KST/MM Internal Investigation Incident Report - Full Investigation & 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 KST 31 KST 33 KST 35 KST 36 KST 56 KST 58 KST Kancil KST Kijang KST Liberty KST Passion KST Pride KST Sky KST Skill KST Super KST Stellar KST Success KST Summit KST Zodiac Maju 510 Maju 511 Maju Loyalty Maju Mars Maju Mercury

  • KST 31
  • KST 33
  • KST 35
  • KST 36
  • KST 56
  • KST 58
  • KST Kancil
  • KST Kijang
  • KST Liberty
  • KST Passion
  • KST Pride
  • KST Sky
  • KST Skill
  • KST Super
  • KST Stellar
  • KST Success
  • KST Summit
  • KST Zodiac
  • Maju 510
  • Maju 511
  • Maju Loyalty
  • Maju Mars
  • Maju Mercury

• Incident Type (select all that apply)

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

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

  • 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

• 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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