Form No: AAA-AAA-MT SOPHIA-AR- IIR-17-00006

Rev: 0

Project: MT SOPHIA

INCIDENT INVESTIGATION REPORT (IIR)

PART A (Type of Accident)
☑ Major Accident (Reportable to MOM under both WSH Act & WIC Act)
☑ Minor Accident [Reportable to MOM under work Injury Compensation (WIC) Act only]
☑ Minor Accident [Non-Reportable to MOM]
☑ Staff Injury / Public Member Injury

PART B (Detail of Accident)
Project : MT SOPHIA

Workplace No. : A22 A23
Place of accident: A22

Occurrence date & time: 22/02/2017 15:25 First reported date & time: 22/02/2017 16:25 Reported by : Adhi

PART C (Detail of Injured / Victim)
Name : Jumadi Date Joined Service : 21/02/2017
Direct Employer : Mr A Fin No. : 001
Work Employer : 00122 Nationality : Indonesia
Date of Birth : 21/02/2017 Marital Status : Married
Gender : Male Designation / Occupation : Supervisor
Race : –

The injured sent to ☑ First Aid ☐ Private Doctor ☐ Hospital ☐ Polyclinic
Name of Clinic / Hospital: RS Ben Mari

PART D (Lost Time)
Estimated (if actual man-day lost is not available)
☑ 3 days or lesser ☐ More than 3 days (consecutive or otherwise)
☐ Hospitalized more than 24 hour ☐ Immediate return to work
☑ First aid given only ☐ Hospital referral
State actual of man-days lost Days
(excluding PH & Sunday)

Period of Medical Leave 2 Days (fr 21/02/2017 to 23/02/2017

PART E (Details of Injury)
Nature of Injury ( Tick wherever applicable)
☑ Chemical Burns
☐ Physical Shock
☐ Fracture
☐ Asphyxia/Drowning
☐ Puncture Wound
☐ Heat Stress and strain
☐ Chemical Burns
☐ Dermatitis/Skin Disease
☐ Noise Induced Deafness
☐ Shoulder to Groin/Hip
☐ Tooth Injury
☐ Permanent Disability
☐ Fatality
☐ Amputation
☐ Poisoning
☐ Effects of Electricity
☐ Bruises/Crushing/Contusions
☐ Effects of Radiation
☐ Faint/Giddy
☐ Heat Burns
☐ Sprain/Strain
☐ Freezing/Frostbite/Hypothermia
☐ Concussion/Internal Injury
☐ Other Injury: (Specify)
☐ Laceration/Cut
☐ Dislocation
☐ Numbness
☐ Eye Injury

Injury Body Part (Tick wherever applicable)
☐ Head/Face/Neck
☐ Injury linked to entire body
☐ Eye
☐ Lower Limbs (Legs) Exact Description
☐ Upper Limbs (Arms)
☐ Feet/Toes (Tick wherever applicable)
☐ Hand/Fingers
☐ Not Applicable
☑ Left
☐ Right

PART F (Description of Accident)
explosions that cause burns
Type of Accident (Tick wherever applicable)
☐ Caught In/Between Objects
☐ Exposure to Electric Current
☐ Suffocation/Drowning
☐ Cut/ Stabbed by Objects
☐ Striking Against Objects
☑ Fires & Explosion
☐ Struck by Moving Objects
☐ Exposure to Biological Materials
☐ Slips, Trips and Falls
☐ Falls from Heights
☐ Struck by Falling Objects
☐ Physical Assault
Stepping on Objects Exposure to Extreme Temperature Over-Exertion and Strenuous
Movements
☐ Other (Specify)

PART G (Causes of Accident)
(1) Direct Causes
I) Unsafe Conditions (Tick whenever applicable)
☑ Absence of safety means / Congestion/ Restricted
☐ 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 (Tick wherever applicable)
☐ Careless / reckless ☐ Taking improper/unsafe position or posture
☐ Disregard instructions ☐ Making safety devices not in operative mode
☐ Driving error ☐ Not attentive while 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 ☐ Others (key details into “Remarks”)
☐ Intentional motive
Remarks:

(2) Root Causes
I) Work Factors (Tick whenever applicable)
☐ 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 (key details into “Remarks”)
Remarks:

ii) Human Factors (Tick whenever applicable)☐ Foul play
☐ 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 Safety management System
I) General (Tick whenever applicable)
☐ 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)
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PART I (Recommendation)
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PART J (Detail of Investigation recorded by Project WSH Committe)
Signature Name Signature Name
Designation WSHO
Company Straits Construction
Date 21/02/2017

PART K (Reviewed by)
Signature –
Name –
Designation (Chairman –Project WSH Committee) / Project Manager / Senior Manager (Projects) Company Straits Construction Singapore Pte Ltd
Date –

PART L (Physical condition worker after treatment )

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PART M (Enclosed Documents)
– Copy of IC/S-Pass/WP – Statement by the injured
– Copy of SOC – Statement by the witness
– Copy of MC – Other: (Specify)
– Copy of Medical Report
– Statement by the injured
– Statement by the witness
– Other: (Specify)fy)

PART N (Scene / Re-enactment Photos)

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Please kindly download the PPT file here.