KSP/Kejora Internal Investigation Incident Report

• Document No.

• Audit Title

• Client / Site / Project

• Investigation conducted on

  Date

• Prepared by

• Location
  Address

Incident Details

• Date & Time of Incident

  Date
• Location of Incident
  Address

• Incident Severity?

  Urgent

  High

  Medium

  Low

  Trivial

• Vessel Name

  Select Kejora Salvo Kejora Indah Kejora Sunrise Kejora Sutra Kejora 41 Kejora 42 Kejora Space Kejora PTP 81 Kejora PTP 82 Kejora Spring Kejora 57 Kejora 59 Kejora Dua Kejora Tujuh Kejora Enam Kejora Lekir Kejora Lima Kejora Prosper Kejora Tuah 4 KSP 43 KSP 44 KSP Leo KSP Libra KSP Phoenix KSP Pisces KSP Scorpius KSP Sculptor KSP Success KSP Summit KSP Sun KSP Virgo KSP Virtue KSP Zenith KSP Pioneer KSP Victory KSP Verona KSP Venus

  • Kejora Salvo
  • Kejora Indah
  • Kejora Sunrise
  • Kejora Sutra
  • Kejora 41
  • Kejora 42
  • Kejora Space
  • Kejora PTP 81
  • Kejora PTP 82
  • Kejora Spring
  • Kejora 57
  • Kejora 59
  • Kejora Dua
  • Kejora Tujuh
  • Kejora Enam
  • Kejora Lekir
  • Kejora Lima
  • Kejora Prosper
  • Kejora Tuah 4
  • KSP 43
  • KSP 44
  • KSP Leo
  • KSP Libra
  • KSP Phoenix
  • KSP Pisces
  • KSP Scorpius
  • KSP Sculptor
  • KSP Success
  • KSP Summit
  • KSP Sun
  • KSP Virgo
  • KSP Virtue
  • KSP Zenith
  • KSP Pioneer
  • KSP Victory
  • KSP Verona
  • KSP Venus

• Incident Type (select all that apply)

  Select Hazard Near-Miss Slip & Fall Accident Injury Theft Fire Property Damage Fatality Illness Loss Time Pollution Others

  • Hazard
  • Near-Miss
  • Slip & Fall
  • Accident
  • Injury
  • Theft
  • Fire
  • Property Damage
  • Fatality
  • Illness
  • Loss Time
  • Pollution
  • Others

• Please describe type of incident

• Type of work

• Type of vessel that was involve in the incident (Third party)

• Name of all personnel on-duty at time of incident?

• Was medical attention administered?

  Yes

  No

• What kind of medical attention was administered?

  Select First Aid Doctor Consulted Hospital Ambulance Medical Attention Declined

  • First Aid
  • Doctor Consulted
  • Hospital
  • Ambulance
  • Medical Attention Declined

• Please provide all details of the medical attention rendered

Incident Summary

• Describe what happened. Please be detailed but state only facts.

• What were the weather / environmental conditions at the time of the incident?

  Select Clear Cloudy Rain Windy Haze Foggy

  • Clear
  • Cloudy
  • Rain
  • Windy
  • Haze
  • Foggy

• Cause( s ) of incident:

• Immediate Action

Evidence and Attachments

• Please attach video or picture evidence

  Media

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• Please add any corrective actions to the appropriate questions above before completing this incident investigation

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

Root Cause Analysis / Contributing Factors

• What were the contributing factors to this incident occurring? (select all that apply)

  Select Equipment Defects Unauthorized Equipment Use Improper Equipment Use Lack of protective safety devices Employee operating at inappropriate speed Equipment used outside rated capacity Lack of PPE Inappropriate PPE Untidy Conditions (Poor Housekeeping) Safety procedures not followed Inadequate ventilation Drugs or Alcohol Fatigue Miscommunication

  • Equipment Defects
  • Unauthorized Equipment Use
  • Improper Equipment Use
  • Lack of protective safety devices
  • Employee operating at inappropriate speed
  • Equipment used outside rated capacity
  • Lack of PPE
  • Inappropriate PPE
  • Untidy Conditions (Poor Housekeeping)
  • Safety procedures not followed
  • Inadequate ventilation
  • Drugs or Alcohol
  • Fatigue
  • Miscommunication

• A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

• Has the root cause of this issue been able to be identified?

  Yes

  No

  N/A

• Why is the root cause for this issue unable to be identified at this time?

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

• What is the root cause of this incident? Please consider and include all contributing factors

• Has the root cause of this issue been rectified or eliminated?

  Yes

  No

• How was the root cause rectified or eliminated?

• Please attach any relevant photos or media

  Media

• Please provide any relevant further details

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

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• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

• Name & Signature of Investigator

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