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TH SAFETY OFFICER
TRAINING COURSE
MODULE IV
PRACTICAL ASSIGNMENTS
ON

ACCIDENT
INVESTIGATION
Date:
Company Address:

SUBMITTED BY
Name:
Home Address:
 CONTENTS
A. Type, nature of business & size of establishment

B. Objective

C. Particular of Company

D. Particular of the Accident

E. Particular of the Injury

F. Person Interviewed

G. Introduction

H. Description of the Accident

I. Observation & Comment

J. Root Cause

K. Recommendations

L. Appendix 1, Photographs
 Appendix 2, Interview victim
Appendix 3, Interveiw witness
Appendix 4, Interview supervisor

M. Accident Report

N. Accident & Incident Investigation Policy

B. Objective
 The objective of any accident investigation is to identify
the casual factors and recommend corrective actions
that will eliminate or minimize them. Investigators
should be objective and should avoid any emphasis on
identifying the individual(s) who could be blamed as this
jeopardizes the investigators’ credibility and
effectiveness.

C. Particular of the Company

1. Name of company : ABC Pte Ltd

2. Address of factory : 2, Woodlands Park

Singapore 1111111

3. Tel : 61234567

4. Factory No : 00366/1977-D
(12/31/1987)

5. Nature of work : Manufacturing of _______

D. Particular of the Accident

 1. Date & Time : 25/1/1996 @ 1230 a.m.

2. Location : Extrusion

3. Nature of Injury : Laceration of the left index finger

4. Type of Machinery : Bare cutter blade involved

E. Particular of the Injury

1. Name :

2. Address :

3. I/C : 8075879

4. Age : 43

5. Nationality : Malaysian

6. Sex : Female

7. Race : Indian

8. Occupation : Machine Operator

9. Working : 9 years
Experience

10 Residence Tel : 2348125

F. Person Interviewed
1. Name :
 Designation : Supervisor

2. Name :

Designation : Technician

G. Introduction
The extrusion department has a total of eight extruders. The
extruders are mainly used for tubing extrusion only. PVC resins are
mixed with plasticizers and other additives and the blend is then fed
to the extruders. The machine then extrudes tubing of different sizes
as required by the schedule.

The tubings are either cut or coiled by an auto spooler and collected
into the chute provided.

The operator will then pack the tubing into bundles and store them in
the rack.

It will then be transferred to the next operation - Set Final

Department.

H. Description of the Accident

 An machine operator was setting up m/c #2. The tubing was jammed at
the extruder head. She attempted to cut the jammed tubing by using a bare
cutter blade (cutter blade with no handle).

In the process, she accidentally cut her left index finger.

Immediately, she was sent to NUH for treatment and received four stitches
on her finger.

She was given 4 days MC by the doctor.

I. Observation & Comment

1. On January 26, 1996 at 8.30 a.m. the supervisor, Mark Chen and I visited the
scene of accident. He described the lost time accident. Photographs were taken
during his demonstration.(As per appendix 1)

2. By observed during the process of the operation, whenever the tubing jammed at
the extruder head the employee will shift the water trough aside. This is enable the
remaining tubing to be discharged. Subsequently, the employee will use a pair of
scissors to cut away the tubing. Thereafter, the operation will resume.

3. At the scene, I collected the Bare cutter blade and the scrap tubing with blood as an
evidence.

4. During the walk around, I had spotted another bare cutter blade lying on one
of the machine. This was left by an employee who had changed the cutter. (The
cutter blade is fitted in the machine for cutting the tubing). Immediately, the blade
was removed by me.

5. The changing of the cutter blade should be in the manner that one to one exchange
from the authorized personal and the used blade will then dispose in a container .

J. Root Cause
The root cause of the accident is injured was not issued with scissors.
 The immediate cause is the bare cutter blade that placed on the
machine which anybody can access to it.

K. Recommendations
* All tool issued to the employees are to be documented. This is served as a record
that employees have been issued the proper tools for their job.

* Employees should report to their supervisor immediately, if the scissors were

missing. So that the supervisor can make necessary arrangement to replace them.

* No others tools can be used to cut the tubing except the scissors only, it is the
best and safe method.

* Yearly refresher training to all the employees will be conducted to remind them
in the correct working method.

Appendix 1 :
 Appendix 2
Interview victim on Feb 8, at 0930 at
Temasek Room
I, Thangamma I/C: from Department. I have been working in the department for about 2
years.

Employee Statement:

Thangamma described the accident, that around 1230a.m she was setting up machine #2.
The tubing was jammed at the extruder head.

She asked the Technician(Raja) for a pair of scissors to cut the tubing in order to continue
the set up. Raja told her that she can use the scissors on the table at the other line.
However, instead she took a bare cutter blade which was lying beside the machine. While
cutting the tubing, accidentally, the blade slipped and as a result, she suffered a deep cut.
Initially, she thought it was a minor injury and received just first aid treatment from her
supervisor Mark . But the index finger was bleeding profusely and she had to be sent to
NUH. In NUH, she received four stitches.

Her hand is all right and getting back to normal ready.

I have been trained by my supervisor to clear the jam by using scissors.

That’s all!

Appendix 3
Interview witness on Feb 8, at 1000 at
Temasek Room
I, Raja, I/C: Department. I have been working in the department for about years.
Statement:

Raja mentioned that he witness the incident, which she was trying to cut the jammed
tubing by using a bare cutter blade. During that point of time I was at the next line in
machine #3. Thangamma ask me for a pair of scissors, but unfortunately that day I forgot
to bring my tool box key. Hence, I told her to take a pair of scissors from the table beside
machine #1.

