavation) Violation readily visible to anyone passing by El Employer received complaints from other El Obligation anticipated: Foreseeable hazard(s) (in, Asbestos With reasonable diligence employer could have known of the presence of the containing construction materials in older blo?gs.) violation? Condition existed long enough for employer awareness OTHER: El LACK OF EMPLOYER KNOWLEDGE REGULATORY: GENERAL: El Posting requirement El Violation is related to safety and health of employees but not Reporting requirement expected to result in death or serious physical harm. Recordkeeping requirement El Lacks evidence of employer knowledge No direct relationship to employee safety and health CONSIDERATION FOR SERIOUS CLASSIFICATION per AB 2774-: What is the actual hazard [describe the speci?c hazardous condition) created by the violation? Failure to ensure that yards were maintained free of dangerous depression could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to depressions on the ground. In what way can an employee actually sustain an injury as a result of that hazard? Failure to ensure that yards were maintained free of dangerous depression could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to depressions on the ground. is there a realistic probability of serous physical harm? Did a serious injury/accident occur as a result of the violation? Failure to ensure that yards were maintained free of dangerous depression could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to depressions on the ground. e, classify this citation as GENERAL. REF: Serious Physical Harm includes "serious injury" defined in BCCR ?342(a) and includes "loss of e?icienty? and hospitalization for any length of time for other than observation. Labor Code ?6432(a)- "any injury or illness specific or cumulative", occurring in the place of employment or in connection therewith that results in 1) inpatient hospitalization for ?other than observation?2) ?Loss of any member of the body? 3 "Serious degree of permanent disfigurement? 4) ?impairment sufficient to afoot "the body or the function of an argon to become permanently and signi?canthr reduced in e?'iciency" Evaluation of steps taken to disc0ver. anticipate 8c prevent the violation: Review of training provided to employees and supervisors as it pertains to preventing employee exposure to the hazard or similar hazards Review of procedures established to discover, control access to and correct the hazard or similar hazards Effectiveness of supervision provided to employees exposed or potentially exposed to the hazard. Procedures for communicating to employees about the employer's health 8L safety rules prOgrams Effectiveness of action taken to eliminate exposure as soon as violation was discovered Use the documentation continuation sheet to document evidence of any of the following: Prior Violations (Repeat) Intentional, Knowing. or Reckless Conduct (Willful) - Willful Elements Worksheet must be attached. Failure to Abate. Page 3 IB Ins ection Number l1055 195 0 Documentation Worksheet-Continuation Establishment Name Blue Apron Inc. Region - 1 District - 5 CSHO ID Optional Report Date/Time 1.5223 036 15 I Severity Extent Likelihood Total Adi.Factors in Notebook 40% Comments: MID/Citation Text T8 CCR ?3650(t)(15) Industrial Trucks - Serious. The forks shall always be carried as low as possible, consistent with safe operations. HQLAIIQN Prior to and during the course of the investigation, including, but not limited to, on 04/13/2015, the employer did not ensure that the forks of its sit down Nissan fork lift were carried as low as possible. 22. Elemental Analysis - List numerically each descriptive?ement of the cited Title 8 CCR section in the Elements column. In the mm column, specify each item of evidence found during the inspection which substantiates the descriptive element hazards, operation, equipment, location and/or measurements). Under Wee, specify the classi?cation of the evidence described under Evidence Summary (see legend at bottom of page). Elements 12th .l a: .E The forks shall always be carried as On 04/ 13/ 15, the Division conducted an inspection at the DO, EA.EOS, low as possible, consistent with safe employer?s yard located at 3151 Regatta Blvd. Building operations. C60, Richmond, CA 94804. Ms. Samantha Bruck, HR Manager informed the Division that on 04/06/15, an employee, Ms. Toiya Adams was injured when the sit down Nissan forklift (chassis N0. CU1F2-9QO985) operated by rolled over and pinned employee?s left foot. The Division was informed that is a Warehouse Associate, authorized by the employer to operate the said forklift. Page 1 [ns ction Number l105519?l 3 Documentation Worksheet-Continuation Ms. Toiya Adams stated that on 04/06/15 was assigned to operate the Nissan forklift at the employer?s yard. loaded a broken table at the loading area using one fork of the forklift. While traveling at the yard to deposit the broken table, the forklift became uncontrollable and started to lean on the right side as soon as it