Corporate Safety & Health Department

Cummins Privileged and Confidential

Fast Track Incident Communication Prepared For and Under the Direction
of Cummins Legal Counsel

Site / Facility Name: (Type name)

Business Unit: (Choose from dropdown list)
Regional Distribution Organization (DBU only): (Type name)
Distributor / Entity (DBU only): (Type name) Fast Track objective:
Country: (Choose from dropdown list) This report is aimed to
Region: (Choose from dropdown list) communicate and warn other
Date of Incident: (mm/dd/yyyy) sites of similar hazards and
Date Reported: (mm/dd/yyyy) help them prevent related
incidents.
Incident Type: (check all that apply) Preventive actions shall be
Major Injury (UK RIDDOR) raised if similar hazards are
Dangerous Occurrence (UK RIDDOR)
present.
Recordable Injury or Illness (US OSHA)
Lost Time Incident (US OSHA)
Near Hit
Contractor

Injury Type: (Choose from dropdown list)

Body Part Injured: (Choose from dropdown list)
Event or Exposure: (Choose from dropdown list)
Direct Source of Incident: (Choose from dropdown list)
Hazard previously identified in risk assessment? (Choose from dropdown list)

Is there a process in place? (Choose from dropdown list)

Is the process capable? (Choose from dropdown list)
Are people trained? (Choose from dropdown list)
Do people follow the instructions? (Choose from dropdown list)
Was the risk assessment of the activity reviewed after the
occurrence of the Incident? (Choose from dropdown list)

What are the lessons learned that can be shared with other sites to
improve the process?

Circumstances:
Please briefly describe here what event(s), condition(s), object(s) or action(s) lead up to the incident and/or happened before the incident. Write your statement for persons unfamiliar with your local environment,
avoid local terminology or acronyms.

Description of the Incident:

Please briefly answer here key questions related to the incident, such as: "Who" (Employee's role, position or general descriptive - visitor, contractor, etc. No names required), "What" (Injury description and
current health condition or describe potential injury if it was a near hit), "Where" (Area description),, "When" (Hour, shift and/or specific situation) and "How" (Specific circumstances at the time of incident). For
a simple incident, provide basic information, for more complex incident, provide more details.

Root Cause Analysis:

Please analyze what caused the former circumstances. Write all 5 causes (Main branch) and branch to accommodate more causes to a particular circumstance or above question. Branching additional causes can happen at any level
of "Why's" (i.e. multiple causes for particular circumstances at any time in the model). You may add as many branches as needed for a complete analysis (Refer to completed template as an example).

Write incident here →

Main Branch Why? Why? Why? Why? Why?
Circumstance or "Why" was the problem originated.
No typing on this line →

Write "Because" answer to the above question.

This "Cause" will be the following question
2nd Branch Why? Why? Why? Why? Why?

No typing on this line →

Additional "Cause" OR circumstance for the above

"Why".
3rd Branch Why? Why? Why? Why? Why?

No typing on this line →

Additional "Cause" OR circumstance for the above

"Why".

Copy/Insert as many branches as needed (unprotect file first) ↓

Short Term Corrective Actions: Responsible Date for completion

Please list the short terms actions taken to prevent this incident from happening again. Actions should assure that identified
hazard(s) is/are eliminated or controlled and is/are related to each "cause" of the previous investigation.

Long Term Corrective/Preventive Actions Responsible Date for completion

Please list the long term actions taken to prevent this incident from happening again. Actions should assure that identified
hazard(s) is/are eliminated or controlled and is/are related to each "cause" of the previous investigation. This actions should
consider similar hazards in different areas of the site.

Photos, Visuals, Presentations or Video Re-creation:

Please paste pictures in this space, with clear explanation, or add attachments / links to files within email message.

