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Format No.

:
ANALYSIS OF ACCIDENT Rev. No / Date :
Name of the Person : EPF No. :
Location of Accident : Date Time
Nature of Injury Reasons
a. Near Miss Individual's Fault Improper machine Function
b. Minor Lack of knowldege Improper Layout
c. Fatal No safety guards Improper Ergonomics followed
d. Dead chemical / environmental effect Others
Action Taken Picture before corrective action Picture aftercorrective action
a. Training Conducted
b. Process Corrected
c. Machine Corrected
d. Layout changed
e.
g.
h.
i.
j.
k
l.
Comments :

Remarks :

HA -Admin GL-Production MR

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