passed over the depressed area. The forklift eventually tipped over/rolled over on its left side upon making a right turn. As a result, sustained a deep laceration at her lower left leg, split left ankle and pressured left heel. admitted that forks of said forklift were lifted high above her level. On 04/27/15, the employer provided the Division a copy of the video footage taken prior to the accident of (see video). The video footage showed that the forklift had a big bump after passing the depressed area at the yard causing the forklift to lose its center of gravity then ?nally rolled over on its side after making a right turn. The video footage also shows that the forks were lifted way above the level of Observation (OB), Employer Admission (EA), Employer Oral Statement (EDS). Other Oral Statement (005), Employer Written Statement (EWS), Other Written Statement (0W5), Photograph Business Record (BR). Document (D0), Sample Measurement (SM), Monitoring Measurement (MM), Equipment/ Parts Machinery (EPM). other: please specify. Exposed Employees Occupation E31353: es Dl?i'toattailm Frequency Exposed Employee Identi?er it Warehouse Associate 25 1 1 Warehouse Associate 25 1 1 EEZ Warehouse Associate 25 1 1 EE3 Additional Witness Documentation See employees signed statements. Assuming that an accident or exposure occurs. what are the likely consequences? [What type of injuries/illnesses is regulation designed to prevent? What kind of injury/illness can occur because violation exists? Can death or Serious physical harm result?) Failure to ensure that the forks of forklifts were carried as low as possible while transporting unsecured and unbalanced materials could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to unbalanced loads loaded on the forks that were lifted high above the ground. Knowledge: ACTUAL MANAGEMENT KNOWLEDGE CONSTRUCTIVE MANAGEMENT KNOWLEDGE [check all ofthefoilowing which apply] Violation common practice at iobsite CI Accident at jobsite previously from same violation Proximity of supervisors to violation El Special duty to inspect (Competent Person at excavation] lB Ins ection Number 1055195 Page 2 0 Documentation Worksheet-Continuation Violation readily visible to anyone passing by El Employer received complaints from other EE's Obligation anticipated: Foreseeable hazard(s) (tie, Asbestos With reasonable diligence employer could have known of the presence of the containing construction materials in older violation? Condition existed long enough for employer awareness OTHER: El LACK or EMPLOYER KNOWLEDGE REGULATORY: GENERAL: El Posting requirement El Violation is related to safety and healdi of employees but not Reporting requirement expected to result in death or serious physical harm. Recordkeeping requirement El Lacks evidence of employer knowledge 0 direct relationship to employee safety and health CONSIDERATION FOR SERIOUS CLASSIFICATION per AB 2774-: What is the actual hazard [describe the speci?c hazardous condition) created by the violation? Failure to ensure that the forks of forklifts were carried as low as possible while tranSporting unsecured and unbalanced materials could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to unbalanced loads loaded on the forks that were lifted high above the ground. in what way can an employee actually sustain an injury as a result of that hazard? Failure to ensure that the forks of forklifts were carried as low as possible while transporting unsecured and unbalanced materials could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to unbalanced loads loaded on the forks that were lifted high above the ground. Is there a realistic probability of serous physical harm? Did a serious injury/accident occur as a result of the violation? Failure to ensure that the forks of forklifts were carried as low as possible while transporting unsecured and unbalanced materials could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to unbalanced loads loaded on the forks that were lifted high above the ground. e, classify this citation as GENERAL. REF: Serious Physical Harm includes "serious injury? de?ned in 8CCR ?342(a) and includes "loss ofe?iciency? and hospitalization for any length of time for other than observation. (Labor Code ?6432(a)- ?any injury or illness speci?c or cumulative?, occurring in the place of employment or in connection therewith that results in 1) inpatient hospitalization for ?other than observation? 2) "Loss of any member of the body" 3 "Serious degree of permanent disfigurement? 