an. INSPECTION NUMBER CITATION ISSUANCE DATE 43 a 8 at: I 5L FINAL CONTEST DATE 0/23/20/ PENALTY AMOUNT 0/ ?0 SUSPENSE DATES PAYMENT PLAN 5 5 5 5 5 A ?Hum (I) United States of America OCCUPATIONAL SAFETY AND HEALTH REIYJEW 1120 20th Street, N.W., Ninth Floo Washington, DC 20036-3457 3 Phone: (202) 606-5400 ax: (202) 606-5050 Secretary of Labor, Complainant, v. Region: Goodyear Tire Rubber Co., OSHRC Docket No.: 12-2133 Respondent. OSHA Inspection No.: 316480094 Notice of Docketing Of Administrative Law Judge?s Decision The Administrative Law Judge?s Report in the above referenced case was docketed with the Commission on 6/27/2013. The decision of the Judge will become a ?nal order of the Commission on 7/29/2013 unless a Commission member directs review of the decision on or before that date. Any party desiring review of the judge?s decision by the Commission must ?le a petition for discretionary review. Any such petition must be received by the Executive Secretary on or before 7/ 17/2013 in order to permit suf?cient time for its review. See Commission Rule 91, 29 CPR. 2200.91. All further pleadings or communications regarding this case shall be addressed to the Executive Secretary with a copy to the DOL Solicitor at the address below. Executive Secretary Charles F. James, Counsel for Appellate Litigation Occupational Safety and Health Review Commission Heather R. Phillips, Counsel for Appellate Litigation 1120 20th St., N.W., Suite 980 Of?ce of the Solicitor, U.S. DOL Washington, D.C. 20036-3419 Room S4004 200 Constitution Avenue, N.W. Washington, D.C. 20210 If directed for Review by the Commission, then the Counsel for Appellate Litigation will represent the Department of Labor. If you have questions, please contact the Executive Secretary?s Of?ce at (202) 606-5400. Ray H. Darling, Jr. Executive Secretary Date: June 27, 2013 Eden Besera, Legal Assistant This notice has been sent to: For the Complainant: Theresa Ball Of?ce of the Solicitor, U.S. DOL 618 Church Street, Suite 230 Nashville, TN 37219-2456 Attorney: Patrick H. Lewis Littler Mendelson, RC. 1100 Superior Avenue, 20th FL Cleveland, OH 44114 0 United States of America OCCUPATIONAL SAFETY AND HEALTH REVIEW COMMISSION 1924 Building - Room 2R90, 100 Alabama Street, SW. Atlanta, Georgia 30303-3104 Secretary of Labor, Complainant v. OSHRC Docket No. 12-2133 Goodyear Tire Rubber Co., Respondent. ORDER OF ERRATUM VACATING AND CORRECTING ORDER APPROVING SETTLEMENT AGREEMENT Complainant?s motion to correct clerical mistake is GRANTED. The Order approving settlement agreement issued on June 7, 2013, shall be vacated. The vacated order approved a settlement which inadvertently assessed an incorrect total penalty amount. This amended order is correctly restated below. Respondent, by letter dated October 18, 2012, contested a serious citation issued to it on September 28, 2012. On June 6, 2013, a settlement agreement was received from the parties which resolves the issues pending before the Commission. The settlement agreement having been considered, it is ORDERED: 1. That the terms of settlement are approved and incorporated herein as part of this order; 2. That the citation and proposed penalties issued to respondent on September 28, 2012, are reclassi?ed, amended and af?rmed in accordance with the terms of settlement and a penalty in the total amount of $12.100.00 is assessed; and 3. That respondent's motion to withdraw its notice ofcontest, pursuant to the terms of settlement, is granted. SO ORDERED. #444?; Date: June 20. 2013 Judge Sharon D. Calhoun 1924 Building, Suite 2R90 100 Alabama Street, SW. Atlanta, Georgia 30303-3104 Phone (404) 562-1640 Fax (404) 562?1650 0 ,1 CERTIFICATE OF SERVICE This is to certify that a copy of the Order of Erratum Vacating and Correcting Order Approving Settlement Agreement was mailed to the parties listed below by ?rst class mail on June 20, 2013. Secretary v. Goodyear Tire Rubber Co. OSHRC Docket No.: 12-2133 For the Secretary of Labor: Theresa Ball Associate Regional Solicitor Of?ce of the Solicitor, U.S. DOL 618 Church Street, Suite 230 Nashville, TN 37219?2456 Attn: Joseph B. Luckett, Esquire For the Employer: Patrick H. Lewis, Esquire Littler Mendelson, RC. 1 100 Superior Avenue, 20'h Floor Cleveland, OH 44114 Darrell Grafton OSHRC 1924 Building, Room 2R90 100 Alabama Street, SW. Atlanta, Georgia 30303 OCCUPATIONAL SAFETY AND HEALTH REVIEW COMNIISSIO 1924 Building - Room 2R90, 100 Alabama Street, SW. Atlanta, Georgia 30303-3104 Phone: (404) 562-1640 Fax: (404)562-1650 NOTICE OF ORDER AND REPORT Secretarv of Labor v. Goodvear Tire Rubber Companv OSHRC Docket No.: 12-2133 1. Please take notice that the accompanying order approving the settlement agreement pursuant to 29 CPR. 2200.100 and 2200.102, the settlement agreement itself, and all other papers comprising the record were mailed on this date to the Review Commission's Executive Secretary, and shall constitute the report of this Administrative Law Judge for the purpose of 29 U.S.C. 6610). 2. Any request for relief from clerical mistakes or errors arising from oversight or inadvertence must be in the form of a written motion (See 29 CPR. 2200.40). The motion should be directed to the Review Commission as follows: Executive Secretary Occupational Safety Health Review Commission One Lafayette Centre 1120 20th Street, NW - 9th Floor Washington, D. C. 20036-3457 The Executive Secretary shall make an appropriate referral of any request for relief. 4. The order shall become ?nal thirty (30) days from the date of its docketing by the Executive Secretary, unless review thereof is directed by a Commission Member within that time. 29 U.S.C. 6610). Mad- Sharon D. Calhoun Judge Date: June 7, 2013 United States of America OCCUPATIONAL SAFETY AND HEALTH REVIEW COMMISSIO 1924 Building - Room 2R90, 100 Alabama Street, Atlanta, Georgia 303 03?3 104 Secretary of Labor, Complainant v. OSHRC Docket No. 12-2133 Goodyear Tire Rubber Co., Respondent. ORDER APPROVING SETTLEMENT AGREEMENT Respondent, by letter dated October 18, 2012, contested a serious citation issued to it on September 28, 2012. On June 6, 2013, a settlement agreement was received from the parties which resolves the issues pending before the Commission. The settlement agreement having been considered, it is ORDERED: 1. That the terms of settlement are approved and incorporated herein as part of this order; 2. That the citation and proposed penalties issued to respondent on September 28, 2012, are reclassi?ed, amended and af?rmed in accordance with the terms of settlement and a penalty in the total amount of $12,000.00 is assessed; and 3. That respondent's motion to withdraw its notice of contest, pursuant to the terms of settlement, is granted. SO ORDERED. M4. Date: June 7, 2013 Judge Sharon D. Calhoun 1924 Building, Suite 2R90 IOO Alabama Street, S.W. Atlanta, Georgia 30303-3104 Phone (404) 562-1640 Fax (404) 562-1650 CERTIFICATE OF SERVICE This is to certify that a copy of the Notice of Order and Report and Order Approving Settlement was mailed to the parties listed below by ?rst class mail on June 7, 2013. Secretary v. Goodyear Tire Rubber Co. OSHRC Docket No.: 12-2133 For the Secretary of Labor: Theresa Ball Associate Regional Solicitor Of?ce of the Solicitor, U.S. DOL 618 Church Street, Suite 230 Nashville, TN 37219-2456 Attn: Joseph B. Luckett, Esquire For the Employer: Patrick H. Lewis, Esquire Littler Mendelson, P.C. 100 Superior Avenue, 20th Floor Cleveland, OH 44114 gawa?M?Q-J Darrell Grafton OSHRC 1924 Building, Room 2R90 100 Alabama Street, SW. Atlanta, Georgia 30303 0 UNITED STATES OF AMERICA OCCUPATIONAL SAFETY AND HEALTH REVIEW COMMISSION SETH D. HARRIS, Acting Secretary of Labor, United States Department of Labor, (Substituted for Hilda L. Solis, Resigned), OSHRC DOCKET NO. 12?2133 INSPECTION NO. 316480094 Complainant REGION IV ,3 at: V. - .1- ;fd?i so GOODYEAR TIRE RUBBER COMPANY, angi ?n r? Respondent . c: 23;, U.) STIPULATION OF SETTLEMENT AND MOTION TO WITHDRAW NOTICE OF CONTEST The parties, as evidenced by the signatures of their respective representatives hereto affixed, intending to fully and finally settle the above action and citations alleged therein, stipulate and agree as follows: 1. In response to the Complaint filed by the complainant, the respondent contested Item Nos. 1 through 3 of Citation and Notification of Penalty No. 1 2. Item No. la of Citation 1, alleging a serious violation of 29 C.F.R. will remain as issued but the penalty is hereby reduced to $4,900. 3. Item No. lb of Citation l, alleging a serious violation of 29 C.F.R. is hereby amended GEMSGEA to Item 1 of Citation 2. The item is other than serious and has no penalty. 4. Item No. 2 of Citation 1, alleging a serious violation of 29 C.F.R. will remain as issued but the penalty is reduced to $4,200. 5. Item No. 3 of Citation l, alleging a serious violation of 29 C.F.R. will be amended to state as follows: 29 CFR One or more methods of machine guarding was not provided to protect the operator and other employees in the machine area from hazards such as those created by point of operation, ingoing nip points, rotating parts, flying chips and sparks: On or' about 5/11/12 at the Tread Server on ARF (Automatic Radial Full-Stage) Tire Machine numbers 33and 56, guarding was not provide to protect employees at the pinch points between the Tread Server and the Drum machinery. The violation is serious and the penalty is $3,000. 6. The total effect of the stipulation of the parties on the assessed penalties for the Citation and Notification of Penalty is a reduction from $20,000 to $12,100. 7. Respondent represents that all violations alleged in the Citation and Notification of Penalty, as amended, have been and will remain abated. I 0 8. None of the foregoing agreements and statements is intended as an admission by Respondent of the allegations contained within the Citation and Notification of Penalty, as amended. The agreements herein are not intended to be used for purposes other than actions or proceedings arising under the Occupational Safety and Health Act of 1970. 9. Respondent will pay the penalty for the Citation and Notification of Penalty, as amended, within 30 days after the date this Stipulation is approved by a final order of the Commission. 10. Respondent hereby withdraws the Notice of Contest as to the Citation and Notification of Penalty. 11. Respondent will comply with all applicable abatement verification provisions of 29 C.F.R. 1903.19, including but not limited to, all certification, documentation, and posting requirements. Abatement and certification thereof shall be accomplished within 30 days after the date this Stipulation is approved by a final order of the Commission by mailing a letter to the Occupational Safety and Health Administration Area Office that issued the Citation, stating that abatement has been completed, the date and method of abatement, and that affected employees and their representatives have been informed of the abatement. Any required abatement documentation shall be submitted along with the abatement certification. 0 12. Each party hereby agrees to bear its own fees (including attorney fees) and other expenses incurred by such party in connection with any stage of this proceeding. 13. The employer agrees to continue to comply with the applicable provisions of the Occupational Safety and Health Act of 1970, and the applicable safety and health standards promulgated pursuant to the Act. 14. Respondent certifies that on sza4? 9, ZGV-3 notice I of the foregoing was given to employees by posting a true copy (as executed by respondent) of this Stipulation, in accordance with Commission's Rule 7(g) and 100(c), 29 C.F.R. 2200.7(g) and ACCORDINGLY, the parties jointly move the Commission for an Order appropriate for final disposition of the Citation and Notification of Penalty. Respectfully submitted, M. PATRICIA SMITH Solicitor of Labor STANLEY E. KEEN Regional Solicitor THERESA BALL Associate Regional Solicitor - 2M PATRICK G. LEWIS B. LUCKETT Attorney Attorney Littler Mendelson, PC U. S. Department of Labor Attorneys for the Respondent Attorneys for the Complainant 0 CERTIFICATE OF SERVICE I certify that a true copy of the Stipulation of Settlement and Motion to Withdraw Notice of Contest was served by first class mail this 4th day of June, 2013, addressed to: Patrick H. Lewis, Esquire Littler Mendelson, PC 1100 Superior Ave., 20th Floor Cleveland, Ohio 44114 WK. 2% ma?a B. LUCKETT Attorney l} CI: U.S. Department of Labor Occupational Safety and Health Administration 950 22nd Street North Suite 1050 Birmingham, AL 35203 Phone: (205)731?1534 FAX: (205)731-0504 Citation and Notification of Penalty To: Inspection Number: 316480094 Goodyear Tire Rubber Co. Inspection Date(s): 05/11/2012-09/27/2012 and its successors Issuance Date: 09/28/2012 922 East Meighan Blvd. Gadsden, AL 35903 Inspection Site: The violation(s) described in this Citation 922 East Meighan Blvd. and Noti?cation of Penalty is (are) alleged Gadsden, AL 35903 to have occurred on or about the day(s) the inspection was made unless otherwise indicated within the description given below. This Citation and Noti?cation of Penalty (this Citation) describes violations of the Occupational Safety and Health Act of 1970. The penalty(ies) listed herein is (are) based on these violations. You must abate the violations referred to in this Citation by the dates listed and pay the penalties proposed, unless within 15 working days (excluding weekends and Federal holidays) from your receipt of this Citation and Noti?cation of Penalty you mail a notice of contest to the U.S. Department of Labor Area Of?ce at the address shown above. Please refer to the enclosed booklet (OSHA 3000) which outlines your rights and responsibilities and which should be read in conjunction with this form. Issuance of this Citation does not constitute a ?nding that a violation of the Act has occurred unless there is a failure to contest as provided for in the Act or, if contested, unless this Citation is af?rmed by the Review Commission or a court. Posting - The law requires that a copy of this Citation and Noti?cation of Penalty be posted immediately in a prominent place at or near the location of the violation(s) cited herein, or if it is not practicable because of the nature of the employer?s operations, where it will be readily observable by all affected employees. This Citation must remain posted until the violation(s) cited herein has (have) been abated, or for 3 working days (excluding weekends and Federal holidays), whichever is longer. Informal Conference - An informal conference is not required. However, if you wish to have such a conference you may request one with the Area Director during the 15 working day contest period. During such an informal conference you may present any evidence or views which you believe would support an adjustment to the citation(s) and/or penalty(ies). If you are considering a rgq?t for an informal conference to discuss any issues related to this Citation and Noti?cation of Penalty, yo must take care to schedule it early enough to allow time to contest after the informal conference, should you decide to do so. Please keep in mind that a written letter of intent to contest must be Citation and Notification of Penalty Page 1 of 9 6/93) ?x - .1 .I 51' submitted to the Area Director within 15 working days of your receipt of this Citation. The running of this contest period is not interrupted by an informal conference. If you decide to request an informal conference, please complete, remove and post the page 5 Notice