I Fatality/Catastrophe Report Fri Apr 10, 2015 03:33:24 PM ?4 VJ RID Of?ce Name Activity Number Activity Type Receipt Date Receipt Time Receipt Type Received By 0950615 American Canyon 974895 09-APR-2015 09:10 AM Email 135240 District Office Establishment Name Blue Apron Inc. Doing Business As (DBA) NAICS Inspected 452910 Primary NAICS 452910 Site Address 3151 Regatta Blvd. Site Phone Site FAX 60 RICHMOND, CA, 94804 Business Address 3151 Regatta Blvd. Business Phone Business FAX 60 RICHMOND, CA, 94804 Mailing Address 3151 Regatta Blvd. Mgmt. Official Samantha Brack Mgmt. Official Phn. (310)-947-5644 60 RICHMOND, CA, 94804 Type of Business Type of Site Activity Warehousing Number of Employees Ownership Private Sector Event Date 06-APR-2015 Event Time 04:30 PM Do Insp? Reason No Insp No. Hospitalized 0 No. Unaccounted 0 No. Fatalities 0 No. Non-Hospitalized 1 Classi?cation Accident Employer Report Date O7-APR-2015 Employer Report 07:25 PM Time Source Type Source Name Phone Employer/Employer Representative Samantha Brack (310)-947-5644 Incident Type Forklift rolled over Preliminary Description (Hazard The operator was on her way to pick up bale along the way there was a broken (missing Description and Location leg) steel table. She picked up the table ?rst and unloaded in the yard. on her way back, employee encountered an uneven concrete while making a right turn causing the forklift to tip over. National Emphasis Local Emphasis Federal Strategic Initiatives Additional Codes Type ID Value Description 14 Travelers Numher Au:va Number OIS ACCIDENT REPORT 974m; Emmumnenmame 32:: warchm aw PM Web 4mm Busmess Address Slveel. CW Cuunly 72m isygiis above me: Faun: Number 3m f??er 5 mm! 'i'fl'b4 3/0 e47x44+ Mawhng Address (She 'Cwly, Caumy 5m: but same as above Awnemsne Address (and any Cuunly Zm mdlrecmms) Same as anave Numbequ '5 ans Number sue Type Sue's waswame (0 6747-4144 Warn/142w: r3 Rammed Mcsua ID) Ream ma Rec", 'B'Eman Fax Hume New [Tune 7 1: Type El Phone Ormne \n person Mama Sauna EE WRep Famfly Mama 51/ Luca' Gm Sfiumwime Type EE Rep EXAEE Fed OSHA E1 0ther(5pemfy) Jaw; source's We Source 5 moves: fisame as my; mu Phone Numhzf ll Man '27" 3/0) 941 444. CIusflicanm El Falamy Reponed by Pruiesslona' Mama NawFarehly Reponea by EE orOtherPany KAcmdent "magma .n Faxahhes Nan- ER 7pc Bile in mm Time For Hasumzm I mm:qu 7.54er rumewr 5E mummy (Speaty Memamsm/cwoman/Hazardous Suhslancey bw'fvf yum lk may 'fo lake baa/cl My 14>> was a bah/mp"; A3) dud M15. fray .f +416 J-nvAf- un/Dcfi 7+ a flu. earn 0" eurwnz b.6515: mwnfi'qfl am 41er andcfinmkfiz a 13"" W3) 744me fforlvr. Imured Employee lnformahon Age Occupallun Injury Toiya Adwa 35 Wart/W Ry?" hf Dateoern "men's {amt/(null) r; a! Nan Re'almn Name Add/ass Phana Locuunn Where Injured - mm Cnmpensahon K1 Manama-m, bani/ch OtherLaw Enforcement ?wre Dept cup omer (SpechJ 5 Agencies Presema we aunw Shem Locawahce ms man mannev Yes NonReasun "2 13:32: 4/ '5 Eve Emu me 4:wa Name Name: Toiya Adams Date of Incident: 4/6/15 Case E2X242 1. Interview associateNVitnesses: 1. Associate was outside moving broken kitchen table to trash area. Forklift tipped over to the left side and fell on her right foot. 911 was called. Fire and ambulance responded 2. No witnesses 2. Examining the workplace for factors associated with the accident/exposure; 1. Initial inspection did not reveal workplace hazards that contributed to accident. 2. Cal OSHA Compliance Of?cer mentioned evenness of back lot cement and type of tires, which we are reviewing. Determining the cause of the accident/exposure; 1. Primary Cause: Employee Driving too fast (over 15 mph) while making sharp turn. 2. Contributing Cause: Employee positioning the forks at height which affected the center of gravity. 