4) "lmpairmentsu?icient? to a?'ect ?the body or the function of an argon to become permanently and significantly reduced in e?icienty" Evaluation of steps taken to discover, anticipate 8; prevent the violation: Review of training provided to employees and supervisors as it pertains to preventing employee exposure to the hazard or similar hazards Review of procedures established to discover, control access to and correct the hazard or similar hazards Effectiveness of supervision provided to employees exposed or potentially exposed to the hazard. Procedures for communicating to employees about the employer's health safety rules 8: programs Effectiveness of action taken to eliminate exposure as soon as violation was discovered Use the documentation continuation sheet to document evidence of any of the following: Prior Violations (Repeat) Intentional, Knowing, or Reckless Conduct [Willqu - Willfu] Elements Worksheet must be attached. Failure to Abate. Page 3 IB Ins ection Number ll 055 195' 0 Documentation Worksheet-Continuation Establishment Name Blue Apron Inc. a Region - 1 District - 5 CSHO lD Optional Report Date/Time [.5223 036 15 Severity Extent Likelihood SAVE Total Adi.Factors in Notebook 40% Comments: IND/Citation Text T8 CCR - Industrial Trucks Loads shall be so balanced, braced, or secured as to prevent tipping and falling. Only stable or safely arranged loads shall be handled. Prior to and during the course of the investigation, including, but not limited to, on 04/13/2015, the employer did not ensure that loads are so balanced, braced or secured to prevent tipping and falling. As a result, 04/06/15 an employee was seriously injured when the forklift operated by the employee to lift and deposit a broken table that was not balanced, braced or secured, tipped over pinning employee?s left leg. 22. Elemental Analysis - List numerically each 51W of the cited Title 8 CCR section in the Elements column. In the column, specify each item of evidence found during the inspection which substantiates the descriptive element hazards, operation, equipment, location and/or measurements). Under specify the classi?cation of the evidence described under Evidence Summary (see legend at bottom of page). Elements than: mum: some Loads shall be so balanced, braced, On 04/13/15, the Division conducted an inspection at the DO.EA. E05. or secured asto prevent tipping and employer?s yard located at 315] Regatta Blvd. Building falling. Only stable or safely C60, Richmond, CA 94304. Ms. Samantha Brock, HR arranged loads shall be handled. Manager informed the Division that on 04/06/15 an employee, Ms. Toiya Adams was injured when the sit down Nissan forkli? (chassis N0. CU1F2-9Q0985) operated by rolled over and pinned employee?s left foot. The Division was informed that is 3 Warehouse Associate, authorized by the employer to operate the said forklift. Page 1 IB Ins ction Number Documentaflon Worksheet-Continuation Ms. Samantha Eruck informed the Division the! EEI was operating the forkliit with the forks elevated above level of During the walk around. it was observed that a portion of the yard where the forklifi traverses had a depression deep enough to cause a forklih to lose its center ofgravity when passing over said depression. Coupled with the ground depression. it was also observed that the tires 0 the forklifl were worn out/bald which could afiect the cenlral balance of said forklifl. Ms. Samantha Bruck committed to have the ground repaired at the earliest and to replace the tire. Two employees--(HES) and I- nrormed the vision that they operated the Nissan Forklifi at the yard for moving supplies. Both EES and EE6 stated that torldih seems to tip over/rollover every time they passed over the depression at the yard. Both EES and E56 also stated that the tires are worn (ml/bald causing the forklifl to travel not "fully balanced". Ms. Toiya Adams also slated that on 04/06/15 EEI was assigned to operate the Nissan forklifi at the employer's yard. loaded a broken table at the loading area using on: of Ike forklifi. While traveling at the yard to deposit Ihc bmken table. the forklifi became uncontrollable and sinned to lean on the right side as soon as it passed over the depressed area. The forklifl eventually tipped over/rolled over on ils lefl side upon making a right turn. As a result, EEI sustained a deep laceration at her lower leh leg, split leh ankle and pressured lefl heel. On 04/27/15, the employer provided the Division a copy the video foolage taken prior to the accident of EEL The video footage showed that the forklifi had a big bump aher passing the depressed area at the yard causing the forklifi to lose its center of gravity then finally rolled over on its side afier making a right turn. The video also shows the broken tahle Iifled on the leh iorks of the forklifi and not balance. braced not secured. - uhsetvaaon (03). Employer Admission (EA), Employer Oral Statement Other ural Statement (005), Employer Written Statement (sws), Other Wntten Statement (owsi, Photograph Business Record Document Sample Measurement (SM), Monitoring Measurement (MM), Equipment/Pam/Machinery other. please specify. Exposed employees Mum" "min "first." exposed :mplayee rdeaahertt Warehouse Arsocrate 15 I 1 Warehouse Assoc-m 25 I a :22 Warehouse Assume 25 [23 lElns t' nNunrber Page 2 ?3 Documentation Worksheet-Continuation Additional Witness Documentation See employees signed statements. Assuming that an accident or exposure occurs. what are the likely consequences? (What type of injuries/illnesses is regulation