eohsms-05-f01 incident & accident investigation report form

Ryobi Kiso (S) Pte Ltd _________________________________________________________________________________________________

EOHSMS-05-F01_Rev0 of 4 Issued on 15 Sept 2010

INCIDENT / ACCIDENT

INVESTIGATION REPORT



INCIDENT / ACCIDENT OCCURRENCE REPORT FORM / INVESTIGATION REPORT

PART A (Type of Incident / Accident) Major Incident / Accident Minor Incident / Accident Staff Injury /Public Member Injury

PART B (Details of Incident / Accident) Project : Place of accident : Occurrence date & time: First reported date & time: Reported by:

PART C (Details of Injured / victim) Name : Employed by : Direct Employer : Employed by : Date of Birth : Nric / Fin No : Gender : Nationality : Race : Martial Status : Date Joined Service : Designation/ Occupation : EMPLOYEE SENT TO: First Aid Private Doctor Hospital Polyclinic Name of clinic / Hospital:

PART D (Lost Time) Estimated (if actual mandays lost is not available) 3 days or lesser More than 3 consecutive days Hospitalized more than 24 hour Immediate return to work First aid given only Hospital referral

State actual of man-day’s lost:

PART E (Details of Injury) Nature of Injury (Use the following codes) ABR : Abrasions/scratches AMP : Amputation ASP : Asphyxia/Drowning BCC : Bruises/Crushing/Contusions BN(C) : Chemical Burns BN(H) : Heat Burns TORSO : Shoulder to Groin/Hip CCS : Concussion/Internal Injury DEATH : Fatality DIS : Dislocation ELECT : Effects of Electricity EYE : Eye Injury FG : Faint/Giddy FT : Fracture FZ : Freezing/Frostbite/Hypothermia HEAT : Heat Stress and strain LC : Laceration/Cut NID : Noise Induced Deafness NUMB : Numbness PERM : Permanent Disability PS : Physical Shock PSN : Poisoning PW : Puncture Wound RDT : Effects of Radiation

SKIN : Dermatitis/Skin Disease SS : Sprain/Strain

TOOTH : Tooth Injury OTHER : Other Injury Injured Bodypart BODY : Injury linked to entire body FEET : Feet/Toes HAND : Hand/Fingers HEAD : Head/Face/Neck LOWER : Lower Limbs (Legs) UPPER : Upper Limbs (Arms) NA : Not Applicable



Nature of Injury Injured Body part Exact Description (State Left/Right) PART F (Description of Incident /Accident) PART G (Causes of Incident / Accident)(1) Direct Causes i ) Unsafe Conditions

Absence of safety means / Congestion/ Restricted action

Inadequate warning system

Dressing apparel hazard Inadequate ventilation Environmental hazard (gas/dust/smoke) Noise hazard High temperature hazard Presence of fire/ explosion hazard Hazardous arrangement / Inadequate guarding Poor housekeeping

Inadequate illumination Radiation hazard Inadequate/ Improper PPE Unsound structure Improperly/ faulty equipment Others (key details refer to “Remarks”) Remarks:

ii ) Unsafe Practice

Careless/ reckless Taking improper/unsafe position or posture Disregard instructions Making safety devices not in operative mode Driving error Not attentive while during working Failure to secure / warn Operating/working at unsafe speed Horseplay Operating/working without authority Under influence of alcohol/drugs Tampering with equipment in motion Improper/wrong use of body part Using improper/unsafe equipment Improper/unsafe lifting/carrying Using proper equipment unsafely Improper working methods & sequence Fail to use proper tools/ equipment Unsafe loading/mixing/placing Intentional motive Others (key details into “Remarks”)

Remarks:

(2) Root Causes i ) Work Factors

Lack of co-ordination/communication Inadequate/lack of work procedures Inadequate/lack of engineering Pressure from external influence Inadequate equipment being used Poor selection/placement Inadequate/lack of maintenance Wear and tear Inadequate/lack of supervision Others Remarks : ii ) Human Factors Foul play Lack of skill Fatigue/stress Lack of training



Inadequate capability Needs conflicting with safety Illness Not qualified Improper or lack of motivation/interest Unsafe attitude Improper assignment of personnel Non human factors Lack of knowledge Others (key details into “Remarks”) Remarks:

(3) Weakness of EOHS System i ) General Safety policy Evaluation, selection and control of SC Safe work practices Safety inspections Safety training Maintenance regime for all machinery Group meetings Risk Assessment and Management Incident investigation and analysis Emergency preparedness

In-house safety rules and regulations Control of movement and use of hazardous substances and materials

Safety promotion Occupational health programs Not applicable Others (key details into “Remarks”)

Remarks:

PART H (Corrective action & Preventive action)

PART I (Recommendation)

.

PART J (Details of Investigation recorded by) Investigated by : Name: Designation: Company: Date: Signature: ________________ Reviewed by : Name: Designation: Company: Date: Signature: _________________

eohsms-05-f01 incident & accident investigation report form

Documents