to Employees next to this Citation and Noti?cation of Penalty as soon as the time, date, and place of the informal conference have been determined. Be sure to bring to the conference any and all supporting documentation of existing conditions as well as any abatement steps taken thus far. If conditions warrant, we can enter into an informal settlement agreement which amicably resolves this matter without litigation or contest. Right to Contest You have the right to contest this Citation and Noti?cation of Penalty. You may contest all citation items or only individual items. You may also contest proposed penalties and/or abatement dates without contesting the underlying violations. unless you inform the Area Director in writing that you in_tend to contest the citatioms) and/or proposed pen_altv(ies) within 15 working days after receipt, the citationgs) and the proposed penalty?es) wi_ll become a ?nal order of the Occupational Safety and Health Review Commission and may not be reviewed by any court or agency. Penalty Payment Penalties are due within 15 working days of receipt of this noti?cation unless contested. (See the enclosed booklet and the additional information provided related to the Debt Collection Act of 1982.) Make your check or money order payable to Please indicate the Inspection Number on the remittance. OSHA does not agree to any restrictions or conditions or endorsements put on any check or money order for less than the full amount due, and will cash the check or money order as if these restrictions, conditions, or endorsements do not exist. Notification of Corrective Action For Egg violation which you do not contest, you are required by 29 CFR 1903.19 to submit an Abatement Certi?cation to the Area Director of the OSHA of?ce issuing the citation and identi?ed above. The certi?cation be sent by you within 10 calendar days of the abatement date indicated on the citation. For Willful and Repeat violations, documents (examples: photos, copies of receipts, training records, etc.) demonstrating that abatement is complete must accompany the certi?cation. Where the citation is classi?ed as Serious and the citations states that abatement documentation is required, documents such as those described above are required to be submitted along with the abatement certi?cate. If the citation indicates that the violation was corrected during the inspection, no abatement certi?cation is required for that item. All abatement verification documents must contain the following information: 1) Your name and address; 2) the inspection number (found on the front page); 3) the citation and citation item number(s) to which the submission relates; 4) a statement that the information is accurate; 5) the signature of the employer or employer?s authorized representative; 6) the date the hazard was corrected; 7) a brief statement of how the hazard was corrected; and 8) a statement that affected employees and their representatives have been informed of the abatement. The law also requires a copy of all abatement veri?cation documents, required by 29 CFR 1903.19 to be sent to OSHA, also be posted at the location where the violation appeared and the corrective action took place. Employer Discrimination Unlawful - The law prohibits discrimination by an employer against an employee for ?ling a complaint or for exercising any rights under this Act. An employee who believes that he/she has been discriminated against may ?le a complaint no later than 30 days after the discrimination occurred with the U.S. Department of Labor Area Of?ce at the address shown above. Citation and Noti?cation of Penalty Page 2 of 9 6/93) Employer Rights and Responsibilities - The enclosed booklet (OSHA 3000) outlines additional employer rights and responsibilities and should be read in conjunction with this noti?cation. Notice to Employees - The law gives an employee or his/her representative the opportunity to object to any abatement date set for a violation if lie/she believes the date to be unreasonable. The contest must be mailed to the US. Department of Labor Area Of?ce at the address shown above and postmarked within 15 working days (excluding weekends and Federal holidays) of the receipt by the employer of this Citation and Noti?cation of Penalty. Inspection Activity Data - You should be aware that OSHA publishes information on its inspection and citation activity on the Internet under the provisions of the Electronic Freedom of Information Act. The information related to these alleged violations will be posted when our system indicates that you have received this citation. You are encouraged to review the information concerning your establishment at If you have any dispute with the accuracy of the information displayed, please contact this of?ce. Citation and Noti?cation of Penalty Page 3 of 9 6/93) ABATEMENT CERTIFICATION Ramona Morris, Area Director US. Department of Labor OSHA 950 22nd Street North Suite 1050 Birmingham, AL 35203 Phone: (205)731-1534 Goodyear Tire Rubber Co. 922 East Meighan Blvd. Gadsden, AL 35903 The hazard referenced in Inspection Number for the violation identi?ed as Citation and Item was corrected on by The hazard referenced in Inspection Number for the violation identified as Citation and Item was corrected on by The hazard referenced in Inspection Number for the violation identified as Citation and Item was corrected on by The hazard referenced in Inspection Number for the violation identi?ed as Citation and Item was corrected on by The hazard referenced in Inspection Number for the violation identi?ed as Citation and Item was corrected on by I attest that the information contained in this document is accurate and that the affected employees and their representatives have been informed of the abatement activities described in this certi?cation. Signature Typed or Printed Name Citation and Noti?cation of Penalty Page 4 of 9 6/93) U.S. Department of Labor 6? . C, Occupational Safety and Health Administration 33? la . a NOTICE TO EMPLOYEES OF INFORMAL CONFERENCE An informal conference has been scheduled with OSHA to discuss the citation(s) issued on 09/28/2012. The conference will be held at the OSHA of?ce located at 950 22nd Street North, Suite 1050, Birmingham, AL, 35203 on at . Employees and/or representatives of employees have a right to attend an informal conference. Citation and Noti?cation of Penalty Page 5 of 9 6/93) U-S- Department Of Labor Inspection Number: 316480094 39f? ?r Occupational Safety and Health Administration a? .. .o i A v.06 Issuance Date: 09/28/2012 M: u? Citation and Notification of Penalty Company Name: Goodyear Tire Rubber Co. Inspection Site: 922 East Meighan Blvd., Gadsden, AL 35903 The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury resulting from an accident. Citation 1 Item 1a Type of Violation: Serious 29 CFR Procedures were not developed, documented and utilized for the control of potentially hazardous energy when employees were engaged in activities covered by this section: On or about 5/2/12 - at #33 ARF (Automatic Radial Full?Stage) Tire Machine on the left side, a procedure was not developed, documented and utilized containing a sequence of actions which safeguarded and controlled all known energy sources and also included procedural steps for restart and shutdown when troubleshooting and testing are necessary. Or, in the alternative - 29 CFR When lockout or tagout devices were temporarily removed from the energy isolating device and the machine or equipment was energized to test or position the machine, equipment or component thereof, the sequence of actions in 29 CFR through were not followed. Abatement Documentation Required Date By Which Violation Must be Abated: 10/04/2012 Proposed Penaity; 5 7000.00 See pages 1 through 5 of this Citation and Noti?cation of Penalty for information on employer and employee rights and responsibilities. Citation and Noti?cation of Penalty Page 6 of 9 4/99) U.S. Department of Labor Inspection Number: 316480094 9? Occupational Safety and Health Administration Inspection Dates: 05/ 1 1/2012-09/27/2012 Issuance Date: 09/28/2012 0 d? Citation and Notification of Penaltv Company Name: Goodyear Tire Rubber Co. Inspection Site: 922 East Meighan Blvd., Gadsden, AL 35903 Citation 1 Item 1b Type of Violation: Serious 29 CFR (C): The energy control procedure did not clearly and speci?cally outline the steps for placement, removal and transfer of lockout devices or tagout devices and the responsibility for them: On or about 5/11/12 - at ARF (Automatic Radial Full-Stage) Tire Machine numbers 31and 56, the Lockout/Tagout Posted Procedure for ARF Tire Machine Elevator" did not state the magnitude of pneumatic energy. On or about 5/ 11/ 12 - at ARF (Automatic Radial Full-Stage) Tire Machine numbers 31and 56, the Lockout/Tagout Posted Procedure for ARF Machine - Center Section" did not state the magnitude of pneumatic energy. On or about 5/ 11/ 12 - at ARF (Automatic Radial Full-Stage) Tire Machine numbers 31and 56, the Lockout/Tagout Posted Procedure for ARF Machine Tread Applier" did not state the magnitude of pneumatic energy. On or about 5/11/12 - at ARF (Automatic Radial Full-Stage) Tire Machine numbers 31and 56, the Lockout/Tagout Posted Procedure for ARF Lock Out" did not state the magnitude of pneumatic energy and did not identify the method or means to control the magnitude of pneumatic energy. Abatement Documentation Required Bate 333! Which Violation Mus-t: be Abated: See pages 1 through 5 of this Citation and Noti?cation of Penalty for information on employer and employee rights and responsibilities. Citation and Noti?cation of Penalty Page 7 of 9 4/99) U.S. Department of Labor Inspection Number: 316480094 ff? ?f Occupational Safety and Health Administration t? 2. Issuance Date: 09/28/2012 :3 av . Citation and Notification of Penalty Company Name: Goodyear Tire Rubber Co. Inspection Site: 922 East Meighan Blvd., Gadsden, AL 35903 Citation 1 Item 2 Type of Violation: Serious 29 CFR Where lockout was used for energy control, the periodic inspection did not include a review, between the inspector and each authorized employee, of that employee?s responsibilities under the energy control procedure being inspected: On or about 5/11/12 - at 922 East Meighan Blvd. Gadsden, AL - a periodic inspection of energy control procedures did not include a review between the inspector and each authorized employee?s responsibilities under the energy control procedure being inspected. Abatement Documentation Required Date By Which Violation Must: be Abated: 10/10/2012 Prdpos?ed Penalty: 6000.00 See pages 1 through 5 of this Citation and Noti?cation of Penalty for information on employer and employee rights and responsibilities. Citation and Noti?cation of Penalty Page 8 of 9 4/99) US. Department of Labor Inspection Number: 316480094 gt? W, Occupational Safety and Health Administration Issuance Date: 09/28/2012 Citation and Notification of Penalty Company Name: Goodyear Tire Rubber Co. Inspection Site: 922 East Meighan Blvd., Gadsden, AL 35903 Citation 1 Item 3 Type of Violation: Serious 29 CFR One or more methods of machine guarding was not provided to protect the operator and other employees in the machine area from hazards such as those created by point of Operation, ingoing nip points, rotating parts, ?ying chips and sparks: On or about 5/11/12 - at the Tread Server on ARF (Automatic Radial Full-Stage) Tire Machine numbers 33and 56, guarding was not provided to protect employees at the pinch points between the Tread Server and the Drum machinery. On or about 5/11/12 - at the Drums on ARF (Automatic Radial Full-Stage) Tire Machine numbers 33and 56, guarding was not provided to protect employees at the rotating drums. Abatement Documentation Required Date By Which Violatitjn Must be Ahmed: 1012452012 Froposed Penalty: $5 @0030 ?ag/(awn. 7?14:th Ramona Morris Area Director See pages 1 through 5 of this Citation and Noti?cation of Penalty for information on employer and employee rights and responsibilities. Citation and Noti?cation of Penalty Page 9 of 9 4/99) U.S. Department of Labor Occupational Safety and Health Administration 950 22nd Street North, Suite 1050 Birmingham, Alabama 35203 Phone: (205) 731-1534 FAX: (205)731-0504 DEBT COLLECTION NOTICE Company Name: Goodyear Tire Rubber Co. Inspection Site: 922 East Meighan Blvd., Gadsden, AL 35903 Issuance Date: 09/28/2012 Summary of Penalties for Inspection Number 316480094 3 20000.00 3 Citation 1, Serious T011514 PROMED ll ll To avoid additional charges, please remit payment to this Area Office for the total amount of the uncontested penalties summarized above. Make your check or money order payable to: Please indicate Inspection Number (indicated above) on the remittance. OSHA does not agree to any restrictions or conditions put on any check or money order for less than the full amount due and will cash the check or money order as if these restrictions or conditions do not exist. If a personal check is issued, it will be converted into an electronic fund transfer (EFT). This means that our bank will copy your check and use the account information on it to electronically debit your account for the amount of the check. The debit from your account will then usually occur within 24 hours and will be shown on your regular account statement. You will not receive your original check back. The bank will destroy your original check, but will keep a copy of it. If the EFT cannot be completed because of insuf?cient funds or closed account, the bank will attempt to make the transfer up to 2 times. Pursuant to the Debt Collection Act of 1982 (Public Law 97-365) and regulations of the U.S. Department of Labor (29 CFR Part 20), the Occupational Safety and Health Administration is required to assess interest, delinquent charges, and administrative costs for the collection of delinquent penalty debts for violations of the Occupational Safety and Health Act. Interest. Interest charges will be assessed at an annual rate determined by the Secretary of the Treasury on all penalty debt amounts not paid within one month (30 calendar days) of the date on which the debt amount becomes due and payable (penalty due date). The current interest rate is Interest will accrue from the date on which the penalty amounts (as proposed or adjusted) become a ?nal order of the Occupational Safety and Health Review Commission (that is, 15 working days from your receipt of the Citation and Noti?cation of Penalty), unless you ?le a notice of contest. Interest charges will be waived if the full amount owed is paid within 30 calendar days of the ?nal order. Page 1 of 2 Delinquent C_h?