designed to prevent? What kind of injury/illness can occur because violation exists? Can death or Serious physical harm result?) Failure to ensure that loads are so balanced, braced or secured to prevent tipping and falling could result to the realistic possibility of a serious injuries such as broken bones to the upper and lower body, head trauma or even death should a forklift tips over roll over while transporting a load that is not balanced, braced or secured and pins the forklift operator. Knowledge: ACTUAL MANAGEMENT KNOWLEDGE >14 CONSTRUCTIVE MANAGEMENT KNOWLEDGE [check all of the following which apply) Violation common practice at jobsite El Accident at jobsite previously from same violation Proximity of supervisors to violation El Special duty to inspect (CO mpetent Person at excavation) Violation readily visible to anyone passing by El Employer received complaints from other EE's El Obligation anticipated: Foreseeable hazard[s) (tie, Asbestos With reasonable diligence employer could have known of the presence of the containing construction materials in older violation? Condition existed long enough for employer awareness El OTHER: El LACK OF EMPLOYER KNOWLEDGE REGULATORY: GENERAL: Posting requirement Violation is related to safety and health Of employees but not Reporting requirement expected to result in death or serious physical harm. Recordkeeping requirement Lacks evidence of employer knowledge El NO direct relationship to employee safety and health CONSIDERATION FOR SERIOUS CLASSIFICATION per AB 2774-: What is the actual hazard (describe the speci?c hazardous condition) created by the violation? Failure to ensure that loads are so balanced, braced or secured to prevent tipping and falling could result to the realistic possibility of a serious injuries such as broken bones to the upper and lower body, head trauma or even death should a forklift tips over roll over while transporting a load that is not balanced, braced or secured and pins the forklift operator. In what way can an employee actually sustain an injury as a result of that hazard? Failure to provide practical training and performance evaluation to employees assigned to operate a sit down forklift could result to the realistic possibility of a serious injuries such as broken bones to the upper and lower body, head trauma or even death should an untrained employee operates a forklift tips over roll over while transporting a load that is not balanced, braced or secured and pins or crushes into the forklift operator. ls there a realistic probability of serous physical harm? Did a serious iniury/accident occur as a result of the violation? Failure to ensure that loads are so balanced, braced or secured to prevent tipping and falling could result to the realistic possibility of a serious injuries such as broken bones to the upper and lower body, head trauma or even death should a forklift tips over roll over while transporting a load that is not balanced, braced or secured and pins the forklift operator. Through reasonable diligence and required IIPP inspections, employer knew or could have known of the violative condition. Coupled with the serious nature of the injuries sustained; classify this citation as SERIOUS. REF: Serious Physical Harm includes ?serious injury? de?ned in 8CCR ?342(a) and includes "loss ofe??iciency? and hospitalization for any length of time for other than observation. (Labor Code ?6432(a)- "any injury or illness specific or cumulative?, occurring in the place of employment or in connection therewith that results in 1) Page 3 IB Ins ection Number 1055 195 0 Documentation Worksheet-Continuation inpatient hospitalization for ?other than observation" 2) "Loss of any member of the body" 3) "Serious degree of permanent dis?guremen t" 4) "impairment sufficient" to affect "the body or the ?mction of an organ to become permanently and significantly reduced in ej?cienl? Evaluation of steps taken to discover. anticipate 8: prevent the violation: Review of training provided to employees and supervisors as it pertains to preventing employee exposure to the hazard or similar hazards Review of procedures established to discover, control access to and correct the hazard or similar hazards Effectiveness of supervision provided to employees exposed or potentially exposed to the hazard. Procedures for communicating to employees about the employer?s health 8: safety rules programs Effectiveness of action taken to eliminate exposure as soon as violation was discovered Use the documentation continuation sheet to document evidence of any of the following: Prior Violations [Repeat] Intentional, Knowing, or Reckless Conduct (Willful) Willful Elemenm Worksheet must be attached. Failure to Abate. Page 4 1 Ins ection Number 1055195l A, Documentation Worksheet-Continuation Establishment Name Blue Apron Inc. Issue Date: - . - . Region - 1 District - 5 Inspection Number CSHO ID Optional Report Date/Time . Citation CIasSi?catioan?ype . - . . . .. 1.5223 036 15 is .. .. sandal-divine 'Citation Itemlhlo. :vmlat- - - REC (it) Exposed m??gc? - - Severity Extent Likelihood '3 -- in CCR ?3668o x32-4-15TotalAd].FactorSIn any"; :5 Abatement?eriod Noteboflk 40% MID/Citation Text T8 CCR ?3668(b)(3) Safe Operation Industrial Trucks. Training program implementation: Training shall consist of a combination of formal instruction lecture, discussion, interactive computer learning, video tape, written material), practical training (demonstrations performed by the trainer and practical exercises performed by the trainee) and evaluation of the operator's performance in the workplace. EQLAIIQN Prior to and during the course of the investigation, including, but not limited to, on 04/13/2015, the employer did not provide practical training and evaluation of the operator?s performance prior to allowing its employees to operate a Nissan gas powered sit down fork lift. As a result, on 04/06/15, an untrained employee was seriously injured when the forklift rolled over on its side and pinned employee?s left leg. 22. Elemental Analysis - List numerically each descriptive element of the cited Title 8 CCR section in the Elements column. In the mm column, specify each item of evidence found during the inspection which substantiates the descriptive element hazards, operation, equipment, location and/or measurements). Under specify the classi?cation of the evidence described under Evidence Summary (see legend at bottom of page]. Elements Edema it yes) Safe Operation Industrial Trucks Training program implementation: Training combination of formal instruction shall lecture, discussion, interactive down computer written material), practical training (demonstrations performed by the and practical performed by the trainee) and of the performance in the workplace. trainer evaluation learning, video exercises forklift. operato r's On 04/13/15, the Division conducted an inspection at the employer?s yard located at 3151 Regatta Blvd. Building C60, Richmond, CA 94804. MS. Samantha Bruck, HR consist of a Manager informed the Division that on 04/06/15 an employee, Ms. Toiya Adams was injured when the sit Nissan forklift (chassis N0. CU1F2-9Q0985) tape, operated by rolled over and pinned employee?s left foot. The Division was informed that is a Warehouse Associate, authorized by the employer to operate the said DO, EA, EOS, 005, OWS, OB, PH, Video IB Ins ection Number 1055 95 Page 1 Worksheet?ontlnuntlon Ms, Samantha Bruck presented three employees who were also working as Warehouse Assuciales and alsn authorized to operate the sit down Nissan iork l' The three emplofis were identified as (EEZ). and 5E4), EE2, and 5E4 lnfonned the Ihal they look a writlen examination in the safe opemion of the crown stand up forklifi and were evaluated by a forklifi anlhoriud trainer prior to being allowed Io operate the stand crown furklifi inside the ware house. EEZV EEJ and EEA all slated thal they were assigned on several occasion to operate the Nissan Forklifi al the yard. EEZV EE3 and E54 also stated that they are not certified to 0pcth the Nissan Forklifl and were never provided actual driving test and evaluation their performance prior to being assigned to operate this and_ also informed the they operated the Nissan Forklih at the yard for moving supplies Both EES and EE6 stated that they were not evaluated prior to being assigned to operale the said forklilt. Ms. Toiya Adams (EEI) alsl) stated that on 04/06/15, she was assigned to operate the Nissan forklifi at the employer's yard. loaded a broken table BI the loading area using one fork of the forklifi. While Iraveling at Ihe yard to deposit the bmken table, the forklifl became uncontrollable and staned to lean on the right side as soon as it passed over the depressed area. The forklifi eventually tipped over/rolled over on its lefi side upon making a right turn. As a result, EEI sustained a deep laceration at her tower lefi leg, split lefl ankle and pressured lefi heel. admitted that she is not cenified to operate the Nissan Forklih and was never provided practical training and evaluation prior to being assigned operate said fork lifi. EEZ, and EEA pmvided the Division a copy 0 their forklifi certification indicating that they were certified to operate specifically the Crown stand up forklifi and the pallet jack. On 05/04/15. the employer provided the Division a copy the updated training provide to ?52. ?53 and 5E4 in the operation or the sit down Nissan Forklih. Observation Employer Admission (EA), Employer Oral Statement (E05), utlter Oral Statement (005), Employer Wt-itnen Statement (Ews), other Written Stapement (ows), Photograph (PH), Business Record Document [170), Sample Measurement (SM), Monitoring Measurement (MM), Equipment/Parts/Machinery other: please specify. IE inspection Nnmher 105m Page 2 0 Documentation Worksheet-Continuation 3 Occupation Emiphpies Frequency Exposed Employee Identifier it 3 Warehouse Associate 25 1 1 Warehouse Associate 25 1 1 EEZ Warehouse Associate 25 1 1 E83 Additional Witness Documentation See employees signed statements. Assuming that an