事故調查報告

1、事故調查報告表Accident/lncident Investigation Form使用說明Guida nee1. 此事故調查報告表用于紀錄廠區(qū)所有事故的具體細節(jié).各廠必須報告實際事故的正式糾正措施（參考00-QS15-8520-100糾正與預防措施），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 & In vestig

2、atio n Process. SITES MUST ALSO REPORT ALL ACTUAL INCIDENTS ON A FORMAL CORRECTIVE ACTION （ref. 00-QS15-8520-100 Corrective and Preve ntive Actio n） AND UPLOAD TO GLOBAL ACCIDENT REPROT SYSTEM WHEN COMPLETED. A full 8D Corrective Actio n form is n ot required for minor in cide nts that do not have b

3、ear ing on the site en viro nmen tal aspects.2. 請使用本表格報告所有相關的事故或意外傷害，.完成第一局部并上報你的直接主管，他/她完成第二部份，識別岀適宜的糾正措施/措施責任人并于 5個工作日內遞交給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 id

4、entifying the appropriate corrective actions / action own ers and forward the form to EH&S Departme nt in five worki ng 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，對于傷亡事故以與需要住院治療的事故，工廠廠長在24小時內向ABC客戶進展匯報（紅色局部僅適用于生產(chǎn)ABC產(chǎn)品工廠區(qū)域）.Report opportu nity: The departme nt should in form EHS firstly whe n the accide n

5、t occurred. For in cide nt thatinvolve fatality or hospitalization, OPM should report the accident to ABC （text in red only applicable to factory area with ABC producti on）.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)相關事故時，廠區(qū)工安人員不須簽核）事故部門/單位主管t廠區(qū)環(huán)安衛(wèi)人員tEHS管理代表t Ops/ functional managerThe evaluat ing procedu

6、re for the accide nt/in cide nt:Unit head t Site EHS member t EHS representative t Ops/ functional manager5. 事故調查報告完成后，由EHS在24小時內將事故情況上報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

7、traffic accide nt outside the pla nt.6. 請于Ops/ functional manager簽核后，本表由廠區(qū)工安人員存查并進展改善追蹤與最后確認After the Ops/func ti onal man ager approval, it should be checked by the site EHS member.Part 1 :事故根本資料 Accident/lncident general data 填寫人Name 報告時間：事故CAPA編號:Report date:Accide nt/ln cide nt nu mber:根 本部門/單位：

8、Department:事故地點/區(qū)域：Accide nt/ln cide nt place:口資 Bas料當事人/卡號：職稱：in formatioName of the victim/ID nu mberJob title:目擊者：Witness :發(fā)生時間：Happening Time :現(xiàn)場訪談人員：Witn ess in terview事發(fā)時作業(yè)容：EmergencyTask Details :detailsAcci（Who:Whe n:Where:What:Why:。How:（1.交通事故請畫發(fā)生點之簡圖請以附件附于本報告之后。2.工安事故請附上事故現(xiàn)場照片與說明于本報告表之后。3.

9、發(fā)生過程的描述請采用5W1H勺方式進展。（1. Traffic accident need to draw the sketchof the accident/lncident place on the next page。2. The EHS related accident need to add thepcU/eSOindPreated introduction on the next page。 3. The accident description should take5W1H Method）r處置情揃an甜8組組TeamInvesName（）Title（職務）Dept.（部門）請

10、列出調查組成員與職務Team member listan alys過Proces分析因素Analysis Factor 原因Root CauseMan（人）Machine（機器）Material（物料） s of root causeMethod/Process (方法或制程)Environment環(huán)境The root cause:Why:Why:Why:You should此局部請采用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 take 5why method to an alyze the reas on that the accide nt happe ned and fi

11、nd the root cause 事故發(fā)生直接原因Cause of injury?被切、割、擦傷Cutti ng、Scratchi ng?被夾、卷 Rolli ng ?被撞 Kn ocki ng ?被扎 injured bysharp object ?被壓 crashed ?勞損 strain ?墜落、滾落 Dropping ?跌倒 Tumble ?觸電 Contact electricity ?被物體砸到Throwing ?碰到化學品或其他危險物質？燙傷燒傷Burning ?火災fire ?爆炸 Explosion?交通事故 Traffic accident?斗毆 fighting?盜竊

12、theft ?闖入 break?其它(請注明)others:發(fā)生原因Injury Reas on:(發(fā)生事故之不平安狀況與不平安行為，可復選 )(Other choices)?設備、設施設置不良Equipment unsafely ?不平安的環(huán)境如地面濕滑unsafe environment (i.e.slippery floor) ? 缺乏勞動保護用品(lack of PPE) ?重復性的動作 (repeated motions)?超負荷運行或者搬運過重物體overload ?所使用的工具不適宜in appropriate tool?保護裝置故障或者失效protective equipmen

13、t or setup malfunction? 整理不善 poor housekeeping? 不平安的姿勢或位置unsafe posture or position?帶電作業(yè) work with live wire?運行/工作在不平安的速度operati ng work ing at unsafe speed人員作業(yè)方法錯誤In correct operati on? 使用未批準的設備或者 物料 unauthorized equipment or materialReas on，?n 其它原因之具體描述Detailed descripti on of other reasons根本原因 Ro

14、ot Reas on :（管理上存在的問題，可復選other choices for the man ageme nt problem）? 未配置防護裝置 not equipped with protective measures? 設備自身缺陷 equipment design defect?未落實設備、設施的保養(yǎng)與檢查Improper maintenance and inspection?未考慮到的新風險 newrisk which was not identified? 人員不知道要求 unaware requirement ? 人員未依規(guī)定操作In correct operati on