3. Looking into the factors mentioned by CSHO. 4. Taking corrective action to prevent the accident/exposure from reoccurring; and 1. Additional signs posted and refresher training for employees to reinforce safe driving practices. In addition. all machines now have a speed regulator that will not allow employees to drive over Tmph. 2. Submitted request to landlord to assess pavement in the back lot. 3. Requested vendorl?Big Joe? to evaluate and ensure the appropriate tires were installed on the vendor?s forklift on 4/7/15. 5. Recording the ?ndings and actions taken. 1. Based on our investigation, the primary cause of the accident was speeding/reckless driving by the associate/forklift operator who then made an abrupt right turn, at which point the forklift tipped over. 2. Forklift provider installed speed regulators on all forklifts and replaced tires. 3. Submitted request to landlord to assess pavement in the back lot. 0 Blue INJURY AND INVESTIGATION REPORT Impamd lMormnunn: in. 0 Adam: nonem-- Injury Tm: af any employze began wurk on date of mury: Dade Hlull5 Tlme: 5-50pm mums) anyone eke see the Injury napoem :1 yes, grve Mutwaslheemplweedo'lng when mum, 111m and palm: 1v Wh mr' w] in"! Taiya um] MWIWIIH [Ema My, 44' Mun. 441 Am" 4o 44? mu mayundtr mm. in" Iver! and. To your knowledge, mu m: :mylavee have amber hark-related mjury/Illness wnne far you? 0 on m: :mulayze sank mean munenn If so, when, Km" 1' 4'04"" ls Emmoyee (a return to work: ND mm Data: WKan (Immuumnmn was required, an male me dmoralsa needs a: De anached) . 9' Blue INJURY AND REPORT Impacted Empluyn Inform-dun: Name Adam: Injury man-union: Tlme or any :mpbyee began work an dam or Injury: 13:23:" paramounij Tlme: 5-503m Managens) an anyone as: see the lnjuty happen? xv yes, give What was the employee :10an when rue/she was Injured or beam: my mam/lg hm kink"; .3111Howdmheinjury/Iunessoccur? nya "nu Mun 44th [gm 4mg: my. 444 Mm am {3 Am@nnct'l mum. thu m; wer! fillfd~ Tn yuur knowledge, an me empmee have amner work-related Injury/limes; while working fix you? m: empmee seek medan 11 so, wneve. Km" KI 15 Employee able tn return to work: ND Return Dam: unKvmun mutton was reun an flare mm M: 4mm needs to be attached) Aruejo, Ronald@DIR From: Bieber, Emily Sent: Monday, May 04, 2015 4:17 PM To: Aruejo, Ronald@ DIR Subject: Blue Apron - Additional Documents Attachments: Scanned from a Xerox Multifunction Device (8).pdf; Toiya Adams Incident and Investigation Ronald, Enclosed please find copies Of the employees? written tests completed in connection with forklift training and a copy of the Adams incident and investigation report. We are still waiting to hear back from our vendor re the forklift manual. If you need any additional information, please let me know. Best, Emily Emily Bieber Morgan, Lewis 8: Bockius LLP One Market, Spear Street Tower San Francisco, CA 94105 Direct: +1.415.442.1236 Main: +1.415.442.1000 Fax: +1.415.442.1001 ebieber@morganlewis.com Assistant: Elaine A. Lostica +1.415.442.1746 elostica@morganlewis.com DISCLAIMER This e-mail message is intended only for the personal use of the recipient(s) named above. This message may be an attorney-client communication and as such privileged and con?dential and/or it may include attorney work product. If you are not an intended recipient, you may not review, copy or distribute this message. If you have received this communication in error, please notify us immediately by e-mail and delete the original message. ForklifttD: i FORKLIFT INSPECTION CHECKLIST mono?: weouesonv mu?mw my suquv ll-u- l5 rig?[K 9-8-15- If 40/; Lllu is? lnepector'slr?dais: 5 6F Us ,r i Won nap-Ir on Emir OK 3 tour OK lam-Ir Rep-Ir ox lion-Ir on Repair Forts. Mast. Chain. Hydraulic Lines Tues. Axles Overhead GuardtROP Fuel Tanlt Comedians Engine Oil Level ,3 Radiator Water Leval (Cold) It Fuel Level 'v Leaks under Fort: Lift Seat and Seat belts Horn andlor Backup alarm Lights Gauges and Imminent: All Brakes Hydraulic Controls a Lift Steering I 5x35flNJKL 23 @395 1. This checklist must be completed daily and retained for documentation for at least one year. 2. If the forklift is found to be unsafe. the condition must be reported immediater to the supervisor and repaired. 