accident or exposure occurs, what are the likely consequences? (What type of injuries/ illnesses is regulation designed to prevent? What kind of injury/illness can occur because violation exists? Can death or Serious physical harm result?) Failure to provide practical training and performance evaluation to employees assigned to operate a sit down forklift could result to the realistic possibility of a serious injuries such as broken bones to the upper and lower body, head trauma or even death should an untrained employee operates a forklift tips over roll over while transporting a load that is not balanced, braced or secured and pins or crushes into the forklift operator. Knowledge: ACTUAL MANAGEMENT KNOWLEDGE CONSTRUCTIVE MANAGEMENT KNOWLEDGE [check all ofthe following which apply) Violation common practice at iobsite CI Accident at jobsite previously from same violation Proximity of supervisors to violation Special duty to inspect (Competent Person at excavation) Violation readily visible to anyone passing by El Employer received complaints from other Obligation anticipated: Foreseeable hazard(s] (119., Asbestos With reasonable diligence employer could have known of the presence of the containing construction materials in older violation? Condition existed long enough for employer awareness OTHER: El LACK OF EMPLOYER KNOWLEDGE REGULATORY: GENERAL: Posting requirement Violation is related to safety and health of employees but not El Reporting requirement expected to result in death or serious physical harm. Recordkeeping requirement El Lacks evidence of employer knowledge No direct relationship to employee safety and health CONSIDERATION FOR SERIOUS CLASSIFICATION per AB 2774-: What is the actual hazard (describe the speci?c hazardous condition) created by the violation? Failure to ensure that the forks of forklifts were carried as low as possible while transporting unsecured and unbalanced materials could result to minor to serious injuries such as broken bones to the upper and lower body, head trauma or even death should an employee is pinned or crushed by a forklift that rolls over on its side due to unbalanced loads loaded on the forks that were lifted high above the ground. In what way can an employee actually sustain an injury as a result of that hazard? Failure to provide practical training and performance evaluation to employees assigned to operate a sit down forklift could result to the realistic possibility of a serious injuries such as broken bones to the upper and lower body, head trauma or even death should an untrained employee operates a forklift tips over/ roll over while transporting a load that is not balanced, braced or secured and pins or crushes into the forklift operator. Is there a realistic probability of serous physical harm? Did a serious injury/accident occur as a result of the violation? Failure to provide practical training and performance evaluation to employees assigned to operate a sit down forklift could result to the realistic possibility of a serious injuries such as broken bones to the upper and lower body, head trauma or even death should an untrained employee operates a forklift tips over/ roll over while transporting a load that is not balanced, braced or secured and pins or crushes into the forklift operator. Page 3 IB Ins ection Number 1055195l 0 Documentation Worksheet-Continuation Through reasonable diligence and required IIPP inspections, employer knew or could have known of the violative condition. Coupled with the serious nature of the injuries sustained; classify this citation as SERIOUS. REF: Serious Physical Harm includes "serious injury? de?ned in BCCR ?342(a] and includes "loss ofe??iciency? and hospitalization for any length of time for other than observation. (Labor Code ?6432(a)- "any injury or illness specific or cumulative?, occurring in the place of employment or in connection therewith that results in 1) inpatient hospitalization for "other than observation" 2) "Loss of any member of the body" 3) "Serious degree of permanent dis?gurement? 4) ?impairmentsu??icient? to affect ?the body or the function of an argon to become permanently and sign?icantb/ reduced in e??iciency? Evaluation of steps taken to discover, anticipate prevent the violation: Review of training provided to employees and supervisors as it pertains to preventing employee exposure to the hazard or similar hazards Review of procedures established to discover, control access to and correct the hazard or similar hazards Effectiveness of supervision provided to employees exposed or potentially exposed to the hazard. Procedures for communicating to employees about the employer?s health safety rules programs Effectiveness of action taken to eliminate exposure as soon as violation was discovered Use the documentation continuation sheet to document evidence of any of the following: Prior Violations (Repeat) Intentional, Knowing, or Reckless Conduct [Willful] - Willful Elements Worksheet must be attached. Failure to Abate. Page 4 IB Ins ection Number 1055195