_irges. A debt is considered delinquent if it has not been paid within one month (30 calendar days) of the penalty due date or if a satisfactory payment arrangement has not been made. If the debt remains delinquent for more than 90 calendar days, a delinquent charge of six percent per annum will be assessed accruing from the date that the debt became delinquent. Costs. Agencies of the Department of Labor are required to assess additional charges for the recovery of delinquent debts. These additional charges are administrative costs incurred by the Agency in its attempt to collect an unpaid debt. Administrative costs will be assessed for demand letters sent in an attempt to collect the unpaid debt. mag 9/2 Ramona Morris Date Acting Area Director Corrective action, taken by you for each alleged violation should be submitted to this of?ce on or about the abatement dates indicated on the Citation and Noti?cation of Penalty. If the hazards itemized on this citation(s) are not abated/corrected and a follow?up inspection is conducted, your establishment may receive a Failure to Abate Citation for the uncorrected hazards with subsequent additional monetary penalties of up to thirty (30) times the original penalty amount of the uncorrected hazards. A work sheet has been provided to assist in providing the required abatement information. A completed copy of this work sheet should be posted at the worksite with the Citation(s). Page}! of 2 CERTIFICATION OF CORRECTIVE ACTION WORKSHEET Company Name: Goodyear Tire Rubber Co. Inspection Site: 922 East Meighan Blvd., Gadsden, AL 35903 Issuance Date: 09/28/2012 List the speci?c method of correction for each item on this citation in this package that does not read "Corrected During Inspection" and return this page with the signed Informal Settlement Agreement to: U.S. Department of Labor - Occupational Safety and Health Administration, 950 22nd Street North, Suite 1050, Birmingham, AL 35203. NAME OF COMPANY OFFICIAL DATE TITLE NOTE: 29 USC Whoever knowingly makes any false statements, representation or certi?cation in any application, record, plan or other documents ?led or required to be maintained pursuant to the Act shall, upon conviction, be punished by a ?ne of not more that $10,000, or by imprisonment for not more than six months or both. POSTING: A copy of the completed Corrective Action Worksheet should be posted for employee review. Page3 of 2 U.S. Department of Labor Occupational Safety and Health Altimmistration Inspection Re Thu Sep 27, 20l2 4:00pm port ID Assignment Nr. ICSI-IO ID) lSunerv rvisor ID Inspection Nr. Opt. Insp. Nr. 0418300 0 (7 316480094 Establishment Name IGoodyear Tire Rubber Co. Site 922 East Meighan Blvd. Site (256) 549-2570 Site (256) 549-2295 Address Gadsden, AL 35903 Phone FAX Mailing 922 East Meighan Blvd. Mail (256) 549~2228 Mail (256) 549-2295 Address Gadsden, AL 35903 Phone FAX Controlling Employer ID (4) Corp Ownership A. Private Sector City I1280 County 055 Legal Entity [Previous Activity (State Only) Related Activity Type Number Satisfied Type Number Satis?ed C. Complaint 207429572 Safety Employed in Establishment gb) (4) Advance Notice? No Category S. Safety Covered By Inspection >3 Union? Yes Interviewed? Yes Controlled By Employer Walkaround? Yes Primary SIC 3011 Secondary SIC Inspected Primary NAICS 326211 Secondary NAICS Inspected NAICS Inspection Type B. Complaint [Reason No Inspection Scope of InSpection B. Partial Inspection Classification Strategic Initiatives National Emphasis Local Emphasis Anticipatory Warrant Served? No Denial Date Date ReEntered Date ReDenied ReEntered Anticipatory Subpoena Served? No Entry 05/11/12 10:00 First Closing Conference 09/27/12 16:30 Opening Conference 05/11/12 11:00 Second Closing Conference 08/10/12 12:00 Walkaround 05/11/12 11:20 Exit 08/10/12 14:00 Days On Site 4 Case Closed No Citations Issued Type ID Optional Information CSHO Signature Date (?27/17, (Rev. '7/02) U.S. Department of Labor Occupational Safety and Health Abutinistration Inspection Narrative Thu Sep 27. 2012 4:00pm Inspection Nr. 316480094 Opt. Case Number Establishment Name Goodyear Tire Rubber Co. Legal Entity I Type of Business [Tire Manufacturer Additional Citation Mailing Addresses 1 Organized Employee Groups 1 nited Steel Workers United Steelworkers Local: 12L (256) 546-4633 Local: (412) 562-2400 110 Hokes St. Five Gateway Center Gadsden, AL 35903 Pittsburgh, PA 15222 Mail Citation? Mail Citation? Authorized Employee Representatives I Employer Representatives Contacted Name [Title annr?rinn anllr Armand? David Haves President iv Dar-un?t! Page 2 1 Thu Sep 27, 2012 4:00pm Goodyear Tire Rubber Co. - - Inspection Nr. 316480094 Entry 05/11/12 10:00 First Closing Conference 09/27/12 16:30 Opening Conference 05/11/12 11:00 Second Closing Conference 08/10/12 12:00 Walkaround 05/11/12 11:20 Exit 08/10/12 14:00 Case Closed Penalty Reduction Factors Size 0 Good Faith 0 History 0 [Followup Inspection? [Reason HG Citations 6/93) (b) (4) (b) (4) (b) (7)(C)(b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C) Page 5 Thu Sep 27, 2012 4:00pm Goodyear Tire Rubber Co. Inspection Nr. 316480094 (Other than 29 CFR 1904 requirements) Does the employer have a recordkeeping program relating to any occupational health issues (monitoring, medical, training, respirator fit tests, ventilation measurements, etc.)? [9 Yes No Are any programs require OSHA ealth standards? CI Yes CI No COMPLIANCE PROGRAMS (engineering controls, PPE, regulated areas, emergency procedures, compliance plans, etc.) Address any relevant compliance efforts reqarding potential health hazards covered by the scope of the inspection. The employer requires the following minimum PPE for this at this location: safety boots, safety glasses, and ear plugs. Depending on the work performing additional PPE may be required. PERSONAL HYGIENE FACILITIES AND PRACTICES - NA (showers, lockers, change rooms, etc.) Are any required by OSHA health standards? Yes I: No What Standards: HAZARD COMMUNICATION PROGRAM - NA ACCESS TO EXPOSURE MEDICAL RECORDS - NA FIRE PROTECTION AND EVACUATION PROCEDURES - NA SYSTEMS SAFETY AND EMERGENCY RESPONSE - NA RESPIRATOR PROGRAM - NA LOCKOUT SAFE WORKPRACTICES - Deficiencies observed were procedures were not utilized (accident related); periodic evaluation of authorized personnel on specific procedures had not been conducted on an annual basis; and procedures did not identify the magnitude of and method or means to control the hazardous energy. The Employer has a Control of Hazardous Energy (CHE) Policy Lockout/Tagout with last review date 1/2012. Generic lockout/tagout training is provided and documented annually. The employer has documented procedures that are periodically reviewed. FIRST AID - A health room with a nurse is available for employees. The Employer will contact 911 is case of an emergency. Gadsden Regional Hospital is located within 0.5 miles from the location. ELECTRICAL SAFE WORKPRACTICES In-house trained electricians are utilized for electrical repairs. Additional PPE is provided based on the job including arc ?ash equipment. The employer has two types of electricians - ticket and shop. Ticket electricians get assignments automatically from the Breakdown screen on computer and go to the job. A shift supervisor only gets involved if problems or need assistance. Shop electricians work specific jobs like preventive maintenance and rebuilds. EXPOSURE CONTROL PLAN - NA LABORATORY STANDARD - NA 6/93) Page 6 Thu Sep 27, 2012 4:00pm Goodyear Tire Rubber Co. Inspection Nr. 316480094 ERGONOMIC PROBLEMS - Based on OSHA 300 logs, 1H Referral 201276441 was submitted due to percentage or recorded cases that appear to be ergonomic related issues were 40-50% for 2009 through 2011 and year-to-date 2012 was at 70%. Yes No If yes, complete items 1 an 2 below. 1. Lifting (10% or more similarly exposed employees injured) a. Total of employees exposed to job: b. Total of cases for job: 2. (10% or more similarly exposed employees have 5% or more CTS cases) a. Total of employees exposed to job: b. Total of cases for job: Other significant injury/illness trends Yes I: No If yes, explain. EVALUATION OF OVERALL SAFETY AND HEALTH PROGRAM General Industry: Yes No Employer has a Safety Health Program Yes No Written Yes No Copy Attached Evaluation of Safety and Health Program (0=Nonexistent 1=Inadequate 2=Average 3=Above average) Written Program Communication to Employees Enforcement Safety Training Program Health Training Program A Accident Investigation Performed 6/93) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C) (b) (7)(C) Page 8 Goodyear Tire Rubber Co. CSHO Signature Accompanied By Thu Sep 27, 2012 4:00pm Inspection Nr. 316480094 Date 7/5/12 6/93) U. S. Department of Li Occupational Safety and Health . .s'ministration Notice of Alleged Safety or Health Hazards Thu May 10, 2012 1:31pm Complaint Number 207429572 Establishment Name Goodyear Tire Rubber Co. Site Address 922 East Meighan Blvd., Gadsden, AL 35903 Site Phone (256) 549-2570 ISite FAX [(256) 549-2295 Mailing Address 922 East Meighan Blvd., Gadsden, AL 35903 Mail Phone (256) 549-2228 Mail FAX (256) 549-2295 Management Official Telephone Type of Business Tire Mfg. Ownership Primary SIC 3011 [Primary NAICS 326211 HAZARD Describe brie?y the hazard(s) which you believe exist. Include the approximate number of employees exposed to or threatened by each hazard. Specify the particular building or worksite where the alleged violation exists. ESCRIPTION: 1. On 5/2/12, an employee sustained crushing injuries when the machine was engaged. Lockout was not utilized. LOCATION: 7/02) Page 2 .- Thu May 10, 2012 1:31pm Goodyear Tire Rubber Co. 1 7 Complaint Nr. 207429572 Has this condition been brought to the attention of: Employer Please Indicate Your Desire: Do NOT reveal my name to the Employer The Undersigned believes that a violation of an Occupational Safety or Health standard exists which is a job safety or health hazard at the establishment named on this form. Complainant Name Telephone Address(Street,City,State,Zip) (7 Signature Date If you are an authorized representative of employees affected by this complaint, please state the name of the organization that you represent and your title: Organization Name: Your Title: WALUSEONLY .. Identification Reporting ID 0418300 Previous Activity 0 Opt. Number Establishment Name Change? Site Address Change? Employer ID (4) City Code County ClNo ElYes [No Code 1280 055 Receipt Received By Send Date:(b) Supervisor(s) Assigned Information El Yes No Time: i I Industry A. Private Sector Ownership Complaint Evaluated By Subject/Severity Evaluation Is this 3 Valid Complaint? -- Yes Formality Formal safety-Serious Migrant Farmworker Camp? -- Send Letter Type glbate Letter Sent [Date Response Due Received Type Date Letterlealuation batement Letter Received Date I Complaint Inspection Planned? [If Yes, Priority: If No, Reason: Action Transfer To (Name) Transfer Date Transfer To Category Strategic Initiatives National Emphasis Local Emphasis Type ID Value Optional Information Close Complaint COMMENTS 7/02) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(D)(b) (7)(D) (b) (7)(C)(b) (7)(C) (b) (7)(C) (b) (7)(C) U. S. Department of Labo- Occupational Safety and Health Asrninistration Referral Report Mon Jul 30, 20 2 4:40pm Reporting ID 0418300 Previous Activity 0 Referral Number 201276441 Establishment Establishment Goodyear Tire Rubber Company Employer Information Name Address 922 East Meighan City Code 1280 County 055 Gadsden AL 35903 We Site Phone (256) 549-2228 Site PM (256) 549-2648 Mallms Address 922 East Meighan Gadsden AL 35903 Mailing Address Phone (256) 549-2228 F831 (256) 549-2648 Industry Type of Business Primary 3011 Primary 326211 No. of (4) Ownership SIC NAICS Employees Ownership A. Private Sector Source Referred By A. CSHO (Within Office)(b) Date Received 07/30/12 Source or Contact (Name, Location, Af?liation, Telephone Number): Referral Classi?cation Health Serious HAZARD DESCRIPTION: OSHA 300 Logs Show potential ergonomic hazards that have trended upward since 2009. The percentage of recorded cases that appear to be ergonomic related are for the following calendar years: 2009 - 40% 2010 - 50% 2011 - 50% and YTD 2012 (as of 5/16/12) - 70%. Referral Send Letter Date Letter Sent Date Response Due Response Received Supervisor(s) Action (Satisfactory or Not Assigned Satisfactory) (7X0) Inspection Planned? Yes If Yes, Priority: If No, Reason: Transfer To (N ame): Transfer Date Transfer To Category: Strategic Initiatives National Emphasis Local Emphasis Optional Type ID Optional Information Value Information Close Referral OSHA-90 (2196) Page? 2 Comments ll Mon Jul 30, 2012 4:40pm Complaint Nr. 1 OSHA-90 (2/96) U. S. Department of Lalz' Occupational Safety and Health Administration Worksheet Fri Sep 28, 2012 8:01am Inspection Number 316480094 Opt. Insp. Number Establishment Name Goodyear Tire Rubber Co. Type of Violation Serious Citation Number 01 Item/Group 001 Number Exposed 1 No. Instances 1 REC A Accident Std. Alleged Vio. 1910.0147( i) Abatement MultiStep Abatements Final Abatement Action Type/Dates Period PPE Period Plan Report 1 10/04/12 Abatement Documentation Required lDate Verified I I [Substance Codes I AVDIVariable Information: I 29 CFR Procedures were not developed, documented and utilized for the control of potentially hazardous energy when employees were engaged in activities covered by this section: On or about 5/2/12 - at #33 ARF (Automatic Radial Full-Stage) Tire Machine on the left side, a procedure was not developed, documented and utilized containing a sequence of actions which safeguarded and controlled all known energy sources and also included procedural steps for restart and shutdown when troubleshooting and testing are necessary. Or, in the alternative - 29 CFR When lockout or tagout devices were temporarily removed from the energy isolating device and the machine or equipment was energized to test or position the machine, equipment or component thereof, the sequence of actions in 29 CFR through were not followed. Penalty Calculations Adjustment Factors Proposed Adjusted Severity Probability Gravity GBP Size Good Faith History Penalty High Greater 10 7000.00 0 0 0 7000.00 Repeat Factor 0 Employee ExposurePhone Address I [Instance Description: A. Hazard B. Equipment C. Location D. Injury/Illness E. Measurements 4. Date/Time 05/02/ 1 1 20. Instance Description - Describe the following: a) - Employees are exposed to the hazards of being struck by, caught in and crushed by moving machinery while performing maintenance activities at #33 ARF lBIHprint(Rev. 9/93) Page 2 Fri Sep 28, 2012 8:01am Goodyear Tire Rubber Co. Inspection Nr. 3164gtv -34 Citation Nr. 01 Item/Group 001 (Automatic Radial Full-Stage) Tire Machine on the left side. An Electrician-Ticket employee was caught between the Live Center and the Elevator resulting in life-threatening injuries. The machine had several trouble calls earlier in the day and one of the elevator bumpers had been replaced. At the time of the accident, the machine had shut down at sequence step 7. The employee was trouble- shooting the bump safety system at the elevator. The O-ring/Transfer-ring and the transfer roll had been moved out of the way and the Live Center had been moved to the up position. The employee was working on the safety switch located behind the elevator. This put the employee in a position between the live center in the up position and the elevator in the down position. While working on the wiring, the operator and the employee noticed that the "Start" light was off so the employee had asked the operator to start the machine. When the operator pushed the start button, the live center activated based on the next sequence step and came down pinning the employee between the live center and elevator. The operator put the machine in manual to move live center off of employee then went and got help. The employer noted in the accident report that the repair had been completed. The employer has five procedures for the ARFs. The Total Isolation procedure shuts down the entire machine. The other four procedures only shut down the specific sections of the machine: Elevator, Center Section, Machine Tread Applier, and Based on the information in the procedures, only the Total Isolation and Elevator procedure would have applied to the area the employee was working in. According to the employer, if the employee had used these procedures she would not have been able to troubleshoot the equipment. Severity: High - Death, amputations and other permanent disabilities could occur if struck by, caught in and crushed by the moving machinery in ARF tire machines. Probability: Greater - In the accident report, the employer and employee stated that they routinely check electrical issues without utilizing lockout/tagout b) Equipment - #33 ARF (Automatic Radial Full-Stage) Tire Machine. c) Location - #33 ARF (Automatic Radial Full-Stage) Tire Machine. d) Injury/Illness - Death, amputations, permanent disabilities, broken bones, contusions and concussion. e) Measurements - CSHO Photos, LOITO documentation 21. Photo Number Location on Video (?i?ffi?fc 3?26)? (7)16: 3? (7 (C) iscussmg Ark (7X0) Stated that during "In troubleshooting phase- employees don?t lock-out until the problem is identified and then the equipment is locked out." and(b) (7) agreed. No one in the room disagreed or disputed the statement. They stated that electric wires the injured employee was working on would have to be live in order to find the short. If the equipment had been locked out then, the employee would not have been able to troubleshoot where the problem was. 24. Comments (Employer, Employee, Closing Conference) Abatement Note: The machine guarding standards, in 29 CFR 1910, Subpart 0, may be used for abatement purposes provided that the machine guarding technique(s) use of machine guards or light curtain) prevent employee exposure to hazardous energy g. moving mechanical parts). 