Incident Rate 2016 Monthly Form Instruction Sheet

****Only Fill In The Columns In Light Blue****

1.) Enter any recordable information in column B (starts at B6) of the FY16 monthly form.
Your goal each month is ZERO Recordables. This also means the KPI for Safety = 0.

2.) Enter the amount of hours worked by all associates in column C (starts at C6) of the
2016 monthly form. Include salary exempt, salary non-exempt, union, non-union, and
temporary employee hours. Note: Exempt level hours are based on a 45 hour work
week.
3.) If you have an incident/injury that results in any lost time (i.e., days away from work,
transfers, etc.), then enter the incident in column C (starts at C22) under the Total Lost
Work Days chart on the 2016 Monthly tab. Note: Day of injury does not count as days
away.

4.) Enter the total amount of days away from work or transferred from regular duties in
column D (starts at D22) under the Total Lost Work Days chart in the 2016 Monthly Tab.
The maximum total days for ANY incident is 180 days – should an injury/incident result in a
Lost Time Accident that has more than 180 calendar days of lost time, cap the total amount
to 180 for that injury/accident. Count ALL calendar days, even weekends. For example, if
an employee sustains an injury on a Thursday and can not work until the following
Monday, there will be a total of 3 lost time days (FRI, SAT & SUN).

5.) Enter the type of injury/accident for that month in the appropriate columns under the
2016 Monthly tab.

6.) Enter any injury information for that month, both Recordables and First Aid Only
injuries, on the worksheet labeled "Accident Corrective Actions". Note: If names are not
allowed to be shared, please leave this spot blank.
7.) You must complete a 5-Why analysis for any accident or major incident and send the
completed 5-Why form to the Corporate Safety Manager within 72 hours of the
accident/incident.

8.) You must complete the top three accomplishment for the month from a safety
standpoint. Accomplishments can be defined as training conducted during the month or
pro-active initiatives that were completed.
 RECORDABLE CRITERIA
The decision tree for recording work related injuries and illnesses below shows the steps
involved in making this determination.

No
Did the employee experience
an injury or illness?

Yes

No Is the injury or illness work

related?

Yes

Is the injury or illness a No Update the previously

No recorded injury or illness
new case?
entry if necessary.

Yes

Does the injury or illness

No meet the general recording Yes
criteria or the application to
specific cases?

Do not record the Record the injury

injury or illness or illness

LTA CRITERIA
The decision tree for determining if all possible actions have been
 LTA CRITERIA
The decision tree for determining if all possible actions have been
taken before determining an injury is a Lost Time Accident (LTA).

Definition: Lost time Accidents occur when an employee sustains a

work-related injury, which results in lost time from work after the day of
the accident.

Has EH&S Rep spoken with

physician about possible work
restrictions or light duty work?

Yes

No Did physician determine that

injured employee required
time away from work?

Yes

No Injury is an LTA
Did the physician agree to
work restrictions?

Yes

Analyze and assign light

duty jobs based on work
restrictions

Injury is recordable
 Basic requirements for determining a recordable injury
A work-related injury or illness must be recorded if it results in one or more of the following:
·         Death
·         Days away from work.
·         Restricted work or transfer to another job.
·         Medical treatment beyond first aid. (see below)
·         Loss of consciousness.
·         A significant injury or illness diagnosed by a doctor or other licensed health care professional.
ury
ollowing:

re professional.
 Monthly Safety Report
REPORTS ARE DUE BY THE 5th of each month. Send to Corporate Safety Manager

Plant: GENERAC MÉXICO

Total DART
OSHA Total Hours Incidence Lost Time
Monthly TRIR YTD Severity RATE DART Rate
Month Recordables Worked YTD Rate 2021 Per Month Case Rate
Hours 2021 Rate 2021 2021 Per YTD 2021
2021 2021 Month YTD
Worked 2021 Month

JAN 0 92,826 92,826 0.00 0.00 JAN 0.00 0.0 0.0 0.00
FEB 0 98,808 191,634 0.00 0.00 FEB 0.00 0.0 0.0 0.00
MAR 2 119,232 310,866 3.35 1.29 MAR 0.64 7.0 0.0 0.64
APR 2 122,008 432,874 3.28 1.85 APR 1.39 29.0 0.0 1.39
MAY 1 140,957 573,831 1.42 1.74 MAY 1.39 32.0 0.0 1.39
JUN 0 149,203 723,034 0.00 1.38 JUN 1.11 32.0 0.0 1.11
JUL 723,034 #DIV/0! 1.38 JUL 1.11 32.0 #DIV/0! 1.11
AUG 723,034 #DIV/0! 1.38 AUG 1.11 32.0 #DIV/0! 1.11
SEP 723,034 #DIV/0! 1.38 SEP 1.11 32.0 #DIV/0! 1.11
OCT 723,034 #DIV/0! 1.38 OCT 1.11 32.0 #DIV/0! 1.11
NOV 723,034 #DIV/0! 1.38 NOV 1.11 32.0 #DIV/0! 1.11
DEC 723,034 #DIV/0! 1.38 DEC 1.11 32.0 #DIV/0! 1.11
Total 5 723,034 1.38 1.11 8.85 1.11

