DOCUMENT REFERENCE HSE MANAGEMENT SYSTEM LTZ ENTERPRISE (PTY) LTD HSEMS/AIMP/CDC/3336/19 ACCIDENT / INCIDENT MANAGEMENT PLAN ACCIDENT / INCIDENT INVESTIGATION REPORT PROJECT NO. PRINCIPAL CONTRACTOR DATE REVISION 00 PAGE 1 OF 3 REPORT NO. SECTION A - INCIDENT CLASSIFICATION (MARK WITH AN “X”) TYPE INJURY EQUIP DAMAGE NEAR MISS DATE FIRE TIME SPILL RELEASE OTHER SPECIFY LOCATION SECTION B: INJURY CLASSIFICATION (MARK WITH AN “X”) FIRST AID MINOR INJURY – FIRST AID MINOR INJURY - MEDICAL TREATMENT MEDICAL TREATMENT CASE – RESTRICTED (LIGHT DUTY) MEDICAL TREATMENT CASE - RESTRICTED (LOSS TIME INJURY) MEDICAL TREATMENT CASE - REPORTABLE (DEPARTMENT OF LABOUR) FATALITY – REPORTABLE (DEPARTMENT OF LABOUR) SECTION C - PRELIMINARY INCIDENT/ACCIDENT INVESTIGATION DOCUMENTATION (FIND ATTACHED) NOTIFICATION OF INCIDENT / ACCIDENT – FLASH REPORT ANNEXURE 1 IDENTIFICATION COPY OF INJURED PERSON/S MEDICAL FITNESS CERTIFICATE OF INJURED PERSON/S LETTER OF GOOD STANDING FEM FORMS ACCIDENT/ INCIDENT STATEMENT (WITNESS) SECTION D - AFFECTED PERSON INFORMATION NAME OF INJURED: CO. NO # HOME ADDRESS: ID NUMBER COMPANY DIRECT SUPERVISOR COMPANY JOB TITLE YEARS IN POSITION JOB SPECIFIC TRAINING YES NO INDUCTION TRAINING MEDICAL CERTIFICATE OF FITNESS YES NO YES NO TASK/ ACTIVITY BODY PART AFFECTED HEAD OR NECK EYE TRUNK FINGER HAND ARM FOOT LEG MULTIPLE INTERNAL INJURY TYPE TREATMENT GIVEN SECTION E - INVESTIGATION NAME OF INVESTIGATOR: CO. NO # DOCUMENT REFERENCE HSE MANAGEMENT SYSTEM LTZ ENTERPRISE (PTY) LTD HSEMS/AIMP/CDC/3336/19 ACCIDENT / INCIDENT MANAGEMENT PLAN ACCIDENT / INCIDENT INVESTIGATION REPORT REVISION 00 PAGE 2 OF 3 COMPANY DESCRIPTION OF INCIDENT Reportable To DOL SAPS Reportable Yes No Yes No DOL Diary No. Name of Inspector: SAPS OB Entry Name of Police Inspector: SAPS Case No Police Inspector Contact No: EQUIPMENT, TOOLS, PLANT AND MACHINERY USED POSITION OF PEOPLE AND PARTS RELEVANT TO WORKING ENVIRONMENT SECTION F – ROOT CAUSE ANALYSIS CONSEQUENCES/ LOSSES TYPE OF INCIDENT RESULTING FROM INCIDENT CONTRIBUTION FACTORS UNSAFE ACT ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Operating without authority Operating at unsafe speeds Making safety devices inoperative Using unsafe equipment Tool wrong for the job Tool used incorrectly Unsafe loading / placing / mixing Unsafe position Working on unsafe equipment Working on moving equipment Horse playing / teasing / distracting Safety Regulation ignored Failure to use protective equipment. Other UNSAFE CONDITIONS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Guarding inadequate Unguarded Defective tools / equipment / substance Hazardous arrangement Unsafe design / construction Poor lighting Poor floor condition Poor ventilation ❑ Other ROOT CAUSES HUMAN BEHAVIOUR WORKING ENVIRONMENT FACTORS SECTION G - CORRECTIVE ACTION Date planned to be implemented DESCRIPTION ACTION TAKEN BY SECTION H - NOTES Actual date implemented HSE MANAGEMENT SYSTEM LTZ ENTERPRISE (PTY) LTD ACCIDENT / INCIDENT MANAGEMENT PLAN ACCIDENT / INCIDENT INVESTIGATION REPORT DOCUMENT REFERENCE HSEMS/AIMP/CDC/3336/19 REVISION 00 PAGE 3 OF 3 SITE RESPONSIBLE PERSON LINE / DIRECT SUPERVISOR SITE SAFETY OFFICER / INVESTIGATOR EFFECTED PERSON/S SIGNATURE SIGNATURE SIGNATURE SIGNATURE DATE DATE DATE DATE