25. Other Employer Information 26. Classification: Serious Knowledge or 0 Repeat? Willful? 9/93) Page 3 Fri Sep 28 2012 8:01am Goodyear Tire Rubber Co. Inspection Nr 31648;? 94 Citation Nr 01 Item/Group 001 First Repeat Second Repeat Repeat Penalty NA NA NA Event Event Code Action Code Citation Type Penalty Abate Final Date Date Order 09/28/12 Add transaction A Add Serious 7000.00110/04/12 OSHA- I BIHprint(Rev. 9/93) U. S. Department of Lab Occupational Safety and Health Administration Worksheet Fri Sep 28, 2012 7:12am Inspection Number 316480094 Opt. Insp. Number Establishment Name Goodyear Tire Rubber Co. Type of Violation Serious Citation Number 01 Item/Group 001 Number Exposed 1 No. Instances REC A Accident Std. Alleged Vio. l910.0147( i) Abatement MultiStep Abatements Final Abatement Action Type/Dates Period PPE Period Plan Report 1 Abatement Documentation Required [Date Verified [Substance Codes I AVDIVariable Information: 0 29 CFR Procedures were not developed, documented and utilized for the control of potentially hazardous energy when employees were engaged in activities covered by this section: On or about 5/2/12 - at #33 ARE (Automatic Radial Full-Stage) Tire Machine on the left side, a procedure was not developed, documented and utilized and a sequence of actions was not followed to control hazardous energy when employees are troubleshooting electrical problem(s) with the Tire Retrieval Chuck/Elevator bump switches exposing employees to struck by, caught in and crushed hazards. Or, in the alternative - 29 CPR When lockout or tagout devices were temporarily removed from the energy isolating device and the machine or equipment was energized to test or position the machine, equipment or component thereof, the sequence of actions in 29 CFR through were not followed. Penalty Calculations Adjustment Factors Proposed Adjusted Severity Probability Gravity GBP Size Good Faith History Penalty High Greater 10 7000.00 0 0 0 7000.00 Repeat Factor 0 Employee Exposure: Occupation Employer [Goodyear Tire Rubber Co. Nr of Employees Duration (7X0) lFrequency (7X0) Employee Name Address Phone @1st Description: A. Hazard B. Equipment C. Location D. Injury/Illness E. Measurementsj 4. Date/Time 05/02/11 20. Instance Description - Describe the following: a) - Employees are exposed to the hazards of being struck by, caught in and crushed by moving machinery while performing maintenance activities at #33 ARE lBIHprint(Rev. 9/93) Page 2 1 Fri Sep 28, 2012 7:12am Goodyear Tire Rubber Co. Inspection Nr. 316481.334 Citation Nr. 01 Item/Group 001 (Automatic Radial Full-Stage) Tire Machine on the left side. An Electrician-Ticket employee was caught between the Live Center and the Elevator resulting in life-threatening injuries. The machine had several trouble calls earlier in the day and one of the elevator bumpers had been replaced. At the time of the accident, the machine had shut down at sequence step 7. The employee was trouble- shooting the bump safety system at the elevator. The O-ring/Transfer-ring and the transfer roll had been moved out of the way and the Live Center had been moved to the up position. The employee was working on the safety switch located behind the elevator. This put the employee in a position between the live center in the up position and the elevator in the down position. While working on the wiring, the operator and the employee noticed that the "Start" light was off so the employee had asked the operator to start the machine. When the operator pushed the start button, the live center activated based on the next sequence step and came down pinning the employee between the live center and elevator. The operator put the machine in manual to move live center off of employee then went and got help. The employer noted in the accident report that the repair had been completed. The employer has five procedures for the ARFs. The Total Isolation procedure shuts down the entire machine. The other four procedures only shut down the specific sections of the machine: Elevator, Center Section, Machine Tread Applier, and Based on the information in the LOITO procedures, only the Total Isolation and Elevator procedure would have applied to the area the employee was working in. According to the employer, if the employee had used these procedures she would not have been able to troubleshoot the equipment. Severity: High Death, amputations and other permanent disabilities could occur if struck by, caught in and crushed by the moving machinery in ARF tire machines. Probability: Greater - In the accident report, the employer and employee stated that they routinely check electrical issues without utilizing lockout/tagout b) Equipment - #33 ARF (Automatic Radial Full-Stage) Tire Machine. c) Location - #33 ARF (Automatic Radial Full-Stage) Tire Machine. d) Injury/Illness - Death, amputations, permanent disabilities, broken bones, contusions and concussion. e) Measurements - CSHO Photos, documentation 21. Photo Number Location on Video 23. Employer Knowledge Yes - During a me7etino (?161/_.scussing AFR LOITO procedures, Mr. stated that during "In troubleshooting phase. employees don?t lock-out until the problem is identified and then the equipment is locked out." and (7 )agreed. No one in the room disagreed or disputed the statement. They stated that electric wires the injured employee was working on would have to be live in order to find the short. If the equipment had been locked out then, the employee would not have been able to troubleshoot where the problem was. 24. Comments (Employer, Employee, Closing Conference) Abatement Note: The machine guarding standards, in 29 CFR 1910, Subpart 0, may be used for abatement purposes provided that the machine guarding technique(s) use of machine guards or light curtain) prevent employee exposure to hazardous energy moving mechanical parts). 25. Other Employer Information 26. Classification: Serious Knowledge or 0 Repeat? Willful? lBIHprint(Rev. 9/93) Page 3 Fri Sep 28, 2012 7:12am Goodyear Tire Rubber Co. Inspection Nr. 31643. )4 Citation Nr. 01 Item/Group 001 First Repeat Second Repeat Repeat Penalty NA NA NA Event Event Code Action Code Citation Type Penalty Abate Final Date Date Order Add transaction A Add Serious 7000.00 lBIHprint(Rev. 9/93) U. S. Department of Lair Occupational Safety and Health Administration Worksheet Fri Sep 28, 2012 7:42am Inspection Number 316480094 Opt. Insp. Number Establishment Name Goodyear Tire Rubber Co. Type of Violation Serious Citation Number 01 Item/Group 001 Number Exposed 3 No. Instances 4 REC Std. Alleged Vio. 1910.0147( ii)(C) Abatement MultiStep Abatements Final Abatement Action Type/Dates Period PPE Period Plan Report 5 10/10/12 Abatement Documentation Required I IDate Verified I I IEbstance Codes I [KID/Variable Information: 29 CFR (C): The energy control procedure did not clearly and specifically outline the steps for placement, removal and transfer of lockout devices or tagout devices and the responsibility for them: On or about 5/11/12 - at ARF (Automatic Radial Full-Stage) Tire Machine numbers 31and 56, the Lockout/Tagout Posted Procedure for ARF Tire Machine Elevator" did not state the magnitude of pneumatic energy. On or about 5/11/ 12 - at ARF (Automatic Radial Full-Stage) Tire Machine numbers 31and 56, the Lockout/Tagout Posted Procedure for ARF Machine Center Section" did not state the magnitude of pneumatic energy. On or about 5/11/ 12 - at ARF (Automatic Radial Full-Stage) Tire Machine numbers 31and 56, the Lockout/Tagout Posted Procedure for ARF Machine Tread Applier" did not state the magnitude of pneumatic energy. On or about 5/ 11/12 - at ARF (Automatic Radial Full-Stage) Tire Machine numbers 31and 56, the Lockout/Tagout Posted Procedure for ARF Lock Out" did not state the magnitude of pneumatic energy and did not identify the method or means to control the magnitude of pneumatic energy. Penalty Calculations Adjustment Factors Proposed Adjusted Severity Probability Gravity GBP Size Good Faith History Penalty High Lesser 05 5000.00 0 0 0 0.00 Repeat Factor 0 Employee Exposure: Occupation Employer IGoodyear Tire 8: Rubber Co. Nr of Employees Duration IFrequency 7 lb) (7) C) Employer Goodyear Tlre Rubber Co. Duration Frequency Nr of Employees Employee Name Occupation lBIHprint(Rev. 9/93) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C)(b) (7)(C) Page 3 Fri Sep 28, 2012 7:42am Goodyear Tire Rubber Co. Inspection Nr. 31648LJJ4 Citation Nr. 01 Item/Group 001 Serious Knowledge or 0 Repeat? Willful?? First Repeat Second Repeat Repeat Penalty Event Event Code Action Code Citation Type Penalty Abate Final Date Date Order 09/28/12 Add transaction A Add Serious 0.00 10/10/12 B/lBIHprint(Rev. 9/93) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C)(b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) Page 3 Fri Sep 28, 2012 7:17am Goodyear Tire Rubber Co. Inspection Nr. 311 00094 Citation Nr. 01 Item/Group 002 Event Event Code Action Code Citation Type Penalty Abate Final Date Date Order Add transaction A Add Serious 6000.00 OSHA- 1 Bl BIHprint(Rev. 9/93) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C) (b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C) (b) (7)(C)(b) (7)(C) (b) (7)(C) (b) (7)(C)(b) (7)(C)(b) (7)(C)(b) (7)(C) ?0 ?0f BANNER the photoelectricspecialist 063;. 0% Sensors Compact modular self-contained photoelectric sensing controls Status Indicator LED (except emitters) Access to Sensitivity Adiustment Lens Centerline 4.5" (114 mm) 1/2" 14 NPSM Conduit Entrance 5 mm screw 1.18" clearance (4) (30,0 mm) 0 Modular design with interchangeable components (scanner blocks, power blocks, and logic timing modules); over 5,000 sensor con?gurations possible 11 Scanner blocks for opposed, retro, diffuse, convergent, and ?ber optic sensing modes (including high-gain models) I Power blocks for ac or dc operation, including 2-wire ac operation 0 Logic modules to support a wide variety of delay, pulse, limit, and rate sensing logic functions Most scanner blocks include Banner?s exclusive, patented AIDTM (Alignment Indicating Device) system, which lights a t0p-mounted indicator LED whenever the sensor sees its own modulated light source, and pulses the LED at a rate proportional to the strength of the received light signal. Printed in USA 3 288 7 Contents Introduction to Modular Sensors page 3 Selection of components and summary of available models pages 4-6 3- and 4-wire Sensors pages 6?23 3- and 4?wire Scanner Blocks pages 6-14 3- and 4-wire Scanner Block modi?cations page 14 3- and 4-wire Power Blocks pages 15-20 3- and 4-wire Logic Modules pages 21-23 2-wire Sensors pages 24-29 2-wire Scanner Blocks pages 24-26 2-wire Power Blocks pages 27-28 2-wire Logic Modules page 29 Accessories pages 30-31 Upper Covers (lens assemblies) page 30 Lower Covers page 30 Mounting Brackets page 31 Quick Disconnect page 31 WARNING photoelectric presence sensors described in this catalog do NOT include the self- eheckiug redundant circuitry necessary to allow their use in personnel safety applications. A sensor failure or malfunction can result in either an energized or a dc-energized sensor output condition. Never use these products as sensing devices for personnel protection. Their use as a safety device may create an unsafe condition which could lead to serious injury or death. Only MACHINE-GUARD and Systems, and other systems so designated, are designed to meet OSHA and ANSI machine safety standards for point-of?operalion guarding devices. No other Banner sensors or controls are designed to meet these standards, and they must NOT be used as sensing devices for personnel protection. WARRANTY: Banner Engineering Corporation warrants its products to be free from defects for one year. Banner Engineering Corporation will repair or replace, free of charge. any product of its manufacture found to be defective at the time it is returned to the factory during the warranty period. This warranty does not cover damage or liability for the improper application of Banner products. This warranty is in lieu of any other warranty either expressed or implied. Banner Engineering Corp. 9714 Tenth Ave. No. Minneapolis, MN 55441 Telephone: (612)544-3164 FAX (applications): (612)544-3573 Selection of UL I-BEA Components sensors are made up of three components: scanner block. power block, and logic module. This is true for all MULTI- BEAMs with the exception of opposed mode emitter units which require only a power block (no logic module). The ?rst decision in the component selection process is to determine which family of MU EAM sensors is appropriate for the applica- tion: 3- and 4-wire, or 2-wire. Next, decide which scanner block (within the selected family) is best for the application. The guidelines in the catalog introduction will help you to determine the best sensing mode. Then narrow the choice by comparing the speci?cations listed in the following charts and on the pages referenced in the charts. Finally, choose a power block and logic module to complete the assembly. Components snap together without inter- Upper Cover (lens) (supplied with Scanner Scanner Block) Logic Module Housing .if; wiring to form a complete photoelectric sensing system that meets your . Power exact requirements while maintaining the simplicity ofa self-contained ?owclr? dOVErh ll Block sensor. (SUPP wn i Operate Select Scanner Block) Logic Wiring If you have any questions about selecting components, Timing Terminals please contact your Banner sales engineer or call Banner's Applications Adjustment Department at (612) 5443 [64 during normal business hours. 