Attachment 1.

( Four pages )
ACCIDENT/INCIDENT INVESTIGATION Report No.(Office Use)

REPORT
PT. XYZ A/I Report Form, 8/00

Use this Form:

FOR INCIDENTS THAT DID OR COULD HAVE RESULTED IN INJURY OR LOSS
1. BASIC DETAILS PLEASE PRINT
Report Date : Time : CLEARLY
Team Leader / Supervisor :

Department/Contractor : Section/Area : Complete all relevant

identifying data

Location of Incident : Date of Incident : Time : Use 24 hr clock or AM/PM

Did this Incident result in : LTI Please tick the box

INJURY PROPERTY DAMAGE NEAR MISS
Injured Name : Property Damaged : Did the incident result in
injury or property damage
or was it a near miss?
Part of Body Injured : Nature of Damage :
Complete all relevant
Nature of Injury or Illness : Estimate of Cost : sections

Object/Equipment/Substance Object/Equipment/Substance
Inflicting Harm : Inflicting Damage or Lost :
Occupation : Experience :

2. RISK POTENTIAL
This incident could have realistically resulted in (tick appropriate box)
LOW POTENTIAL - No incapacity to work When completing this
section ask yourself “If this
- Property damage < Rp. 50 million. happened again, what
realistically is the worst
MEDIUM POTENTIAL - A temporary incapacity to work (1 or more days outcome that could occur?

absence from work)

- A permanent partial incapacity to work
- Plant damage between Rp. 50 million – 100 million
HIGH POTENTIAL - A fatality or total incapacity to work
- Plant damages > Rp. 100 million
Chances of it happening again? (Tick appropriate box) Often : Occasional : Rare : What is the likelihood of a
recurrence?
3. INCIDENT STATEMENT Inspect scene of incident and
make area safe. Establish
Who was involved? • Sequence of Events
What was happening, what went wrong, what were the consequences? • Nature of injuries and or
damage
Where did it happen? • Those involved
When did it happen ?
Employee Witnesses : 1. ……………………. 2……………………….. 3………………………. Attach witnesses statement.

Interview witnesses-
• Time and Location
• Environmental Conditions
• Positions of people,
equipment & Materials
• Other witnesses
• Directions given
• Anything moved, turned
on/off or taken from the
scene
• Actions of person prior,
during and after

Record details
Scene - Diagram & Photos
Statements, Sequence of events
Experience/Training,
instructions given

USE THIS PAGE FIRST AS IMMEDIATE INITIAL INFORMATION BEFORE THE COMPLETE
REPORT
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 Attachment 1. ( Four pages )

Staple additional ACCIDENT/INCIDENT INVESTIGATION

Info here
REPORT
Notification for MEDIUM
potential incidents must be
4. THIS ACCIDENT/INCIDENT HAVE BEEN REPORTED TO : within 24 hours.
‰ Department Manager. Date : Time :

‰ SHE Manager. Date : Time :

(General Manager should be
notified immediately of high
‰ General Manager. Date : Time : potential accidents/
incidents)

5. IMMEDIATE ACTION Scene should be made safe

but where possible not
The Area has been made from any immediate hazard by the following actions disturbed until all details for
the investigation have been
collected eg: photos

