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| Inspection Nr | 123304420 |
| Investigation Nr | 201520848 |
| Line Nr | 4 |
| Age | |
| Sex | |
| Nature of Injury | Fracture |
| Part of Body | Head |
| Source of Injury | Working Surface |
| Event Type | Struck By |
| Environmental Factor | Overhead Moving/Falling Obj Ac |
| Human Factor | Safety Devices Removed/Inoper. |
| Occupation | Occupation not reported |
| Degree of Injury | Fatality |
| Task Assigned | Task regularly assigned |
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