15、?未訂定操作標準 No operation stan dard?未訂定平安衛(wèi)生工作守那么No safety & health rules for work ing? 其它原因之具體描述：Detailed description of other reasonsPart 2 :事故之改善對策 Accident/lncident Improvement Measures:改善r=r對measuFesImprovNO.改善對策Improveme nt Measures執(zhí)行單位Operati on compa ny執(zhí)行人員Operati on people預估完成日期Predicted due dat

16、eeme nt改善對策須針對根本原因分析的結果展開，要能從根本上消除或者減緩事故發(fā)生的可能性Con firmNO.改善狀況Improvi ng state改善后狀況說明After improving state in structi on確認人員Confirm people確認日期Finishing due date OK NG OK NG OK NG OK NG OK NGmprovee%tu0iNG備注Note :1. 改善狀況確認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

17、EHS&S member.2. 請針對各項改善對策分別進展確認其改善狀況（改善完成勾選 0K未改善完成勾選NG）,并請加以說明其改善后之狀況。Please con firm the improveme nt results accord ing to each improveme nt acti on pla n, select OK if thetask is finished, select NG if the task is not finished, and describe its current status.,事故處置狀況評審Check請識別事故所屬等級與現(xiàn)場處置狀況是否妥當Pl

18、ease ide ntify the accide nt/in cide nt grades and the han dli ng con diti on1. 事故所屬類型 Accident type :?損失工時傷害：可記錄傷害或疾病導致一天或多天脫崗，當事件發(fā)生之后Lost Time Injury:Recordable injury or ill ness that results in one (1) or more days away from work after theday on which the in cide nt occurred?財產(chǎn)損失：財產(chǎn)損失超過 2500 美元

19、Real property damage of more than $2500 USD?職業(yè)?。撼擞陕殬I(yè)傷害引起的任何不正常的狀態(tài)或失調，由接觸環(huán)境因素引起的職業(yè)OccupationalIllness: Any abnormal condition or disorder, other than one resulting from an occupationalinjury, caused by exposure to en viro nmen tal factors associated with employme nt.?外部機構走訪：外部機構發(fā)起的因投訴，跟進事件，不符合或現(xiàn)場訪問的

20、調查External Site Inquiryin itiated by a compla int, follow-up to an in cide nt, a non-complia nee, 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 greaterthan 5 gallons (19 liters)?嚴重事件：任何傷害事件導致死亡，骨折，截肢或住院，環(huán)境事件需要報告給政府機構。SgnificantIn cide nt: Any in cide nt in volvi ng an

21、injury that results in a fatality, fracture, amputati onor hospitalization, environmental incidents requiring reporting to a government agency.?重大虛驚：一個事件，能夠導致傷害或疾病、財產(chǎn)損失、泄漏或違規(guī),同時如果發(fā)生會導致一個嚴重事件Sign ifica nt Near Miss: An eve nt that could have resulted in an injury or ill ness, property damage, spill o

22、r non-compliances and if it had occurred would have resulted in a significant in cide nt2. 事故之處理是否妥當Please check the accuracy for the han dli ng con diti on of accide nt/in cide nt.?妥當OK?不妥當NG(如勾選此項,請于 3 中做岀說明)(If the handle results is not appropriately, please make solutions )ng the han dli ng con

23、diti on3. 建議處理方式Solutions :如果事故系因人為誤操作/無權操作/越權操作而造成，請于 3中評估說明對責任人的處理方式(此欄位由EHS人員填寫 written by EHS Dept)是否需進一步之改善丫N Further Detailed In vestigati on Required?如果是提供詳細的適當?shù)氖鹿?事件的調查f Yes Provide details report of the appropriate Accide nt/ln cide nt In vestigati on(此欄位由 EHS人員填寫 written by EHS Dept)Part 4

24、.損失估計 Losses evaluati onlosses間接損失費用(以USD表示)In direct loss (by USD)合(以 USDTotalUSD)計 表示)(by停產(chǎn)損失Stop producti on loss其他費用Other cost預估損失直接損失費用(以USD表示)Direct loss(by USD)合計(以USD表示)Total (by USD)人身損失費用Pers on al loss事故善后處理費用In cide nt subseque nt solv ingcost財產(chǎn)損失費用Property loss醫(yī)療費用Medical cost歇工工資Beoffd

25、uty salary現(xiàn)場搶救費 用Rescuecost現(xiàn)場清理費 用Clea ningcost罰款和賠償 費用Fineandcompe nsate固定資產(chǎn)損失/修繕Perma nent assetsloss/ma intenance流動資產(chǎn)損 失Curre nt assets lossPredicted4278.61其他費用(請說明)Other cost(Pls explain)備注Note :1. 醫(yī)療費用：系指員工因事故而受傷，治療期間之初估醫(yī)療費用。Medical cost: indicate the first evaluation medical losses of staff in

26、jured 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)進展概略估算。Be off duty salary: imputed by (average salary /30)*be off duty days.3. 現(xiàn)場搶救費用：指進展事故搶救時所衍生之費用，(如滅火器填充、緊急應變用品銷耗等費用)。Rescue cost: cost derivative whe n rescue the in cide nt,(eg. fire exti nguisher padd ing or emerge nt and espo

27、nse goods con sume etc.)4. 現(xiàn)場清理費用：指事故發(fā)生后對事故現(xiàn)場進展去除處理之費用。Clea ning cost: clea ning cost for worksite after in cide nt.5. 罰款和賠償費用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)定進展罰款的費用；Fine: puni shed cost by gover nment due to regulatory after in cide nt.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)受影響之客戶的費用。Compe nsati on: compa ny compe nsate the arou nd impacted reside nt or customers whose producti on be i