事故调查报告

1、事故调查报告表Accident/Incident Investigation Form使用说明Guidance 1.此事故调查报告表用于纪录厂区所有事故的具体细节.各厂必须报告实际事故的正式纠正措施(参考00-QS15-8520-100纠正与预防措施),并在完成时上报Global事故上报系统.与环境因素没有关系的事故不需填写全部的8D纠正措施.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.请使用本表格报告所有相关的事故或意外伤害，.完成第一部分并上报你的直接主管,他/她完成第二部份,识别出合适的纠正措施/措施责任人并于5个工作日内递交给EHS部门.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. 汇报时限 : 事故发生单位必须在事故发生后第一时间向EHS汇报，对于伤亡事故以及需要住院治疗的事故，工厂厂长在 24 小时内向ABC客户进行汇报 (红色部分仅适用于生产ABC产品工厂区域). 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.本表由事故单位现场主管(经理，副理）填写后，依下面流程签核。(非环安卫相关事故时，厂区工安人员不须签核)事故部门/单位主管厂区环安卫人员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. 事故调查报告完成后，由EHS在24小时内将事故情况上报Global事故上报系统，厂外交通事故除外。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.请于Ops/ functional manager签核后，本表由厂区工安人员存查并进行改善追踪及最后确认. After the Ops/ functional manager approval, it should be checked by the site EHS member.Part 1：事故基本资料Accident/Incident general data填写人Name： 报告时间： 事故（CAPA）编号：格式为EHSxxxxxx 例：EHS150102 Report date: Accident/Incident number:基本资料Basic

8、 information部门 /单位： Department：事故地点/区域： Accident/Incident place：当事人姓名/卡号： Name of the victim/ID number：职称： Job title: 目击者没有就写“无”：Witness：发生时间：Happening Time：现场访谈人员：Witness interview事发时作业内容： Emergency Task Details：发生过程描述Accident/Incident detailsWho : When: Where: What: Why: 。How: (1.交通事故请画发生点之简图请以附件附

9、于本报告之后。2.工安事故请附上事故现场照片及说明于本报告表之后。3.发生过程的描述请采用5W1H的方式进行。(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)处置情形H

10、andling condition写明处置的经过和处置的结果调查小组（Investigation Team）Name(姓名)Title(职务)Dept.(部门)（请列出调查组成员名单及职务 Team member list）原因分析过程Process of root cause analysis分析因素（Analysis Factor）原因（Root Cause）Man(人)Machine(机器)Material(物料)Method/Process (方法或制程)Environment（环境）Why: Why: The root cause: Why: Why: Why: 不一定是5个WHY,

11、可视情况增加此部分请采用5why的方式分析事故发生的原因，找出事故发生的根本原因（You should take 5why method to analyze the reason that the accident happened and find the root cause）原因分析Reason analysis事故发生直接原因Cause of injury： 被切、割、擦伤 Cutting、Scratching 被夹、卷 Rolling 被撞Knocking 被扎injured by sharp object 被压crashed 劳损 strain 坠落、滚落Dropping 跌倒

12、Tumble 触电Contact electricity 被物体砸到Throwing 碰到化学品或其他危险物质烫伤烧伤Burning 火灾fire 爆炸Explosion 交通事故Traffic accident 斗殴fighting 盗窃theft 闯入 break 其它(请注明)others:发生原因Injury Reason：(发生事故之不安全状况及不安全行为，可复选) (Other choices)设备、设施设置不良Equipment unsafely 不安全的环境 （如地面湿滑）unsafe environment (i.e. slippery floor) 缺乏劳动保护用品 (la

13、ck of PPE) 重复性的动作 (repeated motions) 超负荷运行或者搬运过重物体 overload 所使用的工具不合适inappropriate tool 保护装置故障或者失效 protective equipment or setup malfunction 整理不善 poor housekeeping 不安全的姿势或位置unsafe posture or position 带电作业 work with live wire 运行/工作在不安全的速度operating working at unsafe speed人员作业方法错误Incorrect operation 使用

14、未批准的设备或者物料 unauthorized equipment or material 其它原因之具体描述Detailed description of other reasons 根本原因Root Reason：(管理上存在的问题，可复选other choices for the management problem)未配置防护装置not equipped with protective measures 设备自身缺陷 equipment design defect 未落实设备、设施的保养及检查Improper maintenance and inspection 未考虑到的新风险 ne

15、w risk which was not identified 人员不知道要求unaware requirement 人员未依规定操作Incorrect operation未订定操作标准No operation standard 未订定安全卫生工作守则No safety & health rules for working 其它原因之具体描述: Detailed description of other reasonsPart 2：事故之改善对策Accident/Incident Improvement Measures:改善对策Improvement measuresNO.改善对策I

16、mprovement Measures执行单位Operation company执行人员Operation people预估完成日期Predicted due date改善对策须针对根本原因分析的结果展开，要能从根本上消除或者减缓事故发生的可能性改善状况确认Confirm Improvement situation NO.改善状况Improving state改善后状况说明After improving state instruction确认人员Confirm people确认日期Finishing due dateOK NGOK NGOK NGOK NGOK NGOK NG备注Note：1.

17、改善状况确认之栏位由厂工安人员填写或因情况而定； The column of Confirm Improvement situation need be filled by EHS&S member.2.请针对各项改善对策分别进行确认其改善状况(改善完成勾选OK，未改善完成勾选NG)，并请加以说明其改善后之状况。 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., 事故处置状况评审Checking the handling condition请识别事故所属等级及现场处置状况是否妥当Please identify the accident/incident grades and the handling condition1.事故所属类型Accident type：损失工时伤害: 可记录伤害或疾病导致一天或多天脱岗，当事件发生之后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财产损失:财产损失超过2500美元Real property damage of more than $2500 USD 职业病: 除了由职业伤害引起的任何不正常的状态或失调，由接触环境因素引起的职业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. 外部机构走访：外部机构发起的因投诉，跟进事件，不符合或现场访问的调查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加仑(19升)危害物料泄漏或释放Hazardous Material Spill or release greater than 5 gallons (19 liters

21、)严重事件：任何伤害事件导致死亡，骨折，截肢或住院，环境事件需要报告给政府机构。Significant Incident: Any incident involving an injury that results in a fatality, fracture, amputation or hospitalization, environmental incidents requiring reporting to a government agency. 重大虚惊：一个事件,能够导致伤害或疾病、财产损失、泄漏或违规, 同时如果发生会导致一个严重事件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.事故之处理是否妥当Please check the accuracy for the handling condition of accident/incident. 妥当OK 不妥当NG (如勾选此项,请于3中做出说明) (If the handle

23、 results is not appropriately, please make solutions ) 3. 建议处理方式 Solutions：如果事故系因人为误操作/无权操作/越权操作而造成，请于3中评估说明对责任人的处理方式(此栏位由EHS人员填写written by EHS Dept)是否需进一步之改善 Y N Further Detailed Investigation Required? 如果”是”提供详细的适当的事故/事件的调查If Yes Provide details report of the appropriate Accident/Incident Investig

24、ation (此栏位由EHS人员填写written by EHS Dept)Part 3.事故之进一步改善建议 Further Improvements Suggestions Part 4. 损失估计 Losses evaluation 预估损失Predicted losses直接损失费用(以USD表示)Direct loss(by USD)合计(以USD表示)Total (by USD)人身损失费用Personal loss事故善后处理费用Incident subsequent solving cost财产损失费用Property loss医疗费用Medical cost歇工工资Be of

25、f duty salary现场抢救费用Rescue cost现场清理费用Cleaning cost罚款和赔偿费用Fine and compensate固定资产损失/修缮Permanent assets loss/maintenance流动资产损失Current assets loss4278.61间接损失费用(以USD表示)Indirect loss (by USD)合计(以USD表示)Total (by USD)停产损失Stop production loss其他费用Other cost其他费用(请说明)Other cost(Pls explain)：备注Note：1.医疗费用：系指员工因事

26、故而受伤，治疗期间之初估医疗费用。Medical cost: indicate the first evaluation medical losses of staff injured by incident during treatment.2.歇工工资：以该员工之(职级平均月薪/30)*歇工休养天数进行概略估算。Be off duty salary: imputed by (average salary /30)*be off duty days.3.现场抢救费用：指进行事故抢救时所衍生之费用，(如灭火器填充、紧急应变用品销耗等费用)。Rescue cost: cost derivativ

27、e when rescue the incident,(eg. fire extinguisher padding or emergent and response goods consumeetc. )4.现场清理费用：指事故发生后对事故现场进行清除处理之费用。Cleaning cost: cleaning cost for worksite after incident.5.罚款和赔偿费用Fine and Compensation：罚款：系指事故发生后，公司遭受政府单位依现行法令之规定进行罚款的费用；Fine: punished cost by government due to regulatory after incident.赔偿：系指事故发生后，公司赔偿给周遭受影响之居民或生产受影响之客户的费用。Compensation: company compensate the around impacted resident or customers whose production be impacted after incident.6.流动资产损失：系指在事故发生后造成公司之原材料、燃料、辅助材料、成品、半成品、在制品等损失之费用。Current assets loss: losses of raw materials, fuel