Summarize the Immediate/

Basic causes.
6. CAUSE CHECK LIST ( “Tick” all relevant boxes )
Information entered here will
allow cause analysis for
SUBSTANDARD ACTIONS SUBSTANDARD CONDITIONS future reference
1 Operating equipment without authority 1 Inadequate guard or barriers
2 Failure to warn 2 Inadequate or improper protective equip.
3 Failure to secure/remove/prevent hazard 3 Defective tools, equipment or materials
4 Operating at improper speed 4 Congestion or restricted area
5 Making safety devices inoperable 5 Inadequate warning system
6 Removing safety devices 6 Fire and explosion hazards
7 Using defective equipment 7 Poor housekeeping: Disorder
8 Using equipment improperly 8 Hazardous environmental conditions
9 Failing to use personal protective equip. 9 Noise exposure
10 Improper loading 10 High or low temperature exposure
11 Improper placement 11 Inadequate or excess illumination
12 Improper lifting 12 Inadequate ventilation
13 Improper position for task 13 Other................................................(specify)
14 Servicing equipment in operation
15 Horseplay
16 Other ………………………….( specify )
BASIC CAUSES ( “Tick” all relevant boxes )
PERSONAL FACTORS JOB FACTORS
1 Inadequate capability 1 Inadequate Supervision 5 Inadequate tolls and equip
2 Lack of knowledge 2 Inadequate engineering 6 Inadequate work standards
3 Lack of skill 3 Inadequate purchasing 7 Wear and tear
4 Stress 4 Inadequate maintenance 8 Abuse or misuse
5 Improper motivation 9 Other........................(specify)
6 Other...............(specify)
TYPE OF CONTACT
1 Struck against 4 Caught on 7 Fall on same level
2 Struck by 5 Caught between/under 8 Fall to below
3 Caught in 6 Slip 9 Overexertion/Overstress
10 Other....................(specify)
CONTACT WITH
11 Electricity 13 Chemical 15 Noise
12 Heat/Cold 14 Gas or Hydrocarbon 16 Toxic or noxious substance
17 Other.....................(specify)
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 Attachment 1. ( Four pages )

ACCIDENT/INCIDENT INVESTIGATION
REPORT

7. CORRECTIVE ACTION
Responsibility Date to complete Corrective action should
address basic cause(s).
Corrective Actions (Person)
It should eliminate or reduce
probability of recurrence.
Ensure that action is taken to
institutionalize the fix (CAI).

Update the department

Hazard Register if necessary.

Provide any additional

8. COMMENTS BY PERSON INVESTIGATING (Supervisor, Shift Team Leader or Superintendent) : comments that are not
________________________________________________________________________________________________ covered elsewhere.

________________________________________________________________________________________________ If there is any doubt about

the circumstances of an
________________________________________________________________________________________________ accident ie: fraud, then
contact your Manager ASAP.
I am satisfied that to the best of my knowledge, the incident occurred as described. YES NO
If an injury is involved, notify
SHE of any unusual findings.
Investigator’s Name_____________________________ Investigator’s Signature____________________________
Date / /

9. COMMENTS BY DEPARTMENT MANAGER : The Manager must be

satisfied that the
________________________________________________________________________________________________ investigation is complete.
________________________________________________________________________________________________ Corrective action should be
appropriate, and as far as
________________________________________________________________________________________________ reasonably practical
eliminate, or reduce to an
________________________________________________________________________________________________ acceptable level, the risk of
recurrence.
I am satisfied that all responsible steps have been taken to : ( please tick )

( ) Thoroughly investigate the incident

( ) Identify the basic causes

( ) Identify and implement corrective action

( ) Institutionalize the fix

This investigation will be reviewed by (date) / /

to ensure the corrective actions have been implemented and are effective.
Reviewed by ________________________________ Signature _____________________ Date / /

For all medium/high

potential incidents and those
10. REVIEW BY SHE MANAGER : resulting in lost time injuries
the SHE Manager review
________________________________________________________________________________________________ should -
1. Check the quality of the
________________________________________________________________________________________________ investigation process
2. Ensure corrective actions
________________________________________________________________________________________________ have been completed.
3. Identify key lessons for the
department.
4. Ensure others who need to
Reviewed by ________________________________ Signature _____________________ Date / / know are told

For high potential incidents

and all cases of lost time
11. COMMENTS BY OPERATIONS/GENERAL MANAGER : injury the GM will review
investigation to ensure all
________________________________________________________________________________________________ appropriate action has been
taken.
________________________________________________________________________________________________
GM should be satisfied that
________________________________________________________________________________________________ as far as reasonably
practicable, all steps have
been taken to prevent a
recurrence of high potential
Reviewed by ________________________________ Signature _____________________ Date / / accident or incident.

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