Rev 03 CFM-09-03-03-02
BU Country Region Injury Type: Body Part Injured: Event or Exposure: Direct source of incident: Hazard previously identified in risk assessment:
EMEA (Europe Middle East and Atmospheric & Environmental Yes
CBS USA Africa) Abrasions, scratches Abdomen including internal organs Assaults and Violent Acts Conditions
Biological agents (Insects, No
Corporate(CORP) UK Americas Amputations Ankle Awkward position or posture animals and plants)
Back including spine and spinal Caught in or between by
Distribution Business Unit (DBU) Albania China Amputations, except fingertip cord equipment or objects Building & Facility conditions
Emissions Solutions Business Contact with blood borne
Unit (ESBU) Algeria India Amputations, fingertip Brain, skull, scalp pathogens Chemicals OR Chemical Products
Engine Business Unit (EBU) American Samoa South Pacific Animal or insect bites Buttocks Contact with electrical current CNC equipment
Asphyxiation, strangulation or
Filtration Business Unit (FBU) Angola suffocation Cheek Contact with extreme temperature Confined space
Fuel Systems Business Unit Chest, ribs and internal organs of Contact with moving objects and
(FSBU) Argentina Avulsions chest equipment Containers
Power Generation Business Unit
(PGBU) Armenia Bacterial or Viral Disease Ear Exposure to chemical substance Conveyors
Turbo Technologies Business Unit
(TTBU) Australia Blisters Elbow Exposure to harmful substance Cranes & Hoists

Austria Bruises, contusions Eye Exposure to electromagentic fileds Electrical equipment OR parts
Exposure to poor lighting or Floors, walkways & ground
Bahamas Chemical burns Finger and fingernail excessive lighting surfaces
Exposure to ionizing and non
Bahrain Communicable Disease Exposure Foot ionizing radiation Furniture and/or office conditions
Gas fired equipment AND/OR
Bangladesh Concussions Forearm Exposure to noise ovens
Handtools - non powered
Barbados Crushing injuries Forehead Exposure to vibration AND/OR special devices
Barbuda Cuts, lacerations Groin Fall or jump to lower level Handtools - powered
Deafness, hearing loss or Housekeeping & layout asset
Belgium impairment Gums, tongue, lips Fires and Explosions distribution
Industrial vehicles (Forklift,
Belize Dermatitis Hand(s) Highway accident pickers, etc.)
Benin Dislocations Head and Neck Overexertion Ladders & Stairs
Effects of Environmental
Bermuda conditions Heel, sole or arch Oxygen deficiency Lathes, Mills and/or Drill press
Pedestrian struck by vehicle or
Bhutan Electrical burns Hips and pelvis mobile equipment Lift Tables & lifting equipment

Bolivia Electrocution, electrical shock Jaw, chin Repetitive motion Machinery - maintenance & facility
Botswana Foreign bodies Knee Rubbed or abraded Machinery - miscellaneous
Brazil Fractures Lower Extremities Slip, Trip or Fall on same level Machinery - production
British Virgin isl. Friction burns Lower leg and shin Struck against object Minerals and metals
Other parts & materials (non-
Brunei Frostbite, hypothermia Mouth Struck by industrial vehicle Cummins)
Other rotating non-manual
Bulgaria Heat burns, scalds Multiple body parts Struck by object equipment
Transportation and vehicle
Cambodia Heat Stroke or Fatigue Neck accidents Packaging
Cameroon Hernia Nose Other Pallets & skids
Pelvic region, including internal
Canada Infection, gangrene organs Press
Shoulder, including clavicle and Product, component, part and/or
Cape Verde Musculoskeletal System disorders scapula materials

Cayman Islands Neoplasms, Tumors and Cancers Teeth Racks, Shelving, Storage Units
Central African Rep. Occupational Disease Thigh Robots
Channel Islands Punctures, except bites Thumb and thumbnail Sandblasting equipment
Chile Respiratory System Disease Toe and toenail Table saws
China Soreness, pain Trunk Test cell

Sprains, strains or tears of

Colombia muscle, tendon, ligament or joint Upper arm Welding equipment
Congo Surface wounds and bruises Upper Extremities Other
Cook Islands Tendonitis, tenosynovitis Wrist
Costa Rica Traumatic Injuries Other
Croatia Traumatic injuries to nerve or
spinal cord
Curacao Welder’s flash
Cyprus Other
Denmark
Djibouti
Dominica
Dominican Republic
Egypt
El Salvador
Equatorial Guinea
Eritrea
Ethiopia
Faeroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Hong Kong
Hungary
Iceland
India
Indonesia
Irak
Iran
Ireland
Ireland, Northern
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kenya
Kuwait
Latvia
Lebanon
Liberia
Liechtenstein
Lithuania
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar/Burma
Namibia
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Rwanda
Saba
Saipan
Saudi Arabia
Scotland
Sierra Leone
Singapore
Slovenia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Togo
TrinidadTobago
Tunisia
Turkey
Turkmenistan
United Arab Emirates
U.S. Virgin Islands
U.S.A.
Uganda
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wales
Yemen
Zaire
Zambia
Zimbabwe