事故調(diào)查報告

1、事故調(diào)查報告表Accident/Incident Investigation Form使用說明Guidance 1.此事故調(diào)查報告表用于紀(jì)錄廠區(qū)所有事故的具體細(xì)節(jié).各廠必須報告實(shí)際事故的正式糾正措施(參考00-QS15-8520-100糾正與預(yù)防措施),并在完成時上報Global事故上報系統(tǒng).與環(huán)境因素沒有關(guān)系的事故不需填寫全部的8D糾正措施.This form is for the recording of all kind of the Incidents as detailed in the Site Accident & Incident Reporting & Inv

2、estigation Process. SITES MUST ALSO REPORT ALL ACTUAL INCIDENTS ON A FORMAL CORRECTIVE ACTION (ref. 00-QS15-8520-100 Corrective and Preventive Action) AND UPLOAD TO GLOBAL ACCIDENT REPROT SYSTEM WHEN COMPLETED. A full 8D Corrective Action form is not required for minor incidents that do not have bea

3、ring on the site environmental aspects.2.請使用本表格報告所有相關(guān)的事故或意外傷害，.完成第一部分并上報你的直接主管,他/她完成第二部份,識別出合適的糾正措施/措施責(zé)任人并于5個工作日內(nèi)遞交給EHS部門.Please use this form to report all incidents (near misses) or accidental damage. Complete Part 1 and pass to your immediate manager, he / she will then complete part 2 identifyin

4、g the appropriate corrective actions / action owners and forward the form to EH&S Department in five working days. 3. 匯報時限 : 事故發(fā)生單位必須在事故發(fā)生后第一時間向EHS匯報，對于傷亡事故以及需要住院治療的事故，工廠廠長在 24 小時內(nèi)向ABC客戶進(jìn)行匯報 (紅色部分僅適用于生產(chǎn)ABC產(chǎn)品工廠區(qū)域). Report opportunity：The department should inform EHS firstly when the accident occu

5、rred. For incident that involve fatality or hospitalization, OPM should report the accident to ABC (text in red only applicable to factory area with ABC production) .4.本表由事故單位現(xiàn)場主管(經(jīng)理，副理）填寫后，依下面流程簽核。(非環(huán)安衛(wèi)相關(guān)事故時，廠區(qū)工安人員不須簽核)事故部門/單位主管廠區(qū)環(huán)安衛(wèi)人員EHS管理代表Ops/ functional managerThe evaluating procedure for the a

6、ccident/incident: Unit head Site EHS member EHS representative Ops/ functional manager5. 事故調(diào)查報告完成后，由EHS在24小時內(nèi)將事故情況上報Global事故上報系統(tǒng)，廠外交通事故除外。After the accident investigation report completed, EHS member should upload them to our global accident report system in 24 hours, except the traffic accident out

7、side the plant.6.請于Ops/ functional manager簽核后，本表由廠區(qū)工安人員存查并進(jìn)行改善追蹤及最后確認(rèn). After the Ops/ functional manager approval, it should be checked by the site EHS member.Part 1：事故基本資料Accident/Incident general data填寫人Name： 報告時間： 事故（CAPA）編號：格式為EHSxxxxxx 例：EHS150102 Report date: Accident/Incident number:基本資料Basic

8、 information部門 /單位： Department：事故地點(diǎn)/區(qū)域： Accident/Incident place：當(dāng)事人姓名/卡號： Name of the victim/ID number：職稱： Job title: 目擊者沒有就寫“無”：Witness：發(fā)生時間：Happening Time：現(xiàn)場訪談人員：Witness interview事發(fā)時作業(yè)內(nèi)容： Emergency Task Details：發(fā)生過程描述Accident/Incident detailsWho : When: Where: What: Why: 。How: (1.交通事故請畫發(fā)生點(diǎn)之簡圖請以附件附

9、于本報告之后。2.工安事故請附上事故現(xiàn)場照片及說明于本報告表之后。3.發(fā)生過程的描述請采用5W1H的方式進(jìn)行。(1. Traffic accident need to draw the sketch of the accident/Incident place on the next page。2. The EHS related accident need to add the pictures and related introduction on the next page。3. The accident description should take 5W1H Method)處置情形H

10、andling condition寫明處置的經(jīng)過和處置的結(jié)果調(diào)查小組（Investigation Team）Name(姓名)Title(職務(wù))Dept.(部門)（請列出調(diào)查組成員名單及職務(wù) Team member list）原因分析過程Process of root cause analysis分析因素（Analysis Factor）原因（Root Cause）Man(人)Machine(機(jī)器)Material(物料)Method/Process (方法或制程)Environment（環(huán)境）Why: Why: The root cause: Why: Why: Why: 不一定是5個WHY,

11、可視情況增加此部分請采用5why的方式分析事故發(fā)生的原因，找出事故發(fā)生的根本原因（You should take 5why method to analyze the reason that the accident happened and find the root cause）原因分析Reason analysis事故發(fā)生直接原因Cause of injury： 被切、割、擦傷 Cutting、Scratching 被夾、卷 Rolling 被撞Knocking 被扎injured by sharp object 被壓crashed 勞損 strain 墜落、滾落Dropping 跌倒

12、Tumble 觸電Contact electricity 被物體砸到Throwing 碰到化學(xué)品或其他危險物質(zhì)燙傷燒傷Burning 火災(zāi)fire 爆炸Explosion 交通事故Traffic accident 斗毆fighting 盜竊theft 闖入 break 其它(請注明)others:發(fā)生原因Injury Reason：(發(fā)生事故之不安全狀況及不安全行為，可復(fù)選) (Other choices)設(shè)備、設(shè)施設(shè)置不良Equipment unsafely 不安全的環(huán)境 （如地面濕滑）unsafe environment (i.e. slippery floor) 缺乏勞動保護(hù)用品 (la

13、ck of PPE) 重復(fù)性的動作 (repeated motions) 超負(fù)荷運(yùn)行或者搬運(yùn)過重物體 overload 所使用的工具不合適inappropriate tool 保護(hù)裝置故障或者失效 protective equipment or setup malfunction 整理不善 poor housekeeping 不安全的姿勢或位置unsafe posture or position 帶電作業(yè) work with live wire 運(yùn)行/工作在不安全的速度operating working at unsafe speed人員作業(yè)方法錯誤Incorrect operation 使用

14、未批準(zhǔn)的設(shè)備或者物料 unauthorized equipment or material 其它原因之具體描述Detailed description of other reasons 根本原因Root Reason：(管理上存在的問題，可復(fù)選other choices for the management problem)未配置防護(hù)裝置not equipped with protective measures 設(shè)備自身缺陷 equipment design defect 未落實(shí)設(shè)備、設(shè)施的保養(yǎng)及檢查Improper maintenance and inspection 未考慮到的新風(fēng)險 ne

15、w risk which was not identified 人員不知道要求unaware requirement 人員未依規(guī)定操作Incorrect operation未訂定操作標(biāo)準(zhǔn)No operation standard 未訂定安全衛(wèi)生工作守則No safety & health rules for working 其它原因之具體描述: Detailed description of other reasonsPart 2：事故之改善對策Accident/Incident Improvement Measures:改善對策Improvement measuresNO.改善對策I

16、mprovement Measures執(zhí)行單位Operation company執(zhí)行人員Operation people預(yù)估完成日期Predicted due date改善對策須針對根本原因分析的結(jié)果展開，要能從根本上消除或者減緩事故發(fā)生的可能性改善狀況確認(rèn)Confirm Improvement situation NO.改善狀況Improving state改善后狀況說明After improving state instruction確認(rèn)人員Confirm people確認(rèn)日期Finishing due dateOK NGOK NGOK NGOK NGOK NGOK NG備注Note：1.

17、改善狀況確認(rèn)之欄位由廠工安人員填寫或因情況而定； The column of Confirm Improvement situation need be filled by EHS&S member.2.請針對各項改善對策分別進(jìn)行確認(rèn)其改善狀況(改善完成勾選OK，未改善完成勾選NG)，并請加以說明其改善后之狀況。 Please confirm the improvement results according to each improvement action plan, select OK if the task is finished, select NG if the task

18、 is not finished, and describe its current status., 事故處置狀況評審Checking the handling condition請識別事故所屬等級及現(xiàn)場處置狀況是否妥當(dāng)Please identify the accident/incident grades and the handling condition1.事故所屬類型Accident type：損失工時傷害: 可記錄傷害或疾病導(dǎo)致一天或多天脫崗，當(dāng)事件發(fā)生之后Lost Time Injury: Recordable injury or illness that results in

19、one (1) or more days away from work after the day on which the incident occurred財產(chǎn)損失:財產(chǎn)損失超過2500美元Real property damage of more than $2500 USD 職業(yè)病: 除了由職業(yè)傷害引起的任何不正常的狀態(tài)或失調(diào)，由接觸環(huán)境因素引起的職業(yè)Occupational Illness: Any abnormal condition or disorder, other than one resulting from an occupational injury, caused b

