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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
Plate No.:
Improper turning
Vehicle defect
Sudden movement
Following too closely
Improper backing
Wrong lane or position
Improper parking
Other:
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:
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
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
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
Improper Lifting
Improper Positioning
Inadequate Ventilation
Inadequate Warning System
Hazardous Environment
Radiation Exposure
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
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
Inadequate Tools/Equipment
Inadequate Work Standards
Abuse or Misuse
Inadequate Ergonomic Design
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)
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.:
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.
PREMISES &
HOUSEKEEPING
2.6
Compressed Gas
Cylinders &
Pressure
Vessels
2.7 Hazardous
Substances
Controls
1.2
1.3
&
Ventilation: Natural
2.9 Motorized
Equipment
Artificial
1.4
Plant
Facilities
1.5
Hygiene
Pollution:
Air,
5.15 Medical
Examinations
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
3.4 Storage of
Flammable &
Explosive Materials
3.5 Alarm System
2.14 Ergonomics
1.9
Bins
5.5 Other
Communication
System
5.6 First-Aider &
Facilities
3.8 Emergency
Planning
3.9 Fire Prevention and
Protection
Coordinator
2.17Protective Clothing
4.0 Accident
Recording &
Investigation
4.1 Occupational Injury
Record
4.2 Internal Accident
Reporting
& Investigation
4.3 Occupational Injury
Statistics
Removal System
1.10 Color Coding: Plant
& Pipelines
3.0 Mechanical,
Electrical &
PersonalSafeguar
ding
2.1 Machine Guarding
2.2
Equipment
2.19 Respiratory
Equipment
2.20 Hearing
Conservation
for
Safety, Occ.
Hygiene Coor.
5.3 Designation of
Safety
Representatives
5.4 Safety Committees
Assigned To:
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
23/03/2016
24/03/2016
24/03/2016
24/03/2016
5.
Mohammed Pangattil
Date:
Signature:
Supervisors Name:
Managers Name:
P.P. Mani
T. K. Manoharan
Johny Joseph
Date:
Signature:
Date:
Signature:
Date:
Signature:
Supervisors or Investigators
Notes:
Date:
Signature:
Managers Notes:
Date:
Signature:
Date:
Signature:
VP Notes:
Date:
Signature:
Date:
Signature: