.

TRIDENT HYDROJETTING PHILIPPINES INC

Building 4A Lot 24 & 38 Efficiency Avenue, Subic Bay Gateway Park Phase -1, Subic Bay Freeport Zone, Philippines 2222 Tel: 63.47.250 2448 Fax: 63.47.250 2450
NON VAT Reg TIN: 008-720-044-000

ACCIDENT INVESTIGATION INVOLVED

Operation Hazardous Condition
Admin Food Production Improperly Guarded Hazardous Arrangement
Office Food Service Inadequately Guarded Improper Illumination
Maintenance Catering Unguarded Improper Ventilation
Grounds Cleaning Work Clutter Congested Area
Plumbing HVAC Defective Tools,Equipment, Substances No Unsafe Condition
Carpentry Snow Removal Unsafe Design or Construction

Body Part Injured: Right or Left Unsafe Act & Other Factors
None Back Leg Operating w/o authority Equipment Failure
Eye (s) Lungs Knee Unsafe Carrying / Lifting Unsafe Approach
Head Chest Ankle Failure to secure equipment Physical Surroundings
Neck Ribs Hand Procedure not followed Failure to use PPE
Face Abdomen Finger (s) Failure to use proper tool Taking Unsafe Position
Elbow Groin Foot Operating at an unsafe speed or beyond capacity
Wrist Buttocks Toe (s) Other Specify _____________
Nature of Injury: Right or Left Accident Type
Foreign Object Amputation Struck By/Against Over Exertion
Cut Punctured Wound Caught In/On/Between Repetitous Trauma
Hernia Bruise/Contusion Fall Same Level Chemical Exposure
Sprain/Strain Dermatitis Fall Different Level Contact Temp Extremes
Fracture Smashed /Pinched Slip/Trip Chemical Exposure
Burn Chemical Abrasion Vehicle Accident Skin
Burn Thermal Infection No History Available Inhalation
Chemical Irritation Push : Pull Pushing / Pulling Twisting
Other __________ Other ___________

Re-Instructed of Person (s) Involved
Coaching of person (s) Involved
Reprimand of Person (s) Involved
Written (vebal)
Discipline of Person (s) Involved
Written Verbal
Action to Improed Inspection
Actions to Prevent Accident /Inccident Re-Occurrence
Investigate Better Method
Action to Improved Clean - Up
Request Job Safety Analysis
Equipment Replacement or repair
Action to Improved Design
Installation of Guard or Safety Device
Action to Improved Condition

The Causes
Direct Personnel Causes Direct Environment Causes
What did a person - the victim or someone else-do, or fail to do, that contributed What defective or otherwise unsafe condition (s) o
directly to this accident? Be specific, for example: " Operated machinery without equipment, product, working surface, structures,
authority", "Used pipe wrench for hammer; Brushed fillings away with finger directly to this accident? Be specific, for example:
rather than a brush." " Badly worn brake Linings". "Cracked fork on lift t
Indirect Personnel Causes Indirect Environmental Causes
Check item (s) below which best indicate reasons why act identified in above was Check item (s) below which best indicate reasons
commented. Write in information for indirect causes not listed. identified in above existed. Write in information fo
not Listed.
1. Unaware of job hazards 8. Inattentive to hazards 1. Worn out from normal use
2. Unaware of safe method 9. Low level of job skill 2. Abuse or misuse by user
3. Tried to gain or save time' 10. Tied to avoid extra effort 3. Required inspection not Done
4. Acted to avoid discomfort 11. Influence of Emotions 4. Inspection not required
5. Influence of Fatigue 12. Influence of intoxicants 5. Clean-Up failure
6. Influence of Illness 13. Defective vision / hearing 6. Clean-Up not Required
7. Unable to determine 14. Other (explain) 7. Clean-Up not Done
8. Inadequate ventilation
9. Congestion-lack of space
10. Unsafe Design
Primary Unsafe Act Primary Unsafe Condition
Cause
1. Operating or Using equipment without authority 1. Lack of adequate guards and safety devices
2. Failure to secure equipment against unexpected movement 2. Lack of or inadequate warning system
3. Operating or Working at Unsafe Speed 3. Fire and Explosion hazards
4. Failure to warn or signal as required 4. Unexpected movement hazards
5. Removing or making safety devices inoperative 5. Poor housekeeping hazards
6. Using Defective tools or equipment 6. Protruding hazards
7. Using tools or equipment unsafely 7. Close clearance and congestion hazards
8. Taking unsafe position or posture 8. Hazardous atmospheric conditions
9. Servicing moving, energized or otherwise hazardous equipment 9. Hazardous arrangement, Placement or storage
10. Riding hazardous moving equipment 10. Hazardous defect of tools, equipment, etc.
11. Horseplay, distracting,startling,teasing, etc. 11. Inadequate illimunation, intense noise
12. Failure to wear PPE 12. Hazardous personal attire
13. Other than above 13. Other than above
THE CORRECTION
Corrective Action Taken
Check those actions taken to prevent recurrence. Fill in the appropriate box for corrective actions decided upon or planned by not yet initiated or com
1. Reinstructed of those involved 8. Action to improve clean-up 15. Correction of necessary congestion
2. Reprimad of those involved 9. STA done 16. Improve PPE
3. Discipline of those involved 10. Revision STA 17. Order regular pre-job instruction
4. Reinstruction of others doing the job 11. Equipment repair or replacement 18. Order use of safer materials
5. Temporary reaasignment of person 12. Action to improve design 19. Check with manufacturer
6. Permanent reassignment of person 13. Action to improve construction 20. Inform all departmental supervision
7. Action ti improve inspection 14. Installation of guard or safety device 21. Other than above.
 Severity/Treatment
Near Miss
First Aid Only
Medical treatment
Restricted Work
Lost time
Hospitalized
Fatality
Preventable by Employee
Preventable
Non- Preventable
Alleged
Waiting for Review
Comments ___________________

Protective Equipment
Required but Not used
Required AND in use
Not Required
May have reduced injury
would Not Have Affected
Injury
 Request Pre-job Instructions
Correction /Unnecessary Congestion
Improve PPE
Request Safety Observation
Place Work Order Request
Action to Improve
Construction
Other ___________________

fe condition (s) of tools, machinery,

ace, structures, or work area contributed
fic, for example: "Hand railing missing".
cked fork on lift truck."

ndicate reasons why condition

in information for indiret causes

11. Faulty construction

12. Inadequate Illumination
13. Lubrication failure
14. Exposure to corrosion
15. Exposure to vibration
16. Exposure to temp. extreme
17. Tampering
18. Supervisor failed to correct
19. Unable to determine
20. Other (explain)
afety devices
system

n hazards
ons
ment or storage
uipment, etc.
nse noise

initiated or completed
estion

vision