RIGEL METALCRAFT (M) SDN BHD

ACCIDENT INVESTIGATION FORM

I. GENERAL INFORMATION OF INVESTIGATION (MAKLUMAT AM PENYIASATAN) Date (Tarikh)
Investigation Team
(Nama Penyiasat)
Name of Victim Injury
(Nama Mangsa) (Kecederaan)
Department/ Section/ Position Number of safety and health training attended
Number of days the victim doing the same (Bilangan kursus keselamatan dan kesihatan
(Jabatan / Bahagian / Jawatan) task before accident (Bilangan hari mangsa yang dihadiri)
melakukan tugas yang sama sebelum
kemalangan)

II. DETAIL OF ACCIDENT (MAKLUMAT KEMALANGAN) Date & Time (Tarikh & Masa)
Agent Causing Accident
(1)
Operational Form (Jenis operasi kerja)
Accident Classification
(Jenis Kemalangan)

(Agen Kemalangan) Circle relevant item PPE used

(Bulatkan yang berkenaan) (APD yang dipakai)
Type of Accident
(2)

(Jenis Kemalangan) Task performed by one person/ more

Days Lost From (Dari) than one person
(Kerja dilakukan seorang/ lebih dari
(Jumlah hari) To (Hingga) seorang)
III. INVESTIGATION OUTCOME (HASIL SIASATAN)
Accident Photo or Illustration
(Keadaan Tempat
Accident Scene

(Gambar atau lakaran kemalangan)

Kemalangan)
Condition of

Root Cause & Causal Factor of Accident

(Punca Utama dan Penyebab Langsung Kemalangan)

Corrective Action (Tindakan Pembetulan)

Target to Complete (Tarikh Dijangka Siap)

Prepared by: Verified by: Approved by:

__________________________ __________________________________ __________________________________

Name: Name: Name:
Remark:
(1) Agent Causing Accident (e.g. Machines; materials, substances & radiations; means of transport & lifting equipment; working
environment; other equipment; tools…)
(2) Type of Accident (e.g. Caught in or between objects; exposure to or contact with extreme temperatures/ electric current/
harmful substances/ radiations; falls; overexertion or strenuous movement; stepping on, striking against or struck by objects)

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