3- and 4-wrre Systems (pages 6 through 23) Scanner Blocks Model Sensing Mode Range Response Page SBE SBRI Opposed: high speed ISO feet I millisecond p. 7 SBED Opposed: high Speed, narrow beam 10 feet millisecond p. 7 SBEX SBRXI Opposed: high power, long range 700 feet [0 milliseconds p. 7 SBEV SBRXI Opposed: visible beam IOO feet 10 milliseconds p. 7 SBEXD Opposed: high power, wide beam angle 30 feet IO milliseconds p. 7 I SBLVI Retrore?ective: high speed, visible beam 30 feet I millisecond p. 8 SBLVAGI Retrore?ective: polarized beam (anti-glare) [5 feet I millisecond p. 8 SBLI high speed, infrared beam 30 feet I millisecond p. 8 SBLXI high power, long range 100 feet [0 milliseconds p. 8 1 3 a SBDI Di??use (proximity): high speed l2 inches 1 millisecond p. 9 SBDLI Diffuse (proximity): medium range 24 inches millisecond p. 9 SBDXI Diffuse (proximity): high power, long range 6 feet [0 milliseconds p. 9 SBDXIMD Diffuse (proximity): wade beam angle 24 inches 10 milliseconds p. 9 SBCVI Convergent beam: high speed, visible red 1.5-inch focus I millisecond p. l0 Convergent beam: high speed, visible green 1.5?inch focus I millisecond p. to Convergent beam: high speed, infrared [.5-inch focus I millisecond p. l0 SBCI-4 Convergent beam: high speed, infrared 4-inch focus I millisecond p. l0 SBC1-6 Convergent beam: high speed, infrared 6-inch focus I millisecond p. 10 SBCXI Convergent beam: high power. infrared 1.5-inch focus l0 milliseconds p. 0 Convergent beam: high power, infrared 4-inch focus 10 milliseconds p. [0 Convergent beam: high power, infrared 6-inch focus 10 milliseconds p. 10 SBEF SBRFI Opposed ?ber optic (glass fibers): high speed see specs I millisecond p. SBEXF Opposed fiber optic (glass ?bers): high power see specs 10 milliseconds p. ll SBFXI Fiber optic (glass ?bers): high power, infrared see specs [0 milliseconds p. Fiber optic (glass fibers): high speed, infrared see specs I millisecond p. 12 SBFI MHS Fiber optic (glass ?bers): very high speed see specs 0.3 millisecond p. 12 SBFVI Fiber optic (glass ?bers): visible red see specs I millisecond p. [3 Fiber optic (glass ?bers): visible green see Specs 1 millisecond p. l3 SBARI Ambient light receiver see specs l0 milliseconds p. l4 SBARIGH Ambient light receiver: high gain see specs [0 milliseconds p. 14 SBARIGHF Ambient light receiver: for glass ?ber optics see specs 10 milliseconds p. 14 I . Opewmcg CoquaeadG? IIZ NW: [I?ll (7 (C) 35 - 12L 9/1qu 5%-41933. FAX - 6?45- Waste l\b HOICES ST. 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Pm?a ma MES cue?w mg; v-LJH?aeg 77ft? 5728.29 cm M?znsu?'? 50545ch Fido-37 mus-L game and 5'02? 3m . Mapr?oqmas I433: 33 YEW. 069/ Mama F722. MP o?aa?h?bas (4) (4) imaw /W/wu1?, 1071?: a: dome-94: 4) (4) (WW (5) (55% 30525 ?ne. 20? 2012?. (or 5105/?: on fn? MMHE ?ag/?Ah bboq Casi/mus 92mm; Foe. AQFs \r r: AEQ wen u. Mum? Emvgn?ol anon 20.,ng ER. i?wwnJEEMvs \rmmn?ww ?imk?t? ?an $33.9me ?b?hism?w. k. ml}! - Q?ta??t. 609213.556, fur/7?0 (651253 - 155053- Pdhm?h- OSHA '8 Form 300A Year 20 09 Summ?of Work-Related Inl'uries and Illnesses 0, 1W. Number of Cases Total number of Total number of Total number of Total number of death cases with days mes with job other recordable away from work transfer or restriction oases ?43 (G) (H) (I) (J) Number of Days Total number of days Total number of days of away from work job tramfer or restriction MW) (4) (L) Injury and Illness Types Total number of . . . (M) (1.) Injuries 52 (4) Poisonings (2) Skin disorders (5) Hearing (3) Respiratory conditions 9 (6) All other illnesses OMB on. 1233-0176 Establishment information Your estabilshmem name Goodyear Tire 3. Rubber - Gadsden Street City State Industry description (3.3., Manufacture ofmotor truck trailers) Wanna Standard Industrial Classi?cation (SIC). irkmwu 5163715) Employment information (lbw don't have these ?gures. the .) Sign here Annual average number of employees Total hours worked by all employees last year Icemfy' knowledge we entries are true. accurate. and complete. {4221;?5/ Flam ManagePhone Date I OSHA's Form 300 Log of Work-Related Injuries and Illnesses If you're not sure whether a ?so is recordable. call your teen! OSHA Of?ce for help. Identify the person Attention: possible while the information is being used for occupational safety and health purposes. Describe the case This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent proloseionai. speci?c mg Mo [insofar a single case "you need to. You must emulate an Injury and [those hidden: Report (OSHA Form 301) or oquhralantlonn for each initmor illness recorded on this form. CHECK ONL (SHE 20x15: each casc- Year US Department of Labor Occupational Safety and Health Administration -G scam Go Estahl?tshmern name CW Classify the case A MEI. l' '5 . Cage) Employg?s name JOEL. {38me Where Daahhtiuryorl?nessmartsofbody 3:932? ros 39?" "awn-E ?whinlwodor calm-unarm- (9.9., Welded inlwy (9-9- Wmdodrmm enacted. and ommo??ms. aroma: and) injuredormadepersoni? calmness Rminedatwodt Mb 2' :3 Daysaway Jobtramfar Otlurrlcord- :25 g; 5-: Duff! tromwork ?restriction mom? has?ew Gri um, ObiISub: Tire On Cm"; u? 131P 00 0453 #25 Machine Shop Wound.opn.uppgmitenb nos wlo ?3an Mays?days El El 5104 StripMill - - __uays__days - 7 El? DU 131P 00 0450 - - . aloe gmmunos,msmgen [j DD - - 7 W: ram? ?mm?W 53 m-w?e-Pw Li Ll 13111033432 ma BaokOfLong UnolnDept Dislocatim ?ngerNOS,openRightF?mger gm amp?"W" 5500 2Nd Digit-Fore algal?, Conveyor I: a 13113 03 0435 - 9 MD . . BreakDown I __days._days. El DU 13": 08 0496 . .. {28 902.5 anosmm. [j ma Betweenn And as at NOS Right alleys days . I: '3 n1 Mil . wlo omplLaft Finger. _nay= a? 131P 03 0507 - - . .. 13 s1Am= gammagamlpunmenngm E) 7 . - - ?9 same '3 '3 131P_0a__0522 25 . . lsePlySorappmg ash-rue W?zlbuwan forearmLeftAim I: AFN-DODGE Puh?crapor?ngbt PAGETOTALS oc20210. Page 0(2) (0 ii) Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. OSHA's Form 300 Log of Work-Related Injuries and Illnesses You weptofeseionai. Report 301) orequivaiantfonntoreadi hluryerilhess recorded onth'istorrn. Identify the person Describe the case CHECK ONE DOA Classify the case 7 Year ELL US Department of Labor Occupational Safety and Health Administration Wman? City State Choc-kins 'lniury? for each case (A) (B) (C) (D) (E) (F) based on the mos: serious sutcsme Case Empioyeesname - Detect Whammeeventoowrred Desoribe? ?hem, of I: - dayetmintmd no. ?gma?ad MG north a?md, 316% ha. case in water was: one time of [Ill-m: eronset end) iniuredormadepetsonill I stillness Hanna-admired (ML a a ?mm mm mm 3mgWork ?restriction ?$9.053? 07/13 mug haadad'ie Heed. Obi/Sub. Overlay [j [j man?days. 07m Overlay Wound. .?'nger [0 er. Jaw??Y5 ow?m '3 ail-laud". aim-nut ?am H03 ,d ?85 7 ?ouidenowsueio?wmgaoamwmw 07m Paint Line Long Line swam/swam. tun-tbs: region Fi? ht Back. J?Jays - ?9 '3 a [3 El El 13113 - - . . .08_0547 7 07/23 MameBetweenBB aAnu sculpwlo mp: [j [j 3?days __dnys L_l lu?_oa_osaz 38/05 QuadOperahorSia?on Omega-r; hand?) Right Hand. a __days .JILdays 131P_oa_0577 Jam 73 n1 swam. hand NOS Rigmi-iand [j [j -_n.days l] 13113 )ana CumgPtosstM 18/19 Grind nd. . Io Salaam; _d - . exnm?tw? '3 ?a El 13:: tarts Shower Spasm.mseie Fi? Mu ioskeietal Mgm? latP oa - . . .0587 pm Hi [j if; [j Amman-DUE] DD PAGETOTALS Pemarenotrequiredto liyouhaveanycemrnenieaboutmese Page Skin Disorder Ros imtory Con?llion Poisoning gHoaring Lon: All Other ilinolaoa 33 3 3 Attention: This form contains information relating to employee health and must be used in a manner that Year 2009 OSH A's Form 300 protects the con?dentiality of employees to the extent . possible while the information is belng used for us Be artment of Labor Log Of Work-Related Injuries and Illnesses occupational safety and health purposes. Occupational Safety andp?ealth Adminis??ation Estabishm Ti - mprofesshnal. Feelfreetom ?mm twofmesfwashglaoeso?youneedto. Youmustoornpletoanlr?uryand City Identify the person Describe the case Classify the case CHECK ONL box {or esch case (A) based on the mos: sencus oulcam?: Io: Em" the mambo: at Check the 3?39 Employee?s name Jog?? 0313?: Where theaters D?go?be injury or llhess. parts of body ;11a;5355- the Injured ?Ml clum- no - (5.9., Welder) mil-W (59- Why dad-north affected. and china/substance that crmdiy Ill worker was. on- two of Illness. or onset end) irqfured or nelson ill 0? illness Flushed aiworlt (M) (9.9. Secund dogma bums an mean-n Mahmud? Days away Oil Away Onjob From transfer Death frornwork ahlocasos Work or lotion Skin Disorder Candillon Polsonlng All Other Illnesses ((1) (2) i3) (4) (5) {fl 13113 as 0305 01/04 #7Pe?e?lizer Pemin' .iower Left .0 b: 4mm was: ?9 El I: [2 1311103 0313 01107 Fm: Fm'ish if; ?days?davs Arm.0bil5ub.'TirasJammedUp I: I DD 131P_oa_oaas 7 01121 nose - Aways?mew . Shoulder. Dwaib: anaimmck. Hagf?tHook a DD 131P_ua_oaea 02112 FomeGrinderm Contusion, rl'mb nos Ann.0biiSub: ?da1rs-15?davs '4 Force 1a1P_oa_o4as 7 )uans SortToForoeGrind [j Jaw??8V3. [j Tires I I F_l - A a VacUHo'ist I 7 Jens 6Tuber StorageArea UmbagoRightBangbUSub: mm [j El 33/19 new rFu SpraWstram' NEG Muswioskeletal 4211mm rye WWI?mtg. ?5 Obi/Sub;UnlmownDust ram?waives..? '131P_?8_0m mm Floa'oving mania, rib NOS.ciosedRight Ribs. _6Ldays__days - I: 131P_os_04a1 was we as ornpl or. -- ?days ?days' meme '3 '3 . a Maya IE LII TU DU 014 'utes espouse,hclud tirn rovl th PAGETOTALS gmmedam :srenozrzquirgtoe 3 f? reapondtomaoolledion OMBoontrolnu-nbor. .. .. 2' 3 Page Attention: This form contains information relating to 7 employee health and must be used in a manner that Year 2009 1 protects the con?dentiality of employees to the extent OSHA 3 Form 300 possible while the information is being used for US Department 01' Labor _Log of Work?Related Injuries and Illnesses occupational safety and health purposes. OccupationalSafety and Heal?, Administration You mustrecordinformatim about hjuryorliinesemetinvohlee lossdw'tsuomeas. 55,33,me ed Youmuszeisoreoord work 190412. You Oily 51313 Identify the person Describe the case Classify the case CHECK ONL box for each case the 01 Check the (A, (B, (C) (D) (E) (F) based on me was! serious ourccme :75: 111 ch Case Em shame . Detect Whereiheeventoowned Desaihe . oi .- deys Iinilmd or eehunner om. hiurv Laadingdocknarm almaed. 33me mm?m ?5a narrator-m: matinee-Him. or ems: end) iniured or made person ill of illness Flames-red at work (M) A 0 a 3 #aanmtOM) Daysmy Jobuensfer O?wrreeord- 9:3: ?hf: as 063111 ironwork ehiecesu Work whmuswon Obi/glib! LJ 09103 Sort Line Hernia. site NOS win new 11 rAbdornen, 512 _.days I owe,? 131P_oe_oeoe 7 09/08 Fame Grinder Frldure forearm NOS. Arm45:11:73.8? 131P_oa_aen 09/19 33 ARF Effects of ebchic current General. Obj/Sub: E1 ?-davs ??days 11 Electrical Circuit I El Jaw??Y? El El El Cl 09/20 Tue Room Wound. open. scalp wlo empl Left Head. ObilSub: Server 131P_oe_os19 09/21 66R1 swim NOS Right Elba-w. Dwain: Stuck Carcass MID [31:1 I email 10105 StodrArea eibow?orearm NOS Right Arm. - Janey: _5?_days 7 owsrb: Rubber El Cl 11m Mold Cleaner Palnthint. shoulder ShouUer. 4313?1518?! r1 th'l'SuiazMnidOaniistRIght I I: 7 um Re ReliTabie $9th. shousdeuam Nos 11' '4 13"? 08 0684 12104 Splice: Somme-ah. shoulder/arm NOS Right _days __dey: Shoulder. Obi/Sub: BeltOn Conveyor I DICK. 12113 as lSFi1 5'1 _dary=?daw 7 Drum Slidier I 12/15 52 Am: Wound. open. shidrmpann wlo empl Flight 55 _5_daye . DD 13113 as 0699 Scalp WSW 5' 12/19 istSiegeMael'iine Wotmd, .seelpWoanpl .551 1213 42 0 0 0 instructions. gather ihedetnneededend complete and reviewihe eoliedion 01 information. Personsarenot required to Hamil-3844.200 Constiuruon Amue. NW. Washington DC 20210. Donoimdihecompiewd ofrne. Page 4 Injury Skin Disorder Respiratory Poisoning @1691an Loss All Other ilnoases 3 Form 3004 Year20 lg Summary of Work-Related Injuries and Illnesses Wu Form approved OMB on. 1218-0176 overtime Rmnornberbroview?nLog . Establishment Information Ushgt?hoLog. Warmth totalsbelow, ?you m? ?sh mm Goodyear Tire a Ruhber- Gadsden on?. Street . Number of Cases City Sun a? I Total number of Total number of Total number of Total number of . . ndarsuy dam-pm Maugham WM mien- deaths cases with days cases with job other recordable I Tl Fl ?kiwi" away from work transfer or restriction cases re 1' an 9 Standard Industrial Clasi??titm (SIC). it known $763715) 0 13 9 12 Employment information (In-nu don't be dualism-a. the Number of Days Mm: 3mg: lumber oferrployees 4 Total number of days Total number of days of I away from work job transfer or restriction by (L) (G) (H) (I) (J) SIgnhere Injury and Illness Types .4 Total number of . . . WW Plant Hangar (M) . mam-c Title 1 I I I Injuries . 34 (4) Porsomngs 356549-2266 2 - 0 25/ I (2) Skin disorders 0 (5) Hearing a PM: (3) Respiratory conditions 0 (5) All other illnesses Attention: This fonn contains information relating to employee hearth and must be used in a manner that Year 2010 - protects the con?dentiality of employees to the extent OSHA 8 Four: 300 possible while the information is being used for US Department of Labor Log of Work-Related Injuries and Illnesses occupational safety and health potposes. Occupational Safety and mam, Youmustroeordhimnathnebutn Youmustaisoreeuu Whimm?nesseettmare byeWulioensed Mme,? GoodyearTlm8Rubber-Gadsden cereptufassmal Feelfreetousa City Slain leentifytheperson Desc?bethecase Classify?tecase (daysmelnhuednr Worm Case Empbyee'srame ate Wherethe . . no. Injury Wagdadtm Mm mmg. gm am Reunitedat fol-i Ml Days Jobm- . ?mm From I I 9 as 00331 away crush-tenor: cases We? wmhic?or rd am 9 Lo (G) "Warm (31m ZCat Pam' umpto' mum Pans. _days July: mumm?nm '3 El E1 EIEJDEI . 131P_oe_0745 7 2120 Overtaysnnorez Womd. .uppartanb ptten _._days 43.63:: 131P_oe_07-ta :2122 Sprainlshu't,? nos Right .._davs mm tam TroRoom [j __davs [aloe Bala'IaMadine ?wzwm?cum [j [j _days .JILday: [3 (b GIGS 5800mm [j El Cl DU 131t=_oa_o770 3:08 Roma mammal Abdunen. _3?_days__days Cl WSuh. Terry Hill i . . 1* OhiISub:CasseuBOf3m 131P_oa_oete 4114 Bamsm?on mstingJootRight Foot. owstm: [j Juicy: i )017 Drum Booth 3pm Mariam NOS Loft Arm. [j _.2.Ldays 151% btlSub.MDmm 4117 6X3Tuber _days Adar: El El PAGE TOTALS 0 3 5 2 118 470 Page 1 ?'5ch Po Alli! urinesonis eaOtne Dipit?on r?nhas soalioin gres rdomg OSHA's Form 300 Log of Work-Related Injuries and Illnesses Attention: This fonn contains information relating to empioyee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for owupationai safety and heatth purposes. Year 2010 US Department of Labor Occupational Safety and Health Administration Weedbyepfwsi?morihmnedtnami Wigwam GoodyearTiteiRubber-Gadsden minimal. Feeifreetuuse Molimioraehgioeasoiiymmedto. If City State [Identify the person LDescn?be the case Classify the case _l i Case Emptoyee'sname . Detect Wharathoevenl Desmbe? Incas. oi ?3?3??th I ?fties? iniuw memm mm? oronset 'med? orrnedepenonll oii?ness . Remm'rwdat WERRC Aill' we: A ur in esoms ea ?nmaodyieml?ofdl} Days Joblransi'er O?'lerreeord- F3: D: gains-inn Death away arrest-loom ahteases WM orrestiedml :or131P_oo_oa15 04:20 ApexMed-n?ne - Hos Left Leg. . 7 am a a mom DEF 131P 08 0819 - - - . 0422 [j I: 131P_oa_oaz7 04:23 AFremeWmd Up At Feminism stander 7 Piyoutter Obleub:AFrame Re um a? rap 04/30 Vmi14Beit Peininjont. ub: SW39 PlasticOnW 0855 - 2 0502 l: ED 1319 no 0850 - - - - - - - 7 05:24 cumssam-au wwmiegmugowsmon Fri-I 'hl . 5 Leu ?4 _abi. 15:! Ll 131P_08_0m0 36:13 12x5 m1 om 9mm no anpi Le? '_days Ada; 7 Arm.0bjISuhzmalKnifa El '3 Elam?DD 131P as case - 36(22 SEARF [j __days _daya El 3 Can-i" 131P_oa_oaso - - . 3923 Quad [j [j me 55505piml Hernia.uniit' Ioobw Gm F1 _26.days _days ?i ObjISub Ling; NW EDGE 1319_oa_0924 - - . . 8/09 GumCel [j [j _ndaysALdarEIDD-jm Whitman: nuteeper .indudh-ugtirnotore?ewhe 11 7 3 628 1024 21 Page 2 minuscule 630313 yDipiditon rinhess gres rdorng L0 or 55 (3) (4) t5) (6) OSHA 19 Form 300 Log of Work-Rela ted Injuries and Illnesses Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. Year 2010 US Department of Labor Occupational Safety and Hearth Administration Youmustoompietaantnimy and Illness lna?dent Report (OSHA Form imasesthatarec?agnosod a Wei-Whom Fealfreetom it 5mm Goodyear Tire 3. Rubber - Gadsden City State Entity the person [?scn'be the case Classify the case CHECK ONLY ONE box for each case (A) (C) (Di basedonmemostseriousama'or Enter the m? ?1 C339 Employeesm . Dataol? them om" orihess, of . Idays?ielnhindor cannula-choose. no. min Wmdodrm mm? 411mm Warm. oronset aw madepereon?i afi?noss a Rema?nedat memo Alta] A Quiet! t: In earns ea Days Jobbasfer Merma- F: Dlgl?f?m Death away 07mm ablecass Work ?mums(2) (4) tans Sheets Pain' memowsm' _days Adar: Hummus: El 2.