事故调查研究报告

事故调查汇报表Accident/IncidentInvestigationForm使用说明使用说明Guidance1.此事故调查汇报表用于纪录厂区全部事故具体细节.各厂必需汇报实际事故正式纠正方法(参考00-QS15-8520-100纠正和预防方法),并在完成时上报Global事故上报系统.和环境原因没相关系事故不需填写全部8D纠正方法.ThisformisfortherecordingofallkindoftheIncidentsasdetailedintheSiteAccident&IncidentReporting&InvestigationProcess.SITESMUSTALSOREPORTALLACTUALINCIDENTSONAFORMALCORRECTIVEACTION(ref.00-QS15-8520-100CorrectiveandPreventiveAction)ANDUPLOADTOGLOBALACCIDENTREPROTSYSTEMWHENCOMPLETED.Afull8DCorrectiveActionformisnotrequiredforminorincidentsthatdonothavebearingonthesiteenvironmentalaspects.2.请使用本表格汇报全部相关事故或意外伤害，.完成第一部分并上报你直接主管,她/她完成第二部份,识别出适宜纠正方法/方法责任人并于5个工作日内递交给EHS部门.Pleaseusethisformtoreportallincidents(nearmisses)oraccidentaldamage.CompletePart1andpasstoyourimmediatemanager,he/shewillthencompletepart2identifyingtheappropriatecorrectiveactions/actionownersandforwardtheformtoEH&SDepartmentinfiveworkingdays.3.汇报时限:事故发生单位必需在事故发生后第一时间向EHS汇报，对于伤亡事故和需要住院诊疗事故，工厂厂长在24小时内向ABC用户进行汇报(红色部分仅适适用于生产ABC产品工厂区域).Reportopportunity：ThedepartmentshouldinformEHSfirstlywhentheaccidentoccurred.Forincidentthatinvolvefatalityorhospitalization,OPMshouldreporttheaccidenttoABC(textinredonlyapplicabletofactoryareawithABCproduction).4.本表由事故单位现场主管(经理，副理）填写后，依下面步骤签核。(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/functionalmanagerTheevaluatingprocedurefortheaccident/incident:Unithead→SiteEHSmember→EHSrepresentative→Ops/functionalmanager5.事故调查汇报完成后，由EHS在二十四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。Aftertheaccidentinvestigationreportcompleted,EHSmembershoulduploadthemtoourglobalaccidentreportsystemin24hours,exceptthetrafficaccidentoutsidetheplant.6.请于Ops/functionalmanager签核后，本表由厂区工安人员存查并进行改善追踪及最终确定.AftertheOps/functionalmanagerapproval,itshouldbecheckedbythesiteEHSmember.Part1：事故基础资料Accident/Incidentgeneraldata填写人Name：汇报时间：事故（CAPA）编号：格式为EHSxxxxxx格式为EHSxxxxxx例：EHS150102Reportdate:Accident/Incidentnumber:基础资料Basicinformation部门/单位：Department：事故地点/区域：Accident/Incidentplace：当事人姓名/卡号：Nameofthevictim/IDnumber：职称：Jobtitle:目击者没有就写“无”：没有就写“无”Witness：发生时间：HappeningTime：现场访谈人员：Witnessinterview事发时作业内容：EmergencyTaskDetails：发生过程描述Accident/IncidentdetailsWho:When:Where:What:Why:。How:(1.交通事故请画发生点之简图请以附件附于本汇报以后。2.工安事故请附上事故现场照片及说明于本汇报表以后。3.发生过程描述请采取5W1H方法进行。(1.Trafficaccidentneedtodrawthesketchoftheaccident/Incidentplaceonthenextpage。2.TheEHSrelatedaccidentneedtoaddthepicturesandrelatedintroductiononthenextpage。3.Theaccidentdescriptionshouldtake5W1HMethod)处理情形Handlingcondition写明处理经过和处理结果写明处理经过和处理结果调查小组（InvestigationTeam）Name(姓名)Title(职务)Dept.