Doc.code FM-HSE-001-Rev.

01
ACCIDENT/INCIDENT
Rev. 0
INVESTIGATION REPORT
FORM Effectivity January 4, 2023

Account Name: ST. LUKES BGC Control No.

Account Location: BGC TAGUIG Date: APR. 04, 2024

INCIDENT/ ACCIDENT CLASSIFICATION:

( ) Fatality ( ) Medical Treatment (X ) First Aid Treatment ( ) Near Miss ( ) Fire
( ) Property damage ( ) Property Loss ( )Pilferage ( ) Others: ___________________
_________________

ACCIDENT/INCIDENT INFORMATION:
___

Date and Time when the Accident/Incident happened: Equipment/Machinery/Tools Involved:

April 04, 2024/ 7:32PM AHU-6F-074A
Exact Location of the Accident/Incident: Witnesses or Others Involved:
AHU MECHANICAL ROOM 1, 6TH FLOOR
_______________________________

INVOLVED EMPLOYEE INFORMATION:

Employees Name: Age: Sex: Civil Status: Position: Assigned Work:
ARNEL SUMAMPON 34 M SINGLE HVAC TECH QUARTERLY PM AHU
Job at time of injury: Year of experienced: Length of service in the company:
HVAC TECH 5 MONTHS
Contact number 0938 492 4350
Address MC7 Unit 506 Pamayanang Diego Silang Ususan Taguig City

MEDICAL TREATMENT INFORMATION: (Put “NA” if not applicable)

Date and Time of Treatment: Nature of Injury or Illness:
April 04, 2024 CAUGHT BY
Medical Findings: Attended by: FIRST AIDER
LACERATION ON LEFT FOOT FINGER ( LATERAL )
Treatment Given: Final Fit to Work
Pain reliever and Anti tetanus, gave anti biotics and Recommendation: Restricted Work
undergo X-ray For Further Treatment (Hospitalized)
_____________________________________________________________________________________________________________________________ __________

DESCRIPTION OF ACCIDENT/INCIDENT:
Encountered accident at Mechanical Room 1 6th flr. Around 7:32 PM today, HVAC technician was doing Quarterly
Preventive Maintenance of AHU 6F-07A. Safety Shoes of Technician got stuck in the tight portion of AHU during in the
middle of their maintenance. When he tried to pull it out, he got out of balance. So, the safety shoes were left behind
on the corner of the base of motor. His left foot hit the sharp edge of the motor causing lacerations on 2 left fingers
on his foot. Immediately applied First aid on site by Technical Supervisor and Engineer. But also take it to the nearest
clinic for a checkup and medical treatment if necessary.
Upon check up and X-ray, Doctor gave anti-tetanus for the wound and anti-biotics only.

1
 Doc.code FM-HSE-001-Rev.01
ACCIDENT/INCIDENT
Rev. 0
INVESTIGATION REPORT
FORM Effectivity January 4, 2023

Evidence(s):

X Interview/Interrogation Physical Evidence Photo(s) Statement of witnesses

IDENTIFY THE CONTRIBUTING FACTORS:

MANPOWER MACHINE
SAFETY SHOES WAS NOT TIED CORRECTLY,
BEHAVIORAL ISSUE OF WORKER DUE TO SHORCUT OF
WORH PROCEDURE.

MATERIALS METHOD
UNABLE TO DISCHARGE THE PONDING WATER BEFORE
CLEANING OF AHU,

ENVIRONMENT
SLIPPERY FLOORS DUE TO WATER PONDING

ROOT CAUSE OF ACCIDENT/INCIDENT:

UNSAFE ACT OF THE EMPLOYEE SUCH AS, UNTIED SAFETY SHOES, SHORTCUT TO THE SAFE WORK PROCEDURE
AND SLIPPERY ENVIRONMENT DUE TO WATER PONDING.
______________________________________________________________________________________________

CORRECTIVE ACTION TAKEN (action to eliminate the Timeline Action by Status

cause(s) of an incident and to prevent recurrence)
ASAP SITE FACILITY ON GOING
ADVISE THE FM & SAFETY OFFICER TO PROVIDE PROPERLY FIT MANAGER &
SAFETY SHOES TO THE EMPLOYEE, CONDUCT INSPECTION SAFETY OFFICER
AND MONITORING OF PPE ISSUANCE.

ASSESS THE AREA PRIOR TO ACTIVITY,

REVIEW THE WORK PROCEDURE AND CASCADE TO THE
EMPLOYEE

2
 Doc.code FM-HSE-001-Rev.01
ACCIDENT/INCIDENT
Rev. 0
INVESTIGATION REPORT
FORM Effectivity January 4, 2023

PREVENTIVE ACTION TAKEN (action to eliminate the Date Action by Status

cause(s) of the potential incident and to prevent
occurrence)

REMOVED THE WATER PONDING AND ASSIGNED EXPERT ASAP SITE FM & SAFETY ONGOING
WORKER TO COMPLETE THE PM OFFICER

Prepared by:

Name: ROLAND MAGO

Position: EHS OFFICER III