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PERSON(S) INJURED AND/OR WORK RELATED ILLNESS WHICH REQUIRES PROFESSIONAL MEDICAL ATTENTION (Doctor, Nurse,
Paramedic)? YES NO
(IF YES GO TO SECTION 1 IF NO GO TO SECTION 2)
SECTION 1 --- FOR FATALITY, INURY(S) AND/OR WORK RELATED ILLNESS WHICH REQUIRE PROFESSIONAL MEDICAL ATTENTION
1. FATALITY PERSON(S) INJURED WORK RELATED ILLNESS NUMBER OF PEOPLE INJURED/ILL : _____________
2. CLASSIFICATION OF INJURED: EMPLOYEE CONTRACTOR THIRD PARTY OTHERS _____________
3. MEDICAL TREATMENT ADMINISTERED: ONSITE LOCAL CLINIC EMERGENCY ROOM HOSPITAL OTHER ________
4. DID THE INJURED RETURN/ CONTINUE TO WORK ON THE DAY OF THE INJURY? YES NO
5. IF (4) IS NO, DID THE INJURED RETURN TO WORK THE NEXT DAY? YES NO UNKOWN AT THIS TIME
6. IF (5) IS YES, WAS THE INJURED ABLE TO PERFORM THEIR FULL JOB FUNCTION? YES NO
7. IF (5) IS NO, THEN INDICATE ESTIMATED NUMBER OF DAYS INJURED WILL BE AWAY FROM WORK ____________
8. INDICATE INIITAL CLASSIFICATION: LOST TIME , RESTRICTED WORK , MEDICAL TREATMENT UNKOWN AT THIS TIME
NATURE AND EXTENT OF INJURY(S) + SUMMARY OF MEDICAL TREATMENT(S)
SECTION 2
OTHER INCIDENTS, NEAR MISSES, & UNDESIRED EVENTS & ADDITIONAL INFORMATION REGARDING INJURY ILLNESS
ENVIRONMENTAL INCIDENT: SEVERITY: REGULATORY CITATION REGULATORY NOTIFIABLE EVENT
PERONNEL SECURITY THREAT BURGALRY / ROBBERY FIRE MEDIA COVERAGE OF CUSTOMER
MAJOR & SERIOUS NEAR MISSES = EVENTS WHICH POTENTIALLY COULD HAVE CAUSED: FATALITY SERIOUS INJURY
VEHICLE INVOLVED IN THE INCIDENT PROPERTY DAMAGE ESTIMATED > US $ 50,000
SECTION 3
SUMMARY DESCRIPTION OF INCIDENT (WHO, WHAT, HOW, WHEN, WHY):
WHO- MOHAMD SAFDAR / RBT Third party delivery pipe contractor driver / Plate No 5299
WHAT-Pipe unloading to OMSA yard from Dammam Saudi Arabia.
HOW-The truck back hit the connectors stock and fell height 1.5meter from ground.
WHEN-13th March 2014 evening.
WHY-Driver did not manipulate proper the trucks while moving backward.
IMMEDIATE ACTION TAKEN: Photos , Interviews & Statements, Legal & Customer Notifications (when required)
Summary Description of Action
PREPARED BY:Marlo Gagarao TITLE: QAQC Asst SPV DATE: 13th March 2014
SCAS/OMS
SCTPD TOKYO +65 9828 4144 (Michael Pomfret) oms.incident@sumitomocorp.co.jp