3. No forklift shall be operated with a leak In the fuel system. oforkliftsafetycoml . ?1 FORKLIFT SAFETY TRAINING SERVICES. INC. HO. BOX 60577 BOULDER CITY. NV 89006-0577 in Forku? Operator Training NAME: lode. ?liens; company; Arm? DATE: {if SUPERVISOR: The Name of the individual that appears on this test has received a copy of the OSHA CFR 1910.178. Intake Regulation. FORKLIFT SAFETY TRAINING SERVICES, and any of its subsidiarys assume no responsibility nor liability for any or all accidents or Injuries related to the operation of any powered Industrial truck or operator, regardless of causes or loss. WRITTEN TEST: Forklift - FALSE: Circle if the statement is TRUE: circle if the statement is FALSE. 1. The balance pointI or fulcrum of a counter balanced lift truck is the drive axle. 2. Carrying a load very high. raising or lowering a load or forks while traveling will effect the combined center of gravity and will increase the odds for a tip-over accident. 3. Load center is the horizontal halfway point of a load, measured from the face of the forks /ewerds the fork tips, typically 24". 4. Adding weight on the rear of the truck is the proper way to counter balance an overloaded truck. i 3-4 @936? a 996 I i 5. Never lift a load with a single fork. 6. Never tilt the mast forward, except when picking up or depositing a load. 7. Don?t drive up to anyone standing in front of a wall or other ?xed object. 8. When approaching cross aisles or other areas where vision is obstructed, stop and sound the horn and then proceed slowly. 9. The truck horn should be used to warn pedestrians and other traf?c at intersections. blind corners and when you are backing up. 10. The maximum allowable load should be shown on the nameplate of the truck. 11. The load should not be handled if it is so unstable or so insecure that it might come loose while being moved. 12. it is a good practice to keep the lead back against the truck mast as much as possible. 13. Violation of safety rules, near misses. and-occasional damage to stock probably indicates a high accident rate and high maintenance costs. 14. Repairs to industrial trucks should be made only by persons trained and authorized to make them. 15. It is permissible to run over a loose dock plate as long as the truck is not fully loaded. 116') 16. It you see a loose object in your path, it is better to remove it or avoid it rather than to run over it. (Continued on Reverse Side) This Form May Be Reproduced For Classroom Instruction Only. Not For Resale. hi! can. 469G sQ?rg egg QOGm??m??mm?mm 17. Slippery spots caused by oil and water may increase braking distance or cause loss of steering control. 18. If you are not able to see because of a large load in front of you, it is better to drive in reverse rather than to try to see around it on one side. 19. if they ask. maintenance men, repairman or anyone may be lifted on the forks to reach their work. 20. When traveling on a level surface, the forks should be raised no more than 6 to 10 inches. 21. Lift trucks should be inspected daily or at the beginning of each shift. 22. When following another truck it is best to keep behind about three truck 23. It is permissible to let another person walk or stand under the elevated forks or load if you have your emergency brake set. 24. When loading a highway truck or trailer, its wheels should be checked or blocked even though the driver says he set the brakes. 25. Railroad tracks should be crossed at right angles. 26. Smoking is pem'lissible in refueling areas providing you see no leaking fuel. 27. Parked trucks should never block fire equipment. ?re doors or exits. 28. ft cgreful driver may hang his legs outside the truck as long as he is protected by a wide as . 