I then continued to do my work until she shouted at me. I quickly went over and saw her
hand with lots of blood. Immediately, I informed our supervisor Mark Chen.

That’s all!

Appendix 4
Interview the Supervisor on Feb 8, at 1020 at
Temasek Room
I, Mark, I/C: is the supervisor in the Extrusion Department for ‘C’ shift. I have been
working in the department for about one year.
Statement:

I did not see how Thangamma was injured until my subordinate informed me.

After the first aid treatment, the blood still unable to stop fully and I decided to send her to
NUH for treatment.

She was trained by the department supervisor to use scissors to cut the tubing when need to
the jam. There was no document record on the procedures to clear the jam because it is
only hands on training.

All employees in the extrusion department were issued a pair of scissors for that purpose.
But there was no record when we issued to the employees.

That’s all!
ACCIDENT INVESTIGATION
1. Who ( was injured)?
Pangasmay, Machine operator with 2 years experience, working the third shift,
11.00p.m - 7.00a.m

2. What happened?
About 1230 a.m. on January 25, , the injured was setting up machine #2. The
tubing was jammed at the extruder head. She attempted to cut the jammed tubing by
using a bare cutter blade ( cutter blade with no handle).

3. Which part of body injured?

Laceration of the left index finger and received four stitches on her finger.

4. Where did the accident happened?

Extrusion

5. Facts gathering:
a. Visit the scene of accident.
Yes.On Jan 26, at 8.30 a.m

b. What are the evidence collected from the scene?

Bare cutter blade and the scrap tubing with blood.

c. Sketch or picture taken?

Photos was taken. Refer to Appendix 1.

d. Where are the (maintenance, training...) records?

There was no document record on the Job Instruction Breakdown(JIB) or
Job Safety Analysis(JSA).

e. Whose instruction or directive ( to remove, shift...)?

It is part of their routine job.

f. Interview witnesses.
Yes. Refer to the Appendix 2.

g. Interview victim.
Yes. Refer to the Appendix 3.

h. Interview the Supervisor.

Yes. Refer to Appendix 4.
6. What were the immediate cause of the accident?
Using of a Bare cutter blade.

7. Follow-up Action to prevent accident occurred:

Description Date of implementation
a. To emphasize during teamnotes session. Immediate
b. Prepare an JIB/JSA for setting-up of extruder lines. Feb,
c. To source a proper tool for cutting the tubing. Feb,
d. To conduct a survey to find out how many areas are Feb,
using the cutter blade, so that correct tool can be soured.
e. Remove the used blade immediately after changing of Immediate
blade for extruder cutter.
f. Publicize weekly safety message on this and past accidents March,
in the teamnotes.
g. Description of the accident and photos to be displayed on Feb,
the bulletin board.

Appendix 2
 Interview victim on Feb 8, 1996 at 0930 at
Temasek Room

Person Involved:
Statement:

Thangamma described the accident, that around 1230a.m she was setting up machine #2.
The tubing was jammed at the extruder head.

She asked the Technician(Raja) for a pair of scissors to cut the tubing in order to continue
the set up. Raja told her that she can use the scissors on the table at the other line.
However, instead she took a bare cutter blade which was lying beside the machine. While
cutting the tubing, accidentally, the blade slipped and as a result, she suffered a deep cut.
Initially, she thought it was a minor injury and received just first aid treatment from her
supervisor Mark Chen. But the index finger was bleeding profusely and she had to be sent
to NUH. In NUH, she received four stitches.

Questions by
1 How is your hand now?
2 How long have you been working in the
extrusion department?
3 Are you trained to clear the jam?
4 During the training, what type of tool
was used to cut the tubing?
5 Do you know that it is worng to use the
bare cutter for the job, it will cause
injury?
6 Has your supervisor issued you a pair of
scissors for the cutting?
Answers by
Well! It is all right and I am getting back
to normal already.
About 2 years.
Yes, I have been trained by my
supervisor.
Scissors.
Yes, But I just wanted to do it fast so
that the production can resume.
Moreover, the bare cutter was beside the
machine.
No, but there are a few scissors to be
shared within the department.

Appendix 3
 Interview witness on Feb 8, at 1000 at
Temasek Room
Person Involved:
Questions by
1 Did you witness the incident?
2 How did Thangramma got her finger
injured?
3 Where were you at that point of time?
4 Were you issued a pair of scissors?
5 Did she ask you for a pair of scissors?
6 What happened after that?
7 Why didn’t you stop her when she was
using the bare cutter?
Appendix 4
Interview the Supervisor on Feb 8, at 1020 at
Temasek Room
Answers by
Yes.
She was trying to cut the jammed tubing
by using a bare cutter blade.
I was at the next line in machine #3.
Yes. It was inside my tool box.
Yes. But that day I forgot to bring my
tool box key. Hence, I told her to take a
pair of scissors from the table beside
machine #1.
I continued to do my work until she
shouted at me. I quickly went over and
saw her hand with lots of blood.
Immediately, I informed our supervisor
Mark Chen.
It did not occur to me that she might get
injured.
Person Involved:
Questions by
1 Did you send Thangamma to NUH for
treatment?
2 Was she trained to clear the jam?
3 Was Thangamma issued a pair of
scissors?
4 Any record of this tool that was issued
to her?
5 Are you aware that Thangamma does
not have a pair of scissors?
6 Is there any document record on the
procedures to clear the jam?
Answers by
Yes.
Yes. She was trained by the supervisor
to use scissors to cut the tubing.
Yes. All employees in the extrusion
department were issued a pair of
scissors.
No.
Yes. I have noticed her borrowing
scissors from her peer. Infact, I have
raised a purchase order for it few days
ago before this incident.
No. Only hands on training.