Free Accident Report1 - Tennessee

STATE OF TENNESSEE

BOILER OR PRESSURE VESSEL ACCIDENT REPORT
STATE NO. TENN. 1) Name of User 2) Type of boiler or vessel 3) Type accident
(Explosion pressure parts, furnace explosion, dry-fired, etc.)

A.S.M.E. Symbol
(S,H,U, etc.)

Date of Accident Location of Accident
(City & State)

(W.T. boiler, S.M. boiler, air tank, heat exch., etc.)

4) Type of business where used
(Apartment, cannery, school, dry clnrs., sawmill, etc. )

Used for
(Power, Process, Hot Wtr. Htg., etc.)

5) Manufacturer 6) M.A.W.P. 7) Safety valve installed? 8) Date of last inspection 9) Number of Person Killed 10) Disposition of boiler or vessel (if known) 11) Briefly describe apparent cause of accident

Mfgrs. Serial No. Type fuel or source of pressure Set pressure Inspection Cert.approved? Number of persons injured Repaired Replaced

National Board No. Automatic operation?
(Gas, Coal, Electric, Air Comp., etc.)

A.S.M.E.-NB Rated
Expiration Date Approx. property damage Scrapped

Relieving Capacity

Insurance Company Submitted by Located
IN-0927