(部门)（请列出调查组组员名单及职务Teammemberlist）原因分析过程Processofrootcauseanalysis分析原因（AnalysisFactor）原因（RootCause）Man(人)Machine(机器)Material(物料)Method/Process(方法或制程)Environment（环境）Why:Why:Why:Why:TherootcauseTherootcause:Why:Why:Why:Why:Why:不一定是5个不一定是5个WHY,可视情况增加此部分请采取5why方法分析事故发生原因，找出事故发生根本原因（Youshouldtake5whymethodtoanalyzethereasonthattheaccidenthappenedandfindtherootcause）原因分析Reasonanalysis事故发生直接原因Causeofinjury：☐被切、割、擦伤Cutting、Scratching☐被夹、卷Rolling☐被撞Knocking☐被扎injuredbysharpobject☐被压crashed☐劳损strain☐坠落、滚落Dropping☐跌倒Tumble☐触电Contactelectricity☐被物体砸到Throwing☐碰到化学品或其它危险物质☐烫伤烧伤Burning☐火灾fire☐爆炸Explosion☐交通事故Trafficaccident☐斗殴fighting☐偷窃theft☐闯进break☐其它(请注明)others:发生原因InjuryReason：(发生事故之不安全情况及不安全行为，可复选)(Otherchoices)☐设备、设施设置不良Equipmentunsafely☐不安全环境（如地面湿滑）unsafeenvironment(i.e.slipperyfloor)☐缺乏劳动保护用具(lackofPPE)☐反复性动作(repeatedmotions)☐超负荷运行或搬运过重物体overload☐所使用工具不适宜inappropriatetool☐保护装置故障或失效protectiveequipmentorsetupmalfunction☐整理不善poorhousekeeping☐不安全姿势或位置unsafepostureorposition☐带电作业workwithlivewire☐运行/工作在不安全速度operatingworkingatunsafespeed人员作业方法错误Incorrectoperation☐使用未同意设备或物料unauthorizedequipmentormaterial☐其它原因之具体描述Detaileddescriptionofotherreasons根本原因RootReason：(管理上存在问题，可复选otherchoicesforthemanagementproblem)☐未配置防护装置notequippedwithprotectivemeasures☐设备本身缺点equipmentdesigndefect☐未落实设备、设施保养及检验Impropermaintenanceandinspection☐未考虑到新风险newriskwhichwasnotidentified☐人员不知道要求unawarerequirement☐人员未依要求操作Incorrectoperation☐未订定操作标准Nooperationstandard☐未订定安全卫生工作守则Nosafety&healthrulesforworking☐其它原因之具体描述:DetaileddescriptionofotherreasonsPart2：事故之改善对策Accident/IncidentImprovementMeasures:改善对策ImprovementmeasuresNO.改善对策ImprovementMeasures实施单位Operationcompany实施人员Operationpeople预估完成日期Predictedduedate改善对策须针对根本原因分析结果展开，要能从根本上消除或减缓事故发生可能性改善情况确定ConfirmImprovementsituationNO.改善情况Improvingstate改善后情况说明Afterimprovingstateinstruction确定人员Confirmpeople确定日期Finishingduedate□OK□NG□OK□NG□OK□NG□OK□NG□OK□NG□OK□NG备注Note：1.改善情况确定之栏位由厂工安人员填写或因情况而定；ThecolumnofConfirmImprovementsituationneedbefilledbyEHS&Smember.2.请针对各项改善对策分别进行确定其改善情况(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情况。Pleaseconfirmtheimprovementresultsaccordingtoeachimprovementactionplan,selectOKifthetaskisfinished,selectNGifthetaskisnotfinished,anddescribeitscurrentstatus.,事故处理情况评审Checkingthehandlingcondition请识别事故所属等级及现场处理情况是否妥当Pleaseidentifytheaccident/incidentgradesandthehandlingcondition1.事故所属类型Accidenttype：☐损失工时伤害:可统计伤害或疾病造成一天或多天脱岗，当事件发生以后LostTimeInjury:Recordableinjuryorillnessthatresultsinone(1)ormoredaysawayfromworkafterthedayonwhichtheincidentoccurred☐财产损失:财产损失超出2500美元Realpropertydamageofmorethan$2500USD☐职业病:除了由职业伤害引发任何不正常状态或失调，由接触环境原因引发职业OccupationalIllness:Anyabnormalconditionordisorder,otherthanoneresultingfromanoccupationalinjury,causedbyexposuretoenvironmentalfactorsassociatedwithemployment.