20、y exposure to environmental factors associated with employment. 外部機(jī)構(gòu)走訪：外部機(jī)構(gòu)發(fā)起的因投訴，跟進(jìn)事件，不符合或現(xiàn)場訪問的調(diào)查External Site Inquiry initiated by a complaint, follow-up to an incident, a non-compliance, or on-site visit物料泄漏: 大于5加侖(19升)危害物料泄漏或釋放Hazardous Material Spill or release greater than 5 gallons (19 liters

21、)嚴(yán)重事件：任何傷害事件導(dǎo)致死亡，骨折，截肢或住院，環(huán)境事件需要報告給政府機(jī)構(gòu)。Significant Incident: Any incident involving an injury that results in a fatality, fracture, amputation or hospitalization, environmental incidents requiring reporting to a government agency. 重大虛驚：一個事件,能夠?qū)е聜蚣膊?、財產(chǎn)損失、泄漏或違規(guī), 同時如果發(fā)生會導(dǎo)致一個嚴(yán)重事件Significant Near Miss

22、: An event that could have resulted in an injury or illness, property damage, spill or non-compliances and if it had occurred would have resulted in a significant incident 2.事故之處理是否妥當(dāng)Please check the accuracy for the handling condition of accident/incident. 妥當(dāng)OK 不妥當(dāng)NG (如勾選此項,請于3中做出說明) (If the handle

23、 results is not appropriately, please make solutions ) 3. 建議處理方式 Solutions：如果事故系因人為誤操作/無權(quán)操作/越權(quán)操作而造成，請于3中評估說明對責(zé)任人的處理方式(此欄位由EHS人員填寫written by EHS Dept)是否需進(jìn)一步之改善 Y N Further Detailed Investigation Required? 如果”是”提供詳細(xì)的適當(dāng)?shù)氖鹿?事件的調(diào)查If Yes Provide details report of the appropriate Accident/Incident Investig

24、ation (此欄位由EHS人員填寫written by EHS Dept)Part 3.事故之進(jìn)一步改善建議 Further Improvements Suggestions Part 4. 損失估計 Losses evaluation 預(yù)估損失Predicted losses直接損失費(fèi)用(以USD表示)Direct loss(by USD)合計(以USD表示)Total (by USD)人身損失費(fèi)用Personal loss事故善后處理費(fèi)用Incident subsequent solving cost財產(chǎn)損失費(fèi)用Property loss醫(yī)療費(fèi)用Medical cost歇工工資Be of

25、f duty salary現(xiàn)場搶救費(fèi)用Rescue cost現(xiàn)場清理費(fèi)用Cleaning cost罰款和賠償費(fèi)用Fine and compensate固定資產(chǎn)損失/修繕Permanent assets loss/maintenance流動資產(chǎn)損失Current assets loss4278.61間接損失費(fèi)用(以USD表示)Indirect loss (by USD)合計(以USD表示)Total (by USD)停產(chǎn)損失Stop production loss其他費(fèi)用Other cost其他費(fèi)用(請說明)Other cost(Pls explain)：備注Note：1.醫(yī)療費(fèi)用：系指員工因事

26、故而受傷，治療期間之初估醫(yī)療費(fèi)用。Medical cost: indicate the first evaluation medical losses of staff injured by incident during treatment.2.歇工工資：以該員工之(職級平均月薪/30)*歇工休養(yǎng)天數(shù)進(jìn)行概略估算。Be off duty salary: imputed by (average salary /30)*be off duty days.3.現(xiàn)場搶救費(fèi)用：指進(jìn)行事故搶救時所衍生之費(fèi)用，(如滅火器填充、緊急應(yīng)變用品銷耗等費(fèi)用)。Rescue cost: cost derivativ

27、e when rescue the incident,(eg. fire extinguisher padding or emergent and response goods consumeetc. )4.現(xiàn)場清理費(fèi)用：指事故發(fā)生后對事故現(xiàn)場進(jìn)行清除處理之費(fèi)用。Cleaning cost: cleaning cost for worksite after incident.5.罰款和賠償費(fèi)用Fine and Compensation：罰款：系指事故發(fā)生后，公司遭受政府單位依現(xiàn)行法令之規(guī)定進(jìn)行罰款的費(fèi)用；Fine: punished cost by government due to regulatory after incident.賠償：系指事故發(fā)生后，公司賠償給周遭受影響之居民或生產(chǎn)受影響之客戶的費(fèi)用。Compensation: company compensate the around impacted resident or customers whose production be impacted after incident.6.流動資產(chǎn)損失：系指在事故發(fā)生后造成公司之原材料、燃料、輔助材料、成品、半成品、在制品等損失之費(fèi)用。Current assets loss: losses of raw materials, fuel