5-Star Safety and Health Management System

Accident Investigation ( FORM 4.2.1)

(Near-miss Incidents, Loss Accidents, Lost Time Injuries)
Instructions: The investigator must fill in all fields in full and then re-send a copy of the front page to Safety
Department within 24 hours. And send the completed investigation's Final Report to the Industrial Security
Department within 72 hours.

Employee General Information:

Nam
Position: Helper
Badge
11507
Hemraj Poudel Dhan
e:
No.:
Operating
EOA
Business
BSP Juaymah
Sector:
Area:
Line:
Department:
Location: 380 KV Building
Electrical
Accident
Reporting
Overtime:
Yes
No
23/03/2016
23/03/2016
Date:
Date:
Accident
9:45 AM
Reporting
9:55 AM
No. of Overtime hours:
Time:
PM
Time:
PM
Task: Lifting
Shift Start Time:
7:00AM
6:00
PM
Experience: 2
Investigation
23/03/2016
yrs
Date:
Supervisor
Signature:
Date:
P.P. Mani
Name:
Manager
Signature:
Date:
T. K. Manoharan
Name:
Loss Level
Possibility of
Expected Loss
Injury Severity Level
Accident Type
Reoccurrence
No equipment

Low
Low
First-Aid
Near-miss
damage
less than 5000 SR
Medium
Minor
Accident
loss
Medium
more than 5000
Med-High
Med
Loss Time
Property
SR loss
High
Damage
Injury
major damage
High
High
Disability Injury
Vehicle
loss time
No medical treatment
Accident
required
injury
Complete the MVA
Form
Other:
Other
Fire

Occupational
Injury
Control No.
Non-occ.
Injury
The estimated cost of losses__SR
Others

For Motor Vehicle Accident (MVA)

Vehicle Type:
Vehicle No.:
Basic Causes:
Improper speed for existing
condition
Delayed perception
Faulty evasive action

Plate No.:

No. of vehicle involved:

Improper turning

Vehicle defect

Sudden movement
Following too closely

Other party fault

Other party fault

Improper backing
Wrong lane or position

Improper parking
Other:

Traffic signal violation

Body Part
Head
nose/mouth/ear
Arms
Arms
Mid-back
Right leg
Right foot
Other:

neck
shoulder

forehead
chest

eyes
hands

Right eyes
Right hand

Left eye
Left hand

Right arm
Right Arm

Left arm
Left Arm

Right wrist
back

Left wrist
Upper back

Mid-back
Right leg
Right foot

hips
knees
ankles

both Wrists
hand
fingers
right hip
right knee
right ankle

Left hip
Left knee
Left ankle

legs
feet
Feet fingers

Specify:

Right Hand Thumb

Nature of Injury
Traumatic
amputation
Asphyxia

Burn
(Heat or
Chemical)
Other

Contusion
(Bruise)

Skin irritation

Wound

Dislocation

(laceration/abrasion)
Fracture
(Open or Closed)

Heat
exhaustion
Stroke
Hernia

Electrical
Shock

Sprain /
Strain

Foreign
Object

Multiple
Injuries

Inflammation

Puncture

Describe clearly how the accident occurred or Near Miss happened:

While lifting SF6 cylinder by using EOT crane the victims finger caught in between cylinder and sling,
and his lower part of the right hand thumb is hurt.
This accident was taken place while keeping the cylinder from horizontal position to vertical position.
The web sling connected to the cylinder moved to the upward direction and started to swing the cylinder
either side. While watching this rotation the victim suddenly caught the cylinder. That time the sling
again moved and his right hand thumb caught in between sling and cylinder.

Contact Type:
Struck against
Struck by
Caught In

Caught On
Caught
Between
Slip

Fall from same level

Fall to lower level

Electricity
Heat

Overexertion

Cold

Caustics/Acids
Noise
Toxic/Nontoxic
substance

Others (Specify):

Unsafe Acts:
Failure To Warn
Failure To Secure
Operating At Improper Speed
Making Safety Devices Inoperable
Removing Safety Devices
Using Defective Equipment

Using Equipment Improperly

Failure To Wear PPE
Improper Loading
Improper Placement

Improper Lifting
Improper Positioning

Servicing Equipment In Operation

Horseplay
Not Following Procedure
Others (Specify):

Inadequate Ventilation
Inadequate Warning System

Hazardous Environment
Radiation Exposure

Fire & Explosion Hazard

Poor housekeeping

High or Low Temperature Exposure

Inadequate/Excess Illumination

Unsafe Conditions:
Inadequate or Improper PPE
Defective
Tools/Equipment/Materials
Noise Exposure
Congestion/Restricted/Overcrowded
Work Area

Others (Specify):

Absence of Tagline

Descibe the unsafe act(s) / (At Risk Behavior) and unsafe condition(s) existed:
Unsafe Act(s) / (At Risk Behavior):

Victim was trying to adjust the lifted load by his hand instead of using tag line

Unsafe Condition(s) / (High Risk Environment):

No tag line was installed to control the swing of the lifted load

Which job factors lead to the unsafe condition / at risk behavior? Explain
Inadequate Leadership /
Supervision
Inadequate Engineering
Inadequate Purchasing
Others (Specify):

Inadequate Maintenance

Wear and Tear

Inadequate Tools/Equipment
Inadequate Work Standards

Abuse or Misuse
Inadequate Ergonomic Design

Inadequate Leadership / Supervision

Which personal factors lead to the unsafe act? Explain

Inadequate
capability
Other (Specify)

Lack of
Knowledge

Lack of Skill

Stress

Improper
Motivation

Physical
Problem

Lack of Knowledge

Which safety system elements could prevent recurrence or reduce risk? (See
attached list of System Elements)

2.5 Lifting Gears & Machinery

Safety Equipment In Use:

Hard Hat
Hearing
Protection

Safety Shoes

Respirator

Gloves

Goggles

Other (Specify):

Fall Protection

Protective
Clothing

Witnesses :
Name:

Badge No.:

Badge No.:

Name:

Badge No.:

Badge No.:

Name:

Badge No.:

Name: Rakesh Tharu

Badge No.:

Name:
Name:

11707

Sketch the conditions of the near-miss / accident or attach statements from witnesses
or photos if available

While lifting the cylinder, the sling moved and victims right hand thumb caught in between the sling and
cylinder.

5 STAR SAFETY SYSTEM ELEMENTS

1.0

PREMISES &
HOUSEKEEPING

2.6

Compressed Gas
Cylinders &
Pressure
Vessels

1.1 Buildings & Floors

2.7 Hazardous
Substances
Controls

1.2

Lighting: Natural &

Artificial

2.8 Risk Assessment

[HIRA]

1.3
&

Ventilation: Natural

2.9 Motorized
Equipment

Artificial
1.4
Plant
Facilities
1.5

Hygiene

Pollution:

Air,

2.10 Portable Electrical

Equipment
2.11 Electrical

2.23 Control of Usage,

Issue
Maintenance
Record of
PPE
2.24 Notices and Signs:
Electrical &
Mechanical
Safety signs
3.0 Fire Protection
and
Prevention
3.1 Fire Extinguishing
Equipment

4.5 Non-Injury Statistics

5.14 Approved Safety

Training
Courses

4.6 Insurance Costs

5.15 Medical
Examinations

4.7 Incident Recall

5.16 Plant Inspections:

Safety
Representatives
5.17 Management SelfAudits

3.2 Locations Marked &

Floor
Clear
3.3 Maintenance of

5.1 Mangers as
responsible
for HSE
5.2 Person Appointed

5.0 Accident
Recording &
Investigation

5.18 Safety
Specifications:
Purchasing &
Engineering

Ground
& Water

Equipment
Maintenance

1.6 Aisles, Walkways &

Storage
Demarcation
1.7 Good Stacking and
Storage Practices
1.8 Housekeeping

2.12 General Electrical

Installations and
Flameproof
2.13 Hand Tools

3.4 Storage of
Flammable &
Explosive Materials
3.5 Alarm System

2.14 Ergonomics

1.9
Bins

2.15 Head Protectors

3.6 Fire-Fighting Drills

and
Instructions
3.7 Security System

5.5 Other
Communication
System
5.6 First-Aider &
Facilities

2.16Eye & Face

Protection
2.17 Footwear

3.8 Emergency
Planning
3.9 Fire Prevention and
Protection
Coordinator

5.7 First-Aid Training

2.17Protective Clothing

4.0 Accident
Recording &
Investigation
4.1 Occupational Injury
Record
4.2 Internal Accident
Reporting
& Investigation
4.3 Occupational Injury
Statistics

5.9 Injury Experience

and
Safety Boards
5.10 Suggestion
Scheme
5.11 Safety Reference
Library

Scrap & Refuse

Removal System
1.10 Color Coding: Plant
& Pipelines
3.0 Mechanical,
Electrical &
PersonalSafeguar
ding
2.1 Machine Guarding

2.2

Equipment

Lock Out System &

Usage
2.3
Labelling of
Switches,
Isolators & Valves
2.4 Ladders, Stairs,
Walkways &
Scaffolding

2.19 Respiratory
Equipment
2.20 Hearing
Conservation

2.5 Lifting Gears &

Machinery

2.22 Hand Protection

2.21 Safety Harness &

Fall Protection

for

4.4 Internal Accident

Reporting
& Investigation

Safety, Occ.
Hygiene Coor.
5.3 Designation of
Safety
Representatives
5.4 Safety Committees

Control, New Plant

and
Contractors
5.19 Written Safe Work
Procedures
5.20 Planned Task
Observations
5.21 Work Permits

5.22 Off-The-Job Safety

5.23 Health & Safety

Policy

5.8 Publicity, Bulletins,

Newsletter, etc.

5.12 Annual Report :

Loss
Control
Achievements
5.13 Orientation and
Job
Safety Training

Control steps to prevent recurrence :

Steps:
1. Conducted Tool Box Talks
2. Every lifting activity is doing with

the assistance of a rigger

3. Continuous supervision
4. Conducting pre task /tool box
meeting for high risk activities

Assigned To:

The scheduled completion

date:

The actual completion

date:

Area Safety Officer

24/03/2016
24/03/2016

23/03/2016
24/03/2016

24/03/2016
24/03/2016

24/03/2016
24/03/2016

Line Supervisor
Area In charge
Line Supervisor

5.

What follow-up actions that have been implemented to monitor the effectiveness of
corrective actions?
1. Conducted Tool Box Talks
2. Every lifting activity is doing with the assistance of a rigger
3. Continuous supervision
4. Conducting pre task /tool box meeting for high risk activities

The actual completion

date:

23/03/2016
24/03/2016
24/03/2016
24/03/2016

5.

Supervisors or Investigators Notes :

Investigators Name:

Mohammed Pangattil

Date:

Signature:

Supervisors Name:
Managers Name:

P.P. Mani

T. K. Manoharan

Safety Engineers Name:

Johny Joseph

Date:

Signature:

Date:

Signature:

Date:

Signature:

Supervisors or Investigators
Notes:

Date:

Signature:

Managers Notes:

Date:

Signature:

Executive Directors Notes:

Date:

Signature:

VP Notes:

Date:

Signature:

Industrial Security Dept.

Notes:

Date:

Signature: