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Ryobi Kiso (S) Pte Ltd

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INCIDENT / ACCIDENT INVESTIGATION REPORT

EOHSMS-05-F01_Rev0

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Issued on 15 Sept 2010

Ryobi Kiso (S) Pte Ltd


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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 : Gender : Race : Date Joined Service :

Nric / Fin No : Nationality : Martial Status : 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-days lost:

PART E (Details of Injury)


Nature of Injury (Use the following 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 Page 2 of 4

AMP : Amputation BCC : Bruises/Crushing/Contusions BN(H) : Heat Burns CCS : Concussion/Internal Injury DIS : Dislocation EYE : Eye Injury FT : Fracture HEAT : Heat Stress and strain NID : Noise Induced Deafness PERM : Permanent Disability PSN : Poisoning RDT : Effects of Radiation SS : Sprain/Strain OTHER : Other Injury

HAND LOWER NA

: Hand/Fingers : Lower Limbs (Legs) : Not Applicable


Issued on 15 Sept 2010

Ryobi Kiso (S) Pte Ltd


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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 Dressing apparel hazard Environmental hazard (gas/dust/smoke) High temperature hazard Hazardous arrangement / Inadequate guarding Inadequate illumination Inadequate/ Improper PPE Improperly/ faulty equipment Remarks: Inadequate warning system Inadequate ventilation Noise hazard Presence of fire/ explosion hazard Poor housekeeping 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 Remarks:

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)

(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 :

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

ii ) Human Factors Foul play Fatigue/stress


EOHSMS-05-F01_Rev0 Page 3 of 4

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 (Corrective action & Preventive action)

PART I (Recommendation)

PART J (Details of Investigation recorded by) Investigated by : Name: Designation: Company: Date: Reviewed by : Name: Designation: Company: Date:
EOHSMS-05-F01_Rev0 Page 4 of 4

Signature:

________________

Signature: _________________
Issued on 15 Sept 2010

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