RAJAWALI UTARA SDN BHD Form No.

: RU-FF-077

INCIDENT NOTIFICATION FORM Revision No: 1

Effective Date: 28/04/2017

1 Notification Owner details

Report Date / Time Name: 12 November
2 April 2020 2019 Incident Date / Time: 11 Nov 2019@1600
17:30Hrs

Reported By: Mr. Alistair

Mr. Rama Payeng
(Site Engineer)

Reported To: Mr. Polycarp Danson Anak Sigai

(Bumi Utara Construction Staff Only)

Reported By:
Non Employee Type:
Company
(if not Staff - Client/Contractor/Labour Name
Hire/Visitor)

2 Notification Details
Exact Location: Abutment
Bukit MekayBCH23+700km
Sg. Punan Bah
What Happened
Doingaccident
Lorry troubleshooting
and overturnofatPiling Rig.ofAssist
thr middle Chief Mechanic shaft, his left hand hit by hammer while working on
the road.
11.11.19 at 1600hrs.
Potential Consequence / Explain what could have happened?
Preparing
Lost controlto install
due Piling
to slippery Rigdue
road shaft, heFurthermore,
to rain. helping holding thejust
the road shaft,
been while chief
compact mechanic
by roller preparing
compactor . to hammer the
shaft. But, suddenly the shaft moved out and the Chief Mechanic unable to control the hammer and hit his left
hand which holding
Responsible the shaft.
Supervisor: Ling

Is this a work related incident? X Yes No

Justification if not work related:

Immediate Actions Taken:

Was sent to nearby Government Clinic to received immediate treatment.
Report the incident and check for injuries

Were they any Other Involved Persons / Witnesses to the incident? Mr.
Hii Rama
Ting Sing
- Site(Chief Mechanic) - 0178987618
Engineer

3 Incident Type / Consequence

Incident Type (Please tick):
Personal Damage Actual Near Miss (Go to Section 4.1)
Environmental Damage Actual Near Miss (Go to Section 4.2)
Plant / Equipment Damage (Go to Section 4.3)
Non SHE Event Only (Operational) (Go to Section 4.4)

He is refered to Kapit or Sibu hospital for further treatment@x-ray.

2017-04 Page 1 of 1 RU-FF-077

 RAJAWALI UTARA SDN BHD Form No.: RU-FF-077

INCIDENT NOTIFICATION FORM Revision No: 1

Effective Date: 28/04/2017

4 Incident Consequence Specific Details

4.1 Personal Damage Actual or Near Miss
Details of Injured Person
1. Robertson Department of injured Metah Camp Site
Name: Ng. Sama site
Lee Anak Sanggai
2. Chandra Person
General Worker
1. Lorry driver Bumi Utara S/B
Job Title / Occupation: 2. Excavator operator Company Name Rajawali Construction

Summary of injury / Illness: 1. Robert

Base of having lowerfinger
left little back pain
and proximal phalanx fracture.
2. Chandra having small cut/wound on his left knee

Initial Treatment:
1.Robertson - Diagnosis as soft tissue injury and given 4 days MC by Kapit Hospital
Close manual
2.Chandra reduction(CMR)
- Wound and buddy splint. Doctor suggest for surgical but patient wanted to try
having 3 stitches
conservative management first 1.and non-surgical treatment. Next appointment for x-ray is 19 Nov 2019

Shift / Working Hours Details

Type of Employment (Please tick):

Full time casual Full time permanent
Part time casual Part time permanent
Contractor

Shift / Start Time (Please tick): 0600 - 1159 1200 - 1559

Roster Arrangement (Please tick): 1 week roster – 5 days on 2 days off

2 week roster – 9 days on 5 days off

3 week roster – 14 days on 7 days off

Other, please specify:
Consecutive Days Worked:

Average Daily Hours (Please tick): 8 hours or less 8-10 hours 10-12 hours
12-14 hours 14 hours or more

Proportion Shift Worked (Please tick): 25% or less 26% - 50% 51% - 75%

76% - 100% Overtime

Workers experience in Task (in months) :
Hours Awake (Please tick): 1-5 hours 6-10 hours 11-15 hours 16-20 hours 21 hours
or more

Sleep Opportunities

Hours of sleep in the last 24 hours: 1 hour 2 hours 3 hours 4 hours

5 hours 6hours 7 hours 8 hours or more

Hours of sleep within 24 to 48 hours: 1 hour 2 hours 3 hours 4 hours

5 hours 6hours 7 hours 8 hours or more

2017-04 Page 2 of 1 RU-FF-077

 RAJAWALI UTARA SDN BHD Form No.: RU-FF-077

INCIDENT NOTIFICATION FORM Revision No: 1

Effective Date: 28/04/2017

4.2 Environmental Damage Actual or Near Miss

Environmental Details

Impact loss / Type (please Tick)

AIR - Dust, Odour & Emissions RES – Impact on Availability of Resources

ESC - Erosion and Sediment WAS - Waste (Solids, liquids, hazardous and non-hazardous)

FF - Flora and Fauna WAT - Discharges to Surface Waters

HER- Heritage ASS – Acids Sulphates Soils

CON - Contamination to Land & Groundwater DMR – Dirt and Mud on Public Roads
NVL - Noise and Vibration

Details of Environmental Impact:

N/A

Estimated Damage/Repair Cost ($): N/A Was this a Complaint? N/A

4.3 Plant Equipment Damage or Failure

Damage Failure Mobile Fixed Description of Plant / Equipment: Hino FM500 Truck

Damage Details: 1.Right door window broken.

N/A 2.Windscreen plug out but no cracking or broken sign.
3.Bucket alignment out.
4.Clutch malfunction
5.Scratches on right side.

Estimated Damage Cost: Level 1 - >$100K Level 2 - $10K-$100k

Level 3 - $1K-$10K Level 4 - <$1K

Type/Model: HINO - FM2PNPD -13816 Year: 2004

Owner Details: Registration Number: Asset Number:

Name:

Signature: _ _ _ Date:

2017-04 Page 3 of 1 RU-FF-077