29. A professional operator checks each load for stability before moving it. 30. Passing another truck in a narrow aisle is safe if it is going no more than eight miles per houn 31. When taking a load up a ramp greater than a 10 percent slope, the forks or load should be on the uphill side. 32. When going through doorways and under pipes, an operator must know the clearance of large loads. 33. A really pro?cient driver should demonstrate his ability by turning corners as quickly as possible. 34. It is permissible to let another person operate your truck if he says he knows how. 35. When traveling with a load. the mast should be tilted back. 36. The rated capacity of a forldift is determined by the manufacturer at a certain load center. typically 24 inches from the face of the fork towards the tips. 37. Tall lift heights. extended load centers or attachments do not affect the rated capacity of a lift truck. 38. Any condition adversely affecting the safety of the lift may be put in service provided g/du are careful. 3 . Modi?cations and additions which affect the capacity and safe operation of a lift truck can be made only by maintenance personnel. 40. Speed or traveling too fast is one major cause for pedestrian related accidents. This Form May Be Reproduced For Classroom instruction Only. Not For Resale. Copyright! 2004-2013 rammiyjreegmmc-M Qorkliftsafetymo?ll?. FORKLIFT SAFETY TRAINING SERVICES, INC. (702) 294-3970 20. BOX 60577 - BOULDER CITY, NV 89006-0577 The In Operator ?aming NAME: 11. A 0 33L Aerie/x DATELILLEL. DEPT.: SUPERVISOR: The Name of the individual that appears on this test has received a copy of the OSHA CFR 1910.173, Regulation. FORKLIFT SAFETY TRAINING SERVICES, and any of its subsidiary?s assume no responsibility nor liability for any or all accidents or injuries related to the operation of any powered industrial truck or Operator. regardless of causes or loss. This training program and materials are to be used as supplemental tralnhg aids iorthe safe operation of powered industrial trucks. . FORKLIFT DRIVING TEST: mus-r APPROPRIATE Box BELOW) [5 new OPERATOR ORIENTATION El CHANGE lN EQUIPMENT OR WORK PLACE DRIVING EVALUATION Speci?c Powered Industrial Truck Fit?"v" On: 4 a Make:_ Model: SIN: ?'Jepacity: lbs. Un?t: - 1. Operator's ability to perform check-shbe ior safe operation oi truck prior to use. Uses cheat-sheet satisfactorily Faiied to check sateiy items 2. Proper use of controls (understands proper technique and proper direction of movement at control to get the desired direction of movement.) . (A) Clutch operation. Yes - No (B) inching control (auto transmissions). . Yes No (C) Tilt control. Yes NO (D) urt cannot. Yes__? No (E) Attachment controis. Yes No (F) Steering techniques for type of machine being used by Operator. Yes No (Q) Proper positioning of all controls. switches. parking brakes when leaving machine ttended. Yes NO Service brake. Yes _4 NO Parking brake. Yes No 3. Maneuverlng skills. (A) Smooth starting and stoppl . Acceptable Needs Practice Poor Control (B) Sharp turns forward and reverse. Proper speed. Yes No Looks In direction Of travel. Yes NO Carries forks low. Yes NO Clears obstacles by sate distance. Yes 2 No (Continued on Reverse Side) This Form May Be Reproduced For Classroom instruction Only. Not For Resale. topmoznmoe hL-Nl?ighls ?amed up 1013 DRIVING TEST: Forklift (cont) 4. Selecting toads. (A) Proper capaclty for truck used. Yes _4 N0 (B) Proper slza load for and safety at handling. Yes A No (0) Load titer! back agelnst back rest. Yes No (D) Carries had low (lust high enough to clear ?oor obsteotes). Yes No 5. Driving with lead. (A) Smooth and stopping. Yes No (8) Proper speed. Yes i No (0) Sounds hem at Intersections. corners and when backing up. Yes No (D) Keeps to the right in aisles used for two-way traffic. Yes .4 No (E) Travels at least three behind other vehicles. Yes 4 No (F) Handles load In manner to prevent product damage. Yes 4 No 6. Stacking (A) Approaches loads squarely. Yes N0 (B) ?tecks strabht and squarely. Yes (0) 'Does not tier too high. Yes No (D) Deposits load safely; does not use excess action. Yes No (E) When eater:th top load for pickup. uses proper fork spread tor load. Yes No (F) Homes load and lowers to safe level before making turn to proceed In gtrectten of desired travel. as 7. Dock Safety. Checks bridge plates (deck boards) before crossing. m4 No (B) Checks tra?ers for proper wheel checking before entering and properlack Insan of traitors where requlred. Yes No COMMENTS: I r" I - msrauc'roe's SIGNATURE I .. my,? OPERATOR SIGNATURE ?1 up This Form May Be Reproduced For Classroom Instruction Only. Not For Resale. Walnut-2013 nu 'Il'l'l'l Qorkliftsafetyto?l?, FORKLIFT SAFETY TRAINING SERVICES, INC. (702) 294-3970 R0. BOX 60577 BOULDER CITY, NV 89006-0577 ?re In Forklift Operator Training NAME: A 1m.) COMPANY: DEPT.: SUPERVISOR: The Name of the individual that appears on this test has received a copy of the OSHA CFR 1910.173. WW Imoiss Regulation. FOHKUFT SAFETY TRAINING SERVICES, mm, and any of its subsidiary's assume no responsibility nor liability for any or all accidents or injuries related to the operation of any powered industrial truck or operator. regardless of causes or loss. This training program and materials are to be used as supplemental training aids for the sale operation of powered trucks. . FORKLIFT DRIVING TEST: MUST t/ APPROPRIATE eox BELOW) )Zi NEW OPERATOR ORIENTATION El CHANGE EQUIPMENT on WORK PLACE JZGNAL DRIVING Specific Powered Industrial Truck iOn: . -J- A 00' Model; M3 SIN: Amish .. Jepacity: 4 tbs. Units: 1. Operator?s ability to perform check-sheet In cticn for sale operation of truck prior to use. Uses check-sheet satisfactorily Failed to check safety items 2. Proper use of controls (understands proper technique and proper clrection of movement of control to get the desired drestion of movement.) . (A) Clutch operation. Yes - No (B) inching control (auto transmissions). . Yes No to) Yes__? (0) Lift control. Yes?Z No (E) Attachment controls. I Yes?Z Nc__ (F) Steering techniques for type of machine being used by operator. Yes No (G) Proper positioning of all controls, switches. parking brakes when leaving mowended. Yes No (H) Service brake. Yes No Parking brake. Yes _4 No 3. Maneuvean stsliis. (A) Smooth starting and g. Acceptable Needs Practice Poor Control (B) Sharp turns forward and reverse. Proper speed. Yes No Loolcs in direction at travel. Yes No Cantos forks low. Yes No Clears obstacles by sale distance. Yes _4 No (Continued on Reverse Side) This Form May Be Reproduced For Classroom instruction Only. Not For Resale. Copyrighto 2004-2013 DP 1033 DRIVING TEST: Forklift (cont) 4. Selecting loads. (A) Proper capacity for truck used. Yes No (B) Proper size load for visib?ty and solely of handling. 'Yes No (6) Load tilled back against back rest. Yes No (D) Carries load low (lust him annoy: to clear ?oor obstacles). Yes No 5. Driving with lead. (A) Smooth Sterling and stopping. Yes _4 No (B) Proper speed. Yes No (0) Sounds horn at hterseellons. corners and when backing up. Yes No (D) Keeps to the rim! In aisles used for Mos-ray lrefilc. Yes NO Trevols at least three behind other vehioi. Yes 4 No (F) Hendes load in manner to prevent product damage. Yes No 6. Siacidng (A) Approaches loads squarely. Yes _1 N0 (B) sucks straight and merely. Yes No (0) Does not tier too him. Yes 4 No (D) Deposiis load safely; does not use excess tilt action. Yes 4 No (E) When selecting top load for pickup. uses proper fork spread ior load. Yes No (F) Removes load and lowers to sale level before making turn to proceed In erection desired hgveL as 7. Dock eatery. (A) Checks bridge plates (deck boards) before crossing. Yes NO (8) Checks trailers for proper wheel checking before entering and proper jaci?rfinstellei of trailer:l where required. as 0 COMMENTS: . Magi) ?We (la $711084?? mereucron-s SIGNATURE OPERATOR SIGNATURE DATE . A This Form May Be Reproduced For Classroom instruction Only. Not For Resale. no lo, anew