- one an Cassette Wm. opn. upper limb NOS wlo Len ._days __daya Ankle,ObjISub:Camtbo a 0119 Bias 001:1:me wlo anpi Hip. I_days ELDUD 1319 00 0945 .. 8?22 GumCal SUCH: ETD ar25 SortTo Cmveyor Wound. crop! . . 7 ?Wm? Cl *3 . EDD-SIDE Has-m 3.313.: 1 Truck 1 131? 03 0900 . . .. 7 9?22 1043 new - . Wes; a a a 03? kw?; 131? 00 1012 - . . I102 .opm.scalpwlom1pl8eelp.0hl8ub. 131P 03 1014 . - I04 HookLma wmw?Le??m. [j 13111034015 . . . 115 132me mp 03 1020 1 . I19 9mm DD Pub?craportingb ?whamm- inut .indud? tim the PAGE TOTALS 0 0 9 62? - Page 3 rdorng ery (1) (2) Lo [ankRC Po min esonis eaOlne Dipiaiitm mm 503150 in r35 55 (3) (4) (5) l6) Attention: This fonn contains infonnation relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the infonnation is being used for occupational safety and health purposes. OSHA '5 Form 300 Log of Work-Related Injuries and Illnesses Year 2010 US Department of Labor Occupational Safety and Health Administration Youmustalsoleowd amdeea?xandahmdoveqwk-miawd api'lysneim? Good earTlreaRubber-Gadsden Feel?eenouse game an 33mg ease you n. oumusl an OSHAF 301 em I foreach' illnessmeuded thiafonan 6? Sid! eporu arm ?my? on [Eon?fytheperson ?lliesc?bethecase 1 Classify the-case CHECKONLYONEboxforeaduzse - (a . Eden-lemma more In?ry? Case Employee?snama but? Dal?gf mam? 1 no. (9.9..Welderj iru'wy (Wmdodmom ?mm gillness and) him? a meme Pol-i mu Roman-ream (eg.Seoamdegmebmnsonringmeann =wrh== ur in esonis ea our: Death Days Jobbinsfer_ O?terreeord- gm my arrest-?ction able-mes Workorrashic?on rdorng [9.0 (G) Warm (12m 'htF'meHSlDigit __days__day: El EDUC- 1% 1 2:05 Cl _3_dasta_day222 R3095 El !_?_days i i wnetoteviewPmaremmquimam ?3 9 ?2 535 US Commu?onAvm minesanis eaome Dipimnonrinhes soatiom res rdorn 9 Ln er 55 mm (3) (4) (5) (6) Pase4 Form 3004 (Rev. 01,9004) Year 201 1 many of Work-Related Injuries and Illnesses ?mama, 5335;385:733 (tritium-momentum the Mummy. 3 OWVMLOSIO $1 the mtriayuu mad: for ?category. Thu: writ: totals below. mkingmre you'w added ?sum-56 from every page on}: Log If Part ?04.45. In rL-uwdkeepbg tale, for?mhct dauibon rh: mprowsiom for farm. Total of Total number of Tom! numb: of cases with day: cum witltjob other recordable away from ml: transfer or muiction cases 25 LI. 2 (H) (I) (J) saway Totalnumbcr nfdays ofjob transfer or resuicdat (4) $1 (4) winnings 9. (5) Hearing loss 9 All Omar illnesses 1 ans .9 any page?'om February I to April 30 of (he year jbllowing the year covered by [hefty-m. renew albatronGanon-mtm Pam": to the collection ofhformt?an unleash climb): a numb-?6d OMB um WW about these annual: or anycutu-nspeauorthia elm co?cdiam corner US Depmutcm oruhor. OSHA O?ce ofSutistin! .100 Carma-vane. N??wmingon. Faun approved OMB no. t218 Establishment Information Your name (15mm Al City 452% State ZIP Industry description Aim-?an? ofmaor truck "mica-2y Standard Industrial Classi?cation (SIC). ifknowu (mg, 3715) OR North Ametican Industrial Classi?cation (NAICSJ. (9.3.. 3362 (2) Employment information (Ifyw data? have rlacse?gnm. Jr: the Wart-slam on the hack of?iis me to gunman.) Annual average number ofemploye: 4) Total hour: worked by all employees Sign here Knowingly l'nlsit?ying this document may result in a ?ne. lceru?fythat! ha?: examinedthisdocmnem and that to the beat army l-mowledge the mm?cs are true. accurate. and complete. Jim Davis Plum Managu- Cowman)- exccuttvc Til": (256) 549.2266 .. Phone Date .095 Summary OSHA 300 Lo Sharps Injury Log Yes No From Janoary 01, 20h Em 5" -- Select Field - To December 31, 2011 Elf-?523 Select ?eld I as my default Screen El Select Field - 5? I to the Filters saved. g. Ascending f} Descending oort iated Injuries and Illnesses 1 about every work?related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment also record signi?cant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related leet any of the speci?c recording criteria listed in 29 CFR 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an sport (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is recordable, call your local OSHA ascribe the case Classify the ease CHECK ONLY one box for each case based Entaathe number of days t: on the most serious outcome for that case: Wilma? worker (?here the Describe injury or illness, parts of body affected, and lFatali Days ob transfer ther Away from job fin vent bject/ substance that directly injured or made person ill way recordable ork ansj?er ccurred om estriction cases (Days) work "Lane? x8 Nature of Injury/illness:: erh'on; Cause of r-I *1 r? 0 28 xtruder In, n. or Be een, ther; Body - i - 7 tiantcilup nkle(Right); Object Substancezz sidewall cassette. on SW ature of Injury/illnesszz Sprain/Straln/Overexertion; Cause of "1 . r- 0 0 Inspection njury/illness::Strain in or pulling; Body ?4 ?1 Neck.Shoulder 5 Both ort line Nature of Fracture or dislocation; Cause Between, Other; Body - Han Le Ob ect Substan bear trap 7 VMI Area Nature of Injury/Illness: Cause of '7 "l i 9 112 njury/Illness::5train In or pulling; Body hou der 5 Left 'ect Substance:: none 8 Balance Nature of Injury/Illness: Not Determined; Cause of 7 45 79 Machine or Slip to or form different levels (stairs Conveyor ocks, ramps, platforms, scaffolds, ladders, etc); Body I lumbosacral' (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) A Of?ce of Statistics, Room N-3644, 200 Constitution Ave, NW, 0 not send the completed forms to this of?ce. .095 Summary OSHA 300 Sharps Injury Log 'Yes 9 No From January 01, 2012 39 Reset 1' 5V Select new . To December 31, 2012 3 Reset?. Select Field I as my default Screen Select Field I according to the ?lters saved. 5" Ascending Descending Jul-t .5 ated Injuries and Illnesses 1 about every work-related injury or Illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment "so record signi?cant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related meet any of the speci?c recording criteria listed in 29 CFR 1904.8 through 1904. 12. Feel free to use two lines for a single case if you need to. You must compiete an aport (OSHA Form 301) or equivalent fon'n for each injury or illness recorded on this form. If you're not sure whether a case is recordable, call your local OSHA LCH Describe the case Classify the case CHECK ONLY ONE box for each case based on Enter the number ?f day's th Check the most serious outcome for that case: nJured or worker wasTitle Describe injury or illness, parts of body affected, and Fatali Days Job transfer ther Away from job transfer "dry or onset of object/substance that directly injured or made way or restriction recordable work (Days) restriction ~11 illness erson i turn cases Days) work anuary 03, Nature of Injury/illness:: Bruise/Contusion; Cause of 0 0 012 or Slip On same level; Body anuary 06, MI paint Nature of Injury/illness:: Sprain/Strain/Overexertion; 0 101 012 line Cause of in lifting; Body -- Back/lumbosacrai; anuary 13, #7 shear Nature of Injury/:llnessu Bruise/Contusion; Cause of 0 0 2012 against Stationary objects; Body Part 5 Bac dorsal' anuary 15, Nature of Injury/illnessz: Sprain/Straln/Overexertlon; 0 101 xtruder Cause of in lifting; Body Object Substance:: 50 lb separator wen t. MI paint Nature of Injury/illness:: Sprain/Strain/Overexertion,' 0 26 line Cause of ln lifting; Body haulder(s)(Right); OSHA '5 Form 300A Summary of Work-Related Injuries and Illnesses I All establishments covered by Part 1904 must complete this Summary page. even if no work-related injuries or illnesses occurred during the year Remember to rewow the Log to verity that the entries are complete and accurate before completing this summary. Using the Log, count the individual entries you made for each category. Then write the totals below. making sure your've added the entries from every page cases, write Employees. former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or its equivalent. See 29 CFR Part 1904.35. ln OSHA's recordkeepr'ng rule, for further details on the access provisions tor these forms. I I Number of Cases Total number of Total number of deaths cases with days away ?om work 0 1 3 (G) (H) Total number of cases with job Hamster or restrictimi 9 (D Total number of other recordable cases 1 2 (J) Number of Days Total number of days away from work (43 Total number of days of job transfer or restriction Injury and Illness Types Total number of. . . (M) (1) Injuries . 34 (2) Skin disorders 0 (3) ReSpiratory conditions 0 Post this Summary page from February 1 to April 30 of the year following the year covered by the form. (4) Poisonings (5) Hearin (6) All other illnesses Bab 5124/17 Year 20 10 US. Department of Labor Occupational Safety and Health Adminisuatior Form approved OMB no. 1218?0175 Public reporting burden lor this collection at information Is estimated to average 50 minutes per response. including time to revrew the instructions. search and gather the data needed. and complete and review the collection at information Persons are not required to respond to the collection of 'mlormation unless it displays a currently valid OMB control number ll you have any comments about these estimates or any other aspects at this data collection. contact: US Department of Labor. OSHA Ot?co of Statistics. Room DC 20210. Do not send the completed forms to this otlice 6644. 200 Constitution Avenue. NW, Washington. Establishment information Your establishment name Goodyear Tire 3. Rubber - Gadsden Street City State 21 Industry description (eg. Manufacture ofmotor truck trailers) Tire Rubber Manufacturing Standard Industrial Classi?cation ifkrtown (Lg. SIC 3715) Employment information (Ilyon don't have ?Im?s?m- the Warloheer on the back of this page :0 minute.) Knowingly falsifying this document any result in a ?ne. Annual average number ofemployees Total hours worked by all employees last year Sign here I certify that I have examined this document and that to the best of my kmwtedge the entries are true. accurate. and complete. Plant Manager Con'r executive Tut: (2585494266 2 - 9'4 20 Phone Date OSHA 300 (Rev. 01/2004) Log of Work-Related Injuries and Illnesses Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. Year 2012 U.S. Department of Labc Occupational Safety and Health Administratic You must record information about every work -related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond ?rst aid. You must also record signi?cant work?related injuries and illnesses that are agnosed by a physician or licensed health care professional. You must also record work -related injuries and illnesses that meet any of the speci?c recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to . You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you?re not sure whether a case is recordable, call your local OSHA of?ce for help. Identify the person Describe the case (A) (B) (C) (0) Case No. Employee's Name Job Title Date of injury Welder) or onset of illness (mm/day) US-GADSDI N- 12-A-295 4 N- 12-A 296 . (b US-GADSDI 12 A 297 9 US-GADSDI 12-A-298 3 US-GADSDI . (b US GADSDI N12A34 4 January 03, 2012 06, 2012 January 13, 2012 January 15, 2012 Public reporting burden for this collection of information is estimated to average 14 minutes per response, including January 23, 2012 (E) Where the event occurred Loading dock north end) Green Tire Repair Area VMI paint sort li #7 shear #6 extruder VMI paint line sort conveyor February 03, 2012 reroll stat'on (F) Describe injury or illness, parm of body affected, and object/substance that directly injured or made person Second degree burns on right forearm from acetylene torch) Nature of Injury/illness:: Bruise/Contusion; Cause of or Slip On same level; Body Buttock(s); Nature of Injury/illnessz: Sprain/Strain/Overexertion; Cause of Injury/illness::Strain in lifting; Body Back/lumbosacral; Nature of injury/illnessz: Bru'se/Contusion; Cause of I s.:Striking against Stationary objects; Body Back/dorsal; Nature of injury/illness:: Sprain/Strain/Overexertion; Cause of Injury]: ness::Strain in lifting; Body Shoulder(s)(Right); Object] Substance:: 50 lb separator weight. Nature of Injury/illness:: Sprain/Stra'n/Overexertion; Cause of Injury/illness::Strain in lifting; Body Shoulder(s)(Right); Nature of Injury/illnessz: Sprain/Stain/Overexertion; Cause of Injury]: ness::Strain in pushing or pulling; Body Shoulder(s)(Left); Object Substance:: forks on the fork truck Page totals time to review the instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Of?ce of Statistical Analysis, Room -3644, 200 Constitution Avenue, NW, Classify the case CHECK ONLY ONE box for each case based on the most serious outcome for that case: Form approud 0113 no. 1218-0! Establishment name City Enter the number of Check the "injury" days the Injured or ill column or choose one worker was: type of illness: State Remained at work . (M) 3- Away Onjob a 2 from transferor a g; 3 1'3 Days away Job transfer Other record- work restriction a .5 3?2 3 ?5 on". from work arrest-?ction able cases (days) (dayssure to transfer these totals to the Summary page (Form 300A) before you post itPage (1) (2) (3) (4) (5) (5) OSHA Form 300 (Rev. 01/2004) Log of Work-Related Injuries and Illnesses 7.2% Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. Year 2012 9\ us. Department of Lab: Occupational Safety and Health Administratic You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond ?rst aid. You must also record signi?cant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professronal. You must also record work-related injuries and illnesses that meet any of the speci?c recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must compl form. If you're not sure whether a case is recordable, Identify the person Describe the case (A) (B) (C) Case No. Employee's Name Job Title Welder) US-GADSDE 8 US GADSDE 12-A 308 1 t) US-GADSDE N- 1 2-A-309 US GADSDE 12 A-309 US-GADSDE 12-A-31 1 3 PubI-c reporting burden for this coi'ect:on of nfon'nation is estimated to average 14 minutes per response, including (D) Date of injury or onset of Illness (mm/day) February 09, 2012 February 18, 2012 February 23, 2012 February 25, 2012 Ma 03, 2012 (E) levelwind reroll station 12x6 extruder Spur ill 1 sort Bi labie Calamard co eyor (F Where the event Describe injury or illness, parts of occurred Loading dock north end) are an Injury and Illness Incident Report OSHA Form 301 or equivalent form for each injury or illness recorded on th's call your local OSHA of?ce for help . Classify the case CHECK ONLY ONE box for each case based on the most serious outcome for that case: time to rev-ew the -nstructions, search and gather the data needed, and complete and review the collection of infon?natuon. Persons are not required to respond to the collection of information unless it displays a currently valid OMB contrOI number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Oche of Statistical Analysis, Room -3644, 200 Constitution Avenue, NW, Form approted OMB no. 1218-01 Establishment name City Enter the number of Check the "injury" days the Injured or column or choose one worker was: type of illness: State body affected, and object/substance (M) a; u, that directly injured or made person Remained at work . a 3 Second degree burns on right Away -33 forearm from acetylene torch) from transfer or 5 Days away Job brat-aster Other record- work restriction a. 5 3g 8 '5 '5 it": Death from work or restriction able cases (days) (days) 5 8 (G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6) Nature of 1njury/illness:: El 0 92 Sprain/Strain/Overexertion; Cause of 1njury/illness::Caught In, On, or Between, Other; Body Object] Substancez: levelwind Nature of Injury/illnessz: Fracture ocation; Cause of 1njury/illness::Fall/trip trip over object; Body Arm(s), Upper(Right); Object Substance-r the scrap sk'd and the tread tray. Nature of Injury essInjury I ness::Stra'n' ft' 9; Body Back/dorsal; Nature of Injury] ess:: Bru?se/Contus' Ca se of IE 1 ury/illness::Fa It ?p 'p over object; . Body Nature ofI ry essz. 0 16 Spra'lStra?lOve 55':Strain in 'ft?ng; Body (s)(Left); Page totals sure to transfer these totals to the Summary page (Form 300A) before you post itPage (1) (2) (3) (4) (5) (5) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) Attention: This form contains information relating to employee health and must be used in I a manner that protects the con?dentiality of Year 2012 OSHA 5 Form 300 (Rev. 01/2004) employees to the extent possible while the Department of Labc - rm t' bein used for occu ational Log of Work Related Injuries and Illnesses 0 a 9 Occupationm?m and Hem ?minim?: safety and health purposes. You must record information about every wont-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, Form approx ed 0313 no. 84]! days away from work, or medical treatment beyond ?rst aid. You must also record signi?cant work-related injuries and illnesses that are diagnosed by a physician or licensed health Establishment name . care professional. You must also record work-related injuries and illnesses that meet any of the speci?c recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to . You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this City State form. If you ?re not sure whether a case is recordable, call your local OSHA o?ice for help. Classify the case CHECK ONLY ONE box for each case Enter the number of Check the "injury" days the Injured or ill column or choose one based on the most serious outcome 12 A-330 (A) (B) (C) (D) (E) (F) for that case: I .I Case No. Employee's Name Job Title Date of injury where the event Describe Injury or illness, parts of worker was. type Of lness Welder) or onset of occurred body affected, and object/substance (M) a illness Loading dock north that directly injured or made person Remained at 3? a 3 (mm/day) end) ill Second degree burns on right ??112forearm from acetylene tomb) Days away Job transler Other record- work restriction a 3'2 ?5 '5 3 Death from work or restriction able cases (days) (days(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6) US-GADSDE 7 llay 02, 2012 33 Arf Left Side Nature of Injury/illnessz: Crush Injury; 16 0 N-12-A-327 (C of Machine Cause of Injury/illness::Caught In, On, or 1 Between Machine(s) or machine parts; (7 C) Body Back,Chest; us GADSDE I day 03, 2012 Tray on 12 6 Nature ofI ry/illnesszz 0 0 N-12-A-328 Sprain/Strain Overexertion; Cause of IE 3 Injury/I ness::Strain in pushing or pulling; 7 Body Back; us GADSDE ?lay 11, 2012 cure press 428 Nature of Injury/illness: El [j 0 0 [l Bruise/Contusion; Cause of Injury/lilness::Struck By Falling or ?ying object; Body Part(s)" Back,Head; Page totals 1 0 2 16 3 0 Public reporting burden for this collection of information is estimated to average 14 minutes per response, including Be sure to transfer these totals to the Summary page (Form 300A) before you post it. a 3' 5? 5 3 time to revuew the Instruct'ons, search and gather the data needed, and complete and review the collection of 3. 2 2 5 :2 Information. Persons are not required to respond to the collection of information unless it displays a currently valid ,5 1-3 2' 2 2 OMB control number. If yOu have any comments about these estimates or any other aspects of this data collection, Page 4 of 4 t? 3? 8 contact: US Department of Labor, OSHA Of?ce of Statistical Analysis, Room -3644, 200 Constitution Avenue, NW, 5 an; en (1) (2) (3) (4) (5) (6) OSHA :9 Form 3004 (Rev. 01/2004) Summary of Work-Reba ted Injuries and Illnesses warm-m: . mm! All establishments by Pm I904 must complete this Summary page. ewe rl'ao bark-rand mium or ?lm occurred during the par Rant-tuber to review the Log to wily that the eerie: Ire wnplere Ind tarmac before eonqucxing this summry Using the Log. count the entries no trade for each category Then write the totals below, linking sun: addal 1hr: entnet from ears} page with: Log if you lutl no cases. write ?a Emtim former mom. and their repremtiveshavc the ugh: to review the OSHA Form 300 in as mitt-1) 11w, tho have zit-aim! teens to he OSHA Form 301 or equinient See 29 CFR Part :904 15, in twordlreephx rule. for further detu?lson the access prowsiom for thee form Number of Cases Total number ofdeolh Tatal number of Total rumba of Total number of cases with day: onset witlrjob other recordable away from work transfer or restriction cases 9 1.1. 2 (G) (H) (1) Number of Days Total number of days my Total number of days of job from work transfer or "0 (L) Injury and Illness Types Total number of . . (M) lujuttes 5.4. (4) Poisoning: (5) Hearing loss 9. (ll Skin disorders 9 All other illnesses 1 IO (3) Respiratory conditions Post this Summary page from February I to April 30 of the year following co vercd by ?reform. Public reporting burden for this collection ofinformt'run is. estimated to ?true *0 mimtes per response. including time to review the instruction. search and gather the duo needed, end complue and review the collection err-tromm l?euoru It: not required to respond to the collection ormt?orrmtion ul'lir? it I "lid OMB control number "you Int-e utv com about these mutter or my otter axpecu oftlu: data collection. more! US Dorm-mart ofLabor. OSHA Of?ce of Sutistiml Analysis, Room 8-3644. 200 Constitution Avenue. NW. Wa?ungton. DC 20210 Do not send the completed fort-tn to this of?ce Year 201 1 U.S. Department of Labor Occupational Safety and Health Administration Form OMB no 121mm WW. maul Establishment information Your mm??m Street 9325351? mew??903 Cit). gm Statc' Magma industry ducription ring. lung/burr?. ojmomr trailers) Standard Industrial Classi?cation (SIC). if known (eg, OR North Anmam Industrial Classi?cation (NAICS). (25: 3363le Employment information {{fym dm'r lure see the ift-l?f?hr? an the bud' page to estimate Annual average number of employees b) (4) Ira. Total hours worked by all employeu i Sign here Koo? ingly [alsifying this document may result in a ?ne. I certify that have :wnined this document and that to the beat of my knowledge the entries are true. accurate, and complete Jim Din-is pram Manager execum-c Tilic (256) 549-255 .. Phone Date (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) OSHA 300 (Rev. 01/2004) Log of Work-Related Injuries and Illnesses Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. You must record information about every work -related death and about every work -related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record signi?cant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an Injury and Illness Incident Repo form. If you?re not sure whether a case is recordable, call your local OSHA of?ce for help . Identify the person Describe the case (A) (C) (D) Case No. Employee's Name Job Title Date of injury Welder) or onset of Illness (mm/day) Aprl 09, 2011 US-GADSDI 7 US GADSDI 11 A 22] US-GADSDI 11 A-23 4 11 A-23l US-GADSDI N-11-A-234 5 April 12, 2011 C) Ma 12, 2011 May 22, 2011 0 Public reporting burden for this collection of information is estimated to average 14 minutes per response, including (F) Where the event Describe injury or illness, pars of occurred Loading dock north end) 0 trench take-away conveyor 91 R2.5 #7ba ry classi?er work stat'on #6 extruder w-ndup body affected, and object/substance that dlrectly injured or made person ill Second degree burns on right forearm from acetylene torch) Nature of Injury/illness:: Bruise/Contus'on; Cause of In, On, or Between, Other; Body Nature of Injury] essz: Spra?n/Stra' /Ove xert? n; Ca se of injury: ness::Stra'n in orp 9; Body Sho Nature of Inj ry/ 55:: La or Cut; Cause all ry or 'p to or form ffere leve (sta'rs, s, ramps, platforms, scaffolds, ladders, etc); Body Head; Object] Substancen concrete ?oor Nature of Injury/illness:: Soreness/Range of Motion Restricted; Cause of Injury/illness::Strain In reaching; Body Knee(s)(Right); Nature of Injury/illnessz: Sprain/Strain/Overexertion; Cause of Injury/illness::Strain in lifting; Body Shoulder(s)(Left); Object Substance:: empty sidewall liner for levelwinds Page totals time to review the instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Of?ce of Statistical Analysis, Room -3644, 200 Constitution Avenue, NW, rt (OSHA Form 301) or equivalent form for each injury or illness recorded on th 's Classify the case CHECK ONLY ONE box for each case based on the most serious outcome for that case: Year 2011 9 U. S. Department of Lab: Occupational Safety and Health Administratic Form approved OMB no. 1218ch Establishment name City State Enter the number of Check the "Injury" days the Injured or ill column or choose one worker was: type of illness: Remained at work (M) Away On Job 3 2' from transfer or 5 3 Days away Job muster Other record- work restriction 31:: 8 a ?5 3 Death from work orrostriction able cases (days) (dayssure to transfer these totals to the Summary page (Form 300A) before you postltPage 20f8 a I: I U) (1) (2) (3) (4) (5) (6) OSHA :9 Form 300 (Rev. 01/2004) Log of Work-Related Injuries and Illnesses Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. Year 201 1 U. S. Department of Lab: Occupational Safety and Health Administratic -ms?u .5 You must record information about every work -related death and about every work -related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record signi?cant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the speci?c recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to . You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each Injury or illness recorded on this form. If you?re not sure whether a case is recordable, call your local OSHA of?ce for help. Identify the person Describe the case (A) (C) (D) Case No. Employee's Name Job Title Date of injury Welder) or onset of illness (mm/day) May 23, 2011 C). US-GADSDE N-11-A-234 6 US GADSDE 1 1 A-238 US-GADSDE 11 A 240 5 US-GADSDE US-GADSDE N-ll-A-242 'l 01, 2011 )Ju 18, 2011 June 17, 2011 e20,2 11 4 repOrting burden for the collect-on of ?nformation is estimated to average 14 minutes per response, including (E) (F Where the event Describe injury or illness, pars of occurred Loading dock north end) press 314 #6 extruder 55 Arf Gre nTre 1 act 31 R1 body affected, and object/substance that directly injured or made person ill Second degree burns on right forearm from acetylene torch) Nature of Injury/illness: Sprain/StralnlOverexertion; Cause of Injury/illness: :Strain in pushing or pulling; Body Back/Iumbosacral: Nature of Injury/illnessz: Bru'se/Contusion; Cause of I or Slip to or form different levels (stairs, docks, ramps, platforms, scaffolds, ladders, etc); Body Object Substance:z un-anchored steps Nature of Injury/illness:: Bruise/Contusion: Cause of Injury/illness::Striking against Moving parts of machine; Body Shoulder(s)(Right); Object Substance: Tread Server Nature of Injury/illnesszz Sprain/Straln/Overexertion; Cause of Injury/illness::Strain in lifting; Body Shoulder(s)(Left); Nature of Injury/illness:: Sprain/Strain/Overexertion; Cause of in pushing or pulling; Body Page totals time to rev ew the instructions, search and gather the data needed, and complete and review the collection of unfonnation. Persons are not requnred to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: us Department of Labor, OSHA Of?ce of Statistical Analysis, Room -3644, 200 Constitution Avenue, NW, Classify the case CHECK ONLY ONE box for each case based on the most serious outcome for that case: Form approved 0MB no. 1218-01 Establishment name City Enter the number of Check the "injury" days the injured or ill column or choose one worker was: type of Illness: State Remained at work (M) Away Onjob 3 3: El from transfer or a 3 Daysaway Job transfer Othorrecord- work restriction a. 5 la gnu. from work ?restriction able cases (days) (days:fA?EmsBesure to transfer these totals to the Summary page (Form 300A) before you post itPage3of8 (1) (2) (3) (4) (5) (5) OSHA 3? Form 300 (Rev. 01/2004) Log of Work-Related Injuries and Illnesses Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for OCCUpational safety and health purposes. Year 201 1 9 us. Department of Lab: Occupational Safety and Health Administra tic - You must record information about every work -related death and about every work?related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record signi?cant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the speci?c recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you?re not sure whether a case is recordable, call your local OSHA of?ce for help . Identify the person Describe the case (A) (B) (C) (D) Case No. Employee's Name Job Title Date of injury Welder) or onset of illness (mm/day) US-GADSD June 25, 2011 N-l 1-A-24l 8 US GADSD June 27, 2011 ll-A 24? US GADSD I: 4 Ju 28, 2011 11 us GADSD 12, 2011 11 1 July 04, 2011 US-GADSD 11 A 24! 