No. de Total de horas Índice de

accidentes del trabajadas en el Acumulado incidencia por
mes mes anual mes Índice anual

Lost Time Accidents - Days Away, Restricted , or Transferred

Total
Total Lost Total Lost Total Days
Restricted or
Time Time Days Restricted or
Month Transfer
Accidents for Away from Transfer
Accidents for
the month Work duty
month
JAN 0 0 0 0 Incidence Rate =
FEB 0 0 0 0 (Recordables*200000)/# of hours
MAR 1 7 0 0 Severity Rate = Total Lost
APR 2 22 0 0 Days*200000/# of hours worked
MAY 1 3 0 0
DART = (Days Away, Restricted,
JUN 0 0 0 0 Transferred*200000)/# of hours
JUL worked
AUG
SEP Lost Time Accidents occur when
an employee sustains a work-
OCT
related injury which results in lost
NOV time from work AFTER the day of
DEC the accident.
4 32 0 0

2021 RECORDABLES
Strains / Foreign Repetitive
Month Amputation Lacerations Contusions Fracture Burn Dermatitis Other
Sprains Body Motion Totals
JAN 0 0 0 0 0 0 0 0 0 0 0
FEB 0 0 0 0 0 0 0 0 0 0 0
MAR 0 0 2 0 0 0 0 0 0 0 2
APR 0 0 0 2 0 0 0 0 0 0 2
MAY 0 0 0 0 0 0 1 0 0 0 1
JUN 0 0 0 0 0 0 0 0 0 0 0
JUL 0
AUG 0
SEP 0
OCT 0
NOV 0
DEC 0
0 0 2 2 0 0 1 0 0 0 5

Root Cause Analysis

No Standard Unsafe Lifting / Material Repetitive Walking/Working
Month Ergonomics Other
Work Process Condition/Act Bending Handling Motion Surface

JAN 0 0 0 0 0 0 0 0 0
FEB 0 0 0 0 0 0 0 0 0
MAR 1 1 0 0 0 0 0 0 2
APR 0 2 0 0 0 0 0 0 2
MAY 0 1 0 0 0 0 0 0 1
JUN 0 0 0 0 0 0 0 0 0
JUL 0
AUG 0
SEP 0
OCT 0
NOV 0
DEC 0
1 4 0 0 0 0 0 0 5
 EHS Recordable Accident Detail

Situational Analysis / Summary:

Observations:

Preventive actions:

Date Initiated: Initiated By:

Date of Injury: Assigned To:
Date Reported: Sponsor:
Injury Type: Injury Classification:
ent Detail
 PROBLEM SOLVING 5-WHY WORKSHEET
Problem Statement:
Use all 3 paths to thoroughly investigate:

1. WHY the specific noncomformance occurred (Caused By Path)

2. WHY it was not detected by process controls (Not Detected Path)
3. WHY the overall governing system, policies, procedures or process allowed this nonconformance to occur (Process /
System Path)

Check for continuity of logic by reading back using the "Therefore" test.
Caused By?

Caused By?
Therefore
Test

Caused By?

Caused By?
Not Detected?

Caused By?

Caused By? Caused By?

Caused By? Nonconformance

Caused By?
Process / System?

Caused By?

Caused By? Caused By?

Caused By? Not Detected

Verification Criteria: Caused By?

The true root cause has been reached when the final why satisfies the following criteria:
1. It initiates and causes the event we are seeking to explain Caused By?
2. It is directly controllable
3. The elimination of that root cause will result in the elimination or reduction of the problem
Caused By?

Systemic
Corrective (long term) Action: Responsibility Start Date Completion Date Notes

Submit Completed form to Director-EHS within 72 hours for recordable

 Incident Investigation C
MEXICO FACILITIES
# DOI Associate Injury Dept
1

3
Incident Investigation Corrective Action Tracking

Corrective Actions
 Actions #DIV/0!
As of: Injuries 100%

Responsible Due Date 0 0

LIST YOUR TOP 3 SAFETY ACCOMPLISHMENTS FOR THE MO

GENERAC MÉXICO

1 A workshop was held with Telecom staff to review the risk an

and training was given in the handling of chemicals, hazardo
and spill containment.

Periodic medical examinations began.

3
We got the Civil Protection programa authorization from V
Municipality.
TS FOR THE MONTH IN THIS DOCUMENT

XICO

view the risk analysis station by station,

emicals, hazardous waste management,
ainment.

minations began.

horization from Villa de Tezontepec

lity.