☐外部机构走访：外部机构提议因投诉，跟进事件，不符合或现场访问调查ExternalSiteInquiryinitiatedbyacomplaint,follow-uptoanincident,anon-compliance,oron-sitevisit☐物料泄漏:大于5加仑(19升)危害物料泄漏或释放HazardousMaterialSpillorreleasegreaterthan5gallons(19liters)☐严重事件：任何伤害事件造成死亡，骨折，截肢或住院，环境事件需要汇报给政府机构。SignificantIncident:Anyincidentinvolvinganinjurythatresultsinafatality,fracture,amputationorhospitalization,environmentalincidentsrequiringreportingtoagovernmentagency.☐重大虚惊：一个事件,能够造成伤害或疾病、财产损失、泄漏或违规,同时假如发生会造成一个严重事件SignificantNearMiss:Aneventthatcouldhaveresultedinaninjuryorillness,propertydamage,spillornon-compliancesandifithadoccurredwouldhaveresultedinasignificantincident2.事故之处理是否妥当Pleasechecktheaccuracyforthehandlingconditionofaccident/incident.☐妥当OK☐不妥当NG(如勾选此项,请于3中做出说明)(Ifthehandleresultsisnotappropriately,pleasemakesolutions)3.提议处理方法Solutions：假如事故系因人为误操作/无权操作/越权操作而造成，请于3中评定说明对责任人处理方法(此栏位由EHS人员填写writtenbyEHSDept)是否需深入之改善YFORMCHECKBOX NFORMCHECKBOXFurtherDetailedInvestigationRequired?假如”是”提供具体合适事故/事件调查If‘Yes’–ProvidedetailsreportoftheappropriateAccident/IncidentInvestigation(此栏位由EHS人员填写writtenbyEHSDept)Part3.事故之深入改善提议FurtherImprovementsSuggestionsPart4.损失估量Lossesevaluation预估损失Predictedlosses直接损失费用(以USD表示)Directloss(byUSD)累计

(以USD表示)Total(byUSD)人身损失费用Personalloss事故善后处理费用Incidentsubsequentsolvingcost财产损失费用Propertyloss医疗费用Medicalcost歇工工资Beoffdutysalary现场抢救费用Rescuecost现场清理费用Cleaningcost罚款和赔偿费用Fineandcompensate固定资产损失/修缮Permanentassetsloss/maintenance流动资产损失Currentassetsloss4278.61间接损失费用(以USD表示)Indirectloss(byUSD)累计

(以USD表示)Total(byUSD)停产损失Stopproductionloss其它费用Othercost其它费用(请说明)Othercost(Plsexplain)：备注Note：1.医疗费用：系指职员因事故而受伤，诊疗期间之初估医疗费用。Medicalcost:indicatethefirstevaluationmedicallossesofstaffinjuredbyincidentduringtreatment.2.歇工工资：以该职员之(职级平均月薪/30)*歇工休养天数进行概略估算。Beoffdutysalary:imputedby(averagesalary/30)*beoffdutydays.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、紧急应变用具销耗…等费用)。Rescuecost:costderivativewhenrescuetheincident,(eg.fireextinguisherpaddingoremergentandresponsegoodsconsume…etc.)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。Cleaningcost:cleaningcostforworksiteafterincident.5.罚款和赔偿费用FineandCompensation：罚款：系指事故发生后，企业遭受政府单位依现行法令之要求进行罚款费用；Fine:punishedcostbygovernmentduetoregulatoryafterincident.赔偿：系指事故发生后，企业赔偿给周遭受影响之居民或生产受影响之用户费用。Compensation:companycompensatethearoundimpactedresidentorcustomerswhoseproductionbeimpactedafterincident.6.流动资产损失：系指在事故发生后造成企业之原材料、燃料、辅助材料、成品、半成品、在制品等损失之费用。Currentassetsloss:losses