5 Public reporting burden for this collection of information is estimated to average 14 minutes per response, 'nclod?r?g (E) (F) Where the event Describe injury or illness, parts of occurred Loading dock north end) Tire Mach'ne 95 Drum Booth ad extruder head #4 banbury cutter Store room body affected, and object/substance that directly Injured or made person ill Second degree burns on right forearm from acetylene torch) Na re of Injury/illness:: Bru'se/Contusion; Cause of Injury] 55 :Struck By Tapping, sliding or rolling 0 ct, Body AnklelLeft); Object Substance:: Pin Truck Nature of Injury/illnessz: Cause of Injury/? ness::5train in pushing or pulling; Body Shoulder(s)(Right); Nature of Inj rylillnessz: Sp [Stra? lOverexertion; Cause of Injury] 5.:Strain in pushing or on mg; Body Shoulder(s)(Left); Object Substancezz rubber push out clean out Nature of Injury/illness:: Lacerat'on or Cut; Cause of Injury/illness::5truck By Hand Tool or machine in use; Body Ha d(s)(Right); Object] Substancez: rubber cutting knife Nature of Injury/illness:: In?ammation/Swelling; Cause of Injury/illness: 'Struck By Fall'ng or 9 object; Body Object] Substance:: a 'tiona part on shelf Page totals time to review the instructions, search and gather the data needed, and complete and review the collectfon of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Of?ce of Statistical Analysis, Room -3644, 200 Constitution Avenue, NW, Classify the case CHECK ONLY ONE box for each case based on the most serious outcome for that case: Form approved 0318 no. 1218-01 Establishment name City Enter the number of Check the "injury" days the injured or ill column or choose one worker was: type of illness: State i Remained at work (M) g- Away Onjob 8 3: - from transferor a .53 Daycaway Jobtransfar Othorrecord- work restriction a 32 :3 3g Death from work able cases (days) (daysJrsure to transfer these totals to the Summary page (Form 300A) before you postit.32 Page4of8 2 ?8 8 2 a: in (1) (2) (3) (4) (5) (5) OSHA Form 300 (Rev. 01/2004) Log of Work-Related Injuries and Illnesses Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. Year 201 1 U.S. Department of Labc Occupational Safety and Health Administratir. -e?nsg . You must record information about every work -related death and about every work -related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record care professional. You must also record work-related injuries and illnesses that me use two lines for a smgle case if you need to . You must complete an Injury and ill form. If you ?re not sure whether a case is recordable, Identify the person Describe the case ness Incident Report call your local OSHA of?ce for help . signi?cant work -related injuries and illnesses that are diagnosed by a physician or licensed health et any of the speci?c recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to (OSHA Form 301) or equivalent form for each injury or illness recorded on this Classify the case CHECK ONLY ONE box for each case based on the most serious outcome for that case: Establishment name City Form approved 0MB no. 1218-0] State Enter the number of Check the "injury" days the injured or ill column or choose one (C) (D) (E) (F) s' of illness: Case No. Employee's Name Job Title Date of injury Where the event Describe injury or illness, pars of worker wa Welder) or onset of occurred (9.9. body affected, and object/substance (H) ?5 u, Loading dock north that directly injured or made person Remalned at work 3' (mm/day) end) ill Second degree burns on right Away are forearm from acetylene torch) 2 5 L- 01 Days away Job transfer Other rocord- work restriction a. 3- ?g ?5 ?5 3 Death from work or restriction able cases (days) (days) '5 8 a? (G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6) US-GADSD July 15, 2011 1 Spur sort Nature of Injury/illness:: Laceration or 12 42 line Cut; Cause of Injury/illness::Caught In, [21 0 On, or Between, Other; Body Finger(s)(Right); 2 July 24, 2011 32 Art Nature of Injury/illness:: Fracture or 0 135 El 11 A-25: dislocation; Cause of 5 Injury/illness::Caught In, On, or Between Machine(s) or machine parts; Body Arm(Left); US GADSDI 7 August 01, 2011 #5 ply cutter Nature of Injury/illness:: 62 11 A 25? Sprain/Strain/Overexertion; Cause of 5 Injury/illness: :Strain in pushing or pulling; Body (7 (C UppertRight): August 17, 2011 all 5 db dresser Nature of Injury/illness:: 27 23 N-11 A 257 Sprain/Strain/Overexertion; Cause of [21 9 in lifting; Body ,1 US-GADSDE August 22, 2011 98 2.5 machine Nature of Injury/illness:: 92 35 "a Sprain/Strain/Overexertion; Cause of I2 5 Injury/illness: :Strain in pushing or pulling; . Body Back; US-GADSDE August 25, 2011 RBO71 Nature of Injury/illness:: 6 48 N-11-A-263 Sprain/Strain/Overexertion; Cause of 0 in pushing or pulling; . Body Shoulder(s)(Left); Page totals Public reporting burden for this collection of information is estimated to average 14 minutes per response, including Be sure to transfer these totals to the Summary page (Form 300A) before you post it. a i: 2? 5 3 time to review the instructions, search and gather the data needed, and complete and review the collection of 3 3 .2 5 information. Persons are not required to respond to the collection of information unless it displays a currently valid .5 g' 2 OMB control number. If you have any comments about these estimates or any other aspects of this data collectioncontact: US Department of Labor, OSHA Of?ce of Statistical Analysis, Room ~3644, 200 Constitution Avenue, NW, g" in (1) (2) (3) (4) (5) (6) relating to employee health and must be used in OSHA F0 rm 300 (Rev. 01/2004) a manner that protects the con?dentiality of Year 2011 'bl h'l th employees tot extent possr re U. S. Department of La bc Attention: This form contains information information is being used for occupational Log of Work-Related Injuries and Illnesses safetyand health pumases_ Occupation? Safetyand Hem Administratit You must record information about every work -related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, Form approved 0313 no. 1218?01 days away from work, or medical treatment beyond first aid. You must also record signi?cant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the speci?c recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you?re not sure whether a case is recordable, call your local OSHA of?ce for help . CHECK ONLY ONE box for each case Establishment name City State Enter the number of Check the "injury" days the injured or ill column or choose one based on the most serious outcome (A) (C) (D) (E) case: - of illn 55: Case No. Employee's Name Job Title Date of injury Where the event Describe injury or illness, parts of . . worker as. Welder) or onset of occurred body affected, and object/substance '5 illness Loading dock north that directly injured or made person Remained at work I: a (mm/day) end) Second degree burns on right Away forearm from acetylene torch) transfer 3? L- 5 3 Days away Job transfer Other record- work restriction 32 .5 q; Death from work or restriction able cases (days) (days) 5 8 a f: (G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (5) US-GADSDE N-ll-A?264 US GADSDE 11 A-267 US-GADSDE 11 A-271 US-GADSDE 11 A-273 US-GADSDE N-11-A-274 8 I US-GADSDE ll-A 278 January 29, 2011 Booking Station Nature of Injury/illness:: 0 Sprain/Strain/Overexertion; Cause of Injury/illness::Strain In reaching; Body Shoulder(s)(Left); September Trucking Aisle Nature of Injury/illness:: Fracture or 0 0 2011 Calender dislocation; Cause of Injury/illness: :Struck El El By Other Object; Body Toe(s); Object 5ubstance:: back left tire gSeptemberOB, apex Natureoflnjury/illnessz: 57 113 2011 department Sprain/Strain/Overexertion; Cause of Injury/illness::5train in pushing or pulling; Body October 03, 2011 1 hook line Nature of Injury/illness:: I: 39 130 spiral Bruise/Contusion; Cause of lnjury/illness::Caught In, On, or Between, Other; Body Shoulder(s)(LeFt); October 07, 2011 Store Room Nature of Injury/illnesszz Fracture or 0 0 El L?r?Y?j dislocation; Cause of Injury/illness: :Striking against Object(s) being handled; Body Hand(s) (Right); Object Substance:: hydraulic cylinder October22,2011 PaintLine Natureofinjury/illnesszz IE I: 42 117 Sprain/Strain/Overexertion; Cause of 9 lnjury/illness::5train in pushing or pulling; Body Shoulder(s)(Left); Page totals Pub report 9 burde for 5 co act 0 of? rmation is estimated to average 14 minutes per response, including Be sure to transfer these totals to the Summary page (Form 300A) before you post it. 3 g- 2? a 3 time to rev ew the st ct'o 5, sea and gather the data needed, and complete and review the collection of 3. 2 5 format 0 Fe 5 are not req 'red to re po to the collection of information unless it displays a currently valid 5, 2 2' 2 OMB contro number. If you have any comments about these estimates or any other aspects of this data collectioncontact: US Department of Labor, OSHA Of?ce of Statistical Analysis, Room -3644, 200 Constitution Avenue, NW, 9 U1 (1) (2) (3) (4) (5) (6) OSHA 55' Form 300 (Rev. 01/2004) Log of Work-Related Injuries and Illnesses Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. You must record information about every work days away from work, or medical treatment he care professional. You must also record work- use two lines for a single case if you need to . form. If you're not sure whethera case is rec Identify the person Describe the case (A) (B) (C) Case No. Employee's Name Job Title -related death and about every work -related yond ?rst aid. You must also record significant work related injuries and illnesses that meet any of the 5p You must complete an Injury and Illness Incident rdable, call your local OSHA of?ce for help . 9., Welder) US-GADSDE N-ll-A-279 2 US-GADSDE 11 A-280 4 US GADSDE 6 11 A-Z U5 GADSDE 11 A 281 3 US-GADSDE N- 1 1 41-283 6 US-GADSDE a N-l 1 -A-285 Public reporting burden for this collection of info (D) Date of injury or onset of illness (mm/day) October 24, 201 1 October 31, 2011 October 29, 201 1 November 02, 201 1 (E) (F) Where the event Describe injury or illness, parts of occurred Loading dock north end) #10 bb dump sink mold vent table balance reforce work station toe guard unit body affected, and object/substance that directly injured or made person ill Second degree burns on right forearm from acetylene torch) Nature of Injury/illnessz: Laceration or Cut; Cause of Injury/illness::Caught in, On, or Between, Other; Body Finger(s)(Right); Object Substance:: burr on the chain Nature of Injury/illness:: Puncture; Cause of Injury/illness::Struck By Hand Tool or machine in use; Body Lower(Left); Nature of Injury/illness: Laceration or Cut; Cause of By Hand Tool or machine in use; Body Hand(s)(Left); Nature of Injury/illness:: Bruise/Contusion; Cause of injury/illness::Fall/trip trip over object; Body Knee(s)(Left); Object I Substance: fatigue mat njury or illness that involves loss of consciousness, restricted work activity or job transfer, -related injuries and illnesses that are diagnosed by a physician or licensed health eci?c recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to eport (OSHA Form 301) or equivalent form for each injury or illness recorded on this Classify the case CHECK ONLY ONE box for each case based on the most serious outcome for that case: Remained at work Other record- able cases (J) Days away Job transfer from wort: or restriction on (1) Cl El Death (G) El El Year 201 1 93 U.S. Department of Lab: Occupational Safety and Health Administratic State Enter the number of Check the "injury" days the injured or column or choose one worker was: Away from work ways} 00 0 (In job transfer or restriction (L) 0 161 type of illness: z- a .5 (1) El Respiratory a disorder conditlon A 3 Cl El Form approred 0MB no. 1218?0l Establishment name Clty u: Hearing loss 3 Poisoning 1" November 13, 2011 November 29, 201 1 #1 Mateuzzi grinder #12 banbury rmation is estimated to average 14 minutes per response, including Nature of Injury/illness:: Laceration or Cut; Cause of Injury/illness: :Striking against Object(s) being handled; Body Finger(s)(Left); Nature of Injury/illness:: Fracture or dislocation; Cause of By Hand Tool or machine in use; Body Hand(s)(Left); Object] 5ubstance:: batch door on #12 bb Page totals time to review the instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Of?ce of Statistical Analysis, Room -3644, 200 Constitution AvenueOth? Illnesses at Be sure to transfer these totals to the Summary page (Form 300A) before you post it. Page 7 of 8 Injury on Skin disorder Resplratory Poisoning a Hearing loss All other Illnesses 6 OSHA {5 Form 300 (Rev. 01/2004) Log of Work-Related Injuries and Illnesses Attention: This form contains information relating to employee health and must be used in a manner that protects the con?dentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. Year 2011 9\ U. S. Department of Lab: Occupational Safety and Health Administratic You must record information about every work -related death and about eve days away from work, or medical treatment beyond care professional. You must also record work-relat use two lines for a single case if you need to . form. If you?re not sure whether a case is reco (A) (B) (C) Case No. Employee's Name Job Title (D) Date of injury first aid. You must also record signi?cant work ed injuries and illnesses that meet any of the sp You must complete an Injury and Illness Incident rdable, call your local OSHA of?ce for help . Identify the person Describe the case (E) Where the event (F) Describe injury or illness, parts of Classify the case ry work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, -related injuries and illnesses that are diagnosed by a physician or licensed health eci?c recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to eport (OSHA Form 301) or equivalent form for each injury or illness recorded on this CHECK ONLY ONE box for each case based on the most serious outcome for that case: Form approved 0318 no. Illa?Di Establishment name City State Enter the number of Check the "injury" days the injured or ill column or choose one worker was: type of illness: Welder) or onset of occurred body affected, and object/substance (M) u, (Ht illness Loading dock north that directly injured or made person Remained at work g- a E- (mo./day) end) ill (2.9. Second degree burns on right: Away On in 3 *5 5 ca ?.33 forearm from acetylene torch) from transfer or 5 4: 9? Days away Job transfer Other record- work restriction Death from work or restriction able cases (days) (days(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6) US-GADSDI i December 10, spooled tread Nature of Injury/illness:: 99 56 N-11-A-291 2011 storage Bruise/Contusion; Cause of 2 Injury/illness::Caught In, On, or Between Object(s) being handled and other object; Body Hand(s)(Right); Object Substance:: two tread spools US GADSDE 7 December 21, floor vent at Nature of Injury/illness: 0 92 [j 11 A 292 2011 press 320 Sprain/Strain/Overexertion; Cause of 7 Injury/illnessuSlip (not fall): Body I 7) C) Knee(s)(Right); US-GADSDE December 21, press 432 Nature of Injury/illness:: Laceiation or 0 149 11-A 292 2011 Cut; Cause of Injury/illness::Striking 9 against Object(s) being handled; Body 7 Finger(s)(Left); US-GADSDE December 19, gum calender Nature of Injury/illness:: 0 109 El N-12-A-295 2011 wind-up Bruise/Contusion: Cause of 1 7 Injury/illness::Fall/trip trip over object; Body Knee(s)(Left); Object ,r Substance:: concrete floor US-GADSDE 7 February 08, 2011 2nd stage tire Nature of Injury/illness:: Tingling or 15 120 N-12-A-295 (C building machine numbness; Cause of 2 Injury/illness::Repetitive motion; Body (7 (C Wrist(s)(Right); US-GADSDE I April 25, 2011 87R1 Nature of Injury/illness:: 135 Sprain/Strain/Overexertion; Cause of [j 5 Injury/illness::Strain in pushing or pulling; Body Page totals Public reporting burden for this collection of information is estimated to average 14 minutes per response, including Be sure to transfer these totals to the Summary page (Form 300A) before you post it. a. 3 time to review the instructions, search and gather the data needed, and complete and review the collection of 3 2 5 3 information. Persons are not required to respond to the collection of information unless it displays a currently valid 5 g' OMB control number. If you have any comments about these estimates or any other aspects of this data collectioncontact: US Department of Labor, OSHA Of?ce of Statistical Analysis, Room -3644, 200 Constitution Avenuep5 (acct 662:0me Mme/31112 Bate-U NE) P2001050 0,4 Lls'i? or? .mns mom Empww?z: LIST 71+" firm 7pm - 7m 4 cases W6 gee-u (all!) ?near (2690 7 doee??m' 6mg 2.29qu 61 2. TD Mus: luvmv mama?oms 09> W8 weft-4 2. was (.41. (.de CM 6670 09.22? 3to Opezmas 0F JJQB Dwmons 0W5 131an Moo Fvs?' ?ne. EE?oaJamcs W3 $5425 Loo?c?D EVBQV 405 A 241N165) Pa?? 06%- wafer) pa cmE @712 PEQBW VA MN ?77: gamma?1E MY?opy on 7734M 729 00715?2 3 m3 0V HUOEELH. pine? On .23? ma?a 0:2 1:er inFuu an?? 9.7% FUSE e. a mzmeREm? ma? \E?nicm? ??06 gang: Qua ?g mmoenu?t DEM a i? ?nn?mm .3 HWV TIME Etf 2.?ch Rid 3?wm gm?nk ??tmu Ar a?c?m?k. ?x 8 \omnu. [Cm umwn?nvoc gems La 31%: C530 owmm. Smoh mvm?mn ?argon.? qumml ?u mm Camcm (mi 3453.. \UvaW mi x5? ance FR (mayo 7.943% 4% rum. .452! Him gqvindw. ,mmnv 0m 3% Algitamu mlu?ktmul km QVnm?bwmw 4.159:le DUDM maid :91 ac wai Ill.? AFSM r?g at 939.9% :79 abiu? warm?? M?r? Pa 3??l glam 12- #3140? HT 6% Wee 2?5 nor CW7M cu-Mud a 1.51" 1.1911062 612152: i-hm 6-07? 2a) 0F 6%,3 wwgug 31.4 PIPE ?(pr Pw?na?d? H'Mzz 5779:?19 Mam PM 43 P2535273 Inca: mom; Mb) (mm (b) (7)(D) (b) (7)(D) (b) (7)(D) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) (b) (7)(C) ?x ME. Song 925.0 @6531 sngim :9 ERR $60 9% 76w @393 09% mm ?E