EOHSMS-05-F01 Incident & Accident Investigation Report Form

Ryobi Kiso (S) Pte Ltd  ________  ____________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ _____ _

INCIDENT / ACCIDENT INVESTIGATION REPORT

EOHSMS-05-F01_Rev0

Page 1 of 4

Issued on 15 Sept 2010

Ryobi Kiso (S) Pte Ltd  _________________________________________________________________________________________________

INCIDENT / ACCIDENT OCCURRENCE REPORT FORM / INVESTIGATION REPORT PART A (Type of Incident / Acc ident) Major Incident / Accident Minor Incident / Accident Staff Injury /Public Member Injury PART B (Details o f Incid ent / Accid ent) Project : Place of accident : Occurrence date & time: First reported date & time: Reported by: PART C (Details of Injur ed / victim ) Name : Employed by : Direct Employer : Employed by : Date of Birth : Gender : Race : Date Joined Service : EMPLOYEE SENT TO: First Aid Name of clinic / Hospital:

Nric / Fin No : Nationality : Martial Status : Designation/ Occupation : Private Doctor

PART D (Lost Time) Estimated (if actual mandays lost is not availabl e)  3 days or lesser More than 3 consecutive days to work First aid given only Hospital referral

Hospit al

Polycli nic

Hospitalized

more than 24 hour

Immediate return

State actual of man-day’s lo st:

PART E (Details o f Inju ry) Nature of Injury (Use the followin g codes)  ABR : Abrasions/scratches  ASP : Asphyxia/Drowning BN(C) : Chemical Burns TORSO : Shoulder to Groin/Hip DEATH : Fatality ELECT : Effects of Electricity FG : Faint/Giddy FZ : Freezing/Frostbite/Hypothermia LC : Laceration/Cut NUMB : Numbness PS : Physical Shock PW : Puncture Wound SKIN

: Dermatitis/Skin Disease

TOOTH : Tooth Injury Injured Bodypart BODY : Injury linked to entire body FEET : Feet/Toes  HEAD : Head/Face/Neck  UPPER : Upper Limbs (Arms) EOHSMS-05-F01_Rev0

AMP BCC BN(H) CCS DIS EYE FT HEAT NID PERM PSN RDT

: Amputation : Bruises/Crushing/Contusions : Heat Burns : Concussion/Internal Injury : Dislocation : Eye Injury : Fracture : Heat Stress and strain : Noise Induced Deafness : Permanent Disability : Poisoning : Effects of Radiation

SS

: Sprain/Strain

OTHER

: Other Injury

HAND LOWER NA Page 2 of 4

: Hand/Fingers : Lower Limbs (Legs) : Not Applicable Issued on 15 Sept 2010

Ryobi Kiso (S) Pte Ltd  _________________________________________________________________________________________________

Nature of Injury

Injured Body part

Exact Description (State Left/Right)

PART F (Description of Incident /Accident)

PART G (Causes of Incid ent / Accid ent) (1) Direct Causes i ) Unsafe Conditions     

 Absence of safety means / Congestion/ Restricted action Dressing apparel hazard Environmental hazard (gas/dust/smoke) High temperature hazard Hazardous arrangement / Inadequate guarding



Inadequate warning system



Inadequate ventilation Noise hazard Presence of fire/ explosion hazard Poor housekeeping

  









Inadequate illumination Inadequate/ Improper PPE  Improperly/ faulty equipment Remarks:



Radiation hazard Unsound structure Others (key details refer to “Remarks”)

ii ) Unsafe Practice           



Careless/ reckless Disregard instructions Driving error Failure to secure / warn Horseplay Under influence of alcohol/drugs Improper/wrong use of body part Improper/unsafe lifting/carrying Improper working methods & sequence Unsafe loading/mixing/placing Intentional motive



Taking improper/unsafe position or posture Making safety devices not in operative mode Not attentive while during working Operating/working at unsafe speed Operating/working without authority Tampering with equipment in motion Using improper/unsafe equipment Using proper equipment unsafely Fail to use proper tools/ equipment



Others (key details into “Remarks”)

      

Remarks:

(2) Root Causes i ) Work Factors Lack of co -ordination/communication  Inadequate/lack of engineering  Inadequate equipment being used  Inadequate/lack of maintenance  Inadequate/lack of supervision Remarks : 

ii ) Human Factors  Foul play  Fatigue/stress EOHSMS-05-F01_Rev0

    

 

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Inadequate/lack of work procedures Pressure from external influence Poor selection/placement Wear and tear Others

Lack of skill Lack of training Issued on 15 Sept 2010

Ryobi Kiso (S) Pte Ltd  _________________________________________________________________________________________________   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  Safe work practices  Safety training  Group meetings  Incident investigation and analysis 

     

In-house safety rules and regulations





Safety promotion  Not applicable Remarks:



Evaluation, selection and control of SC Safety inspections Maintenance regime for all machinery Risk Assessment and Management Emergency preparedness Control of movement and use of hazardous substances and materials Occupational health programs Others (key details into “Remarks”)

PART H (Correcti ve action & Preventive actio n)

PART I (Recommend ation)

.

PART J (Details of Investigation recorded by) Investigated by : Name: Designation: Company: Date:

Signature:

________________

Reviewed by : Name: Designation: Company: Date: EOHSMS-05-F01_Rev0

Signature: _________________ Page 4 of 4

Issued on 15 Sept 2010