Doc.code FM-HSE-001-Rev.

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

Account Name: St. Luke’s BGC Medical Center Control No.

Account Location: Fort Bonifacio Medical Center Date: May 13, 2024

INCIDENT/ ACCIDENT CLASSIFICATION:

( ) Fatality ( ) Medical Treatment ( ) 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 :

May 13, 2024/ 9:20AM A frame/ Submersible Pump
Exact Location of the Accident/Incident: Witnesses or Others Isnvolved:
Basement 4 Parking area Sumpit 2 Joemar Parañal, Alvin Loberiano , Edwin Silang, John
_______________________________
Aldrel Soliman Romualdo Aslor

INVOLVED EMPLOYEE INFORMATION:

Employees Name: Age: Sex: Civil Status: Position: Assigned Work:
Erwin Gallardo 50 Male Married Electrician
Job at time of injury: Year of experienced: Length of service in the company:
Electrician 14 years 5 months
Contact number 09658402662
Address 792 Purok 6 Sucat Muntinlupa City

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

Date and Time of Treatment: Nature of Injury or Illness:
May 13, 2024/ 10:00am Laceration on head
Medical Findings: Attended by:
Laceration
Treatment Given: Final Fit to Work
Suture on laceration on head Recommendation: Restricted Work
Provide anti – tetanus vaccine injection For Further Treatment (Hospitalized)
Give Co-Amoxiclav and Celecoxib capsule
_____________________________________________________________________________________________________________________________ __________

DESCRIPTION OF ACCIDENT/INCIDENT:

Around 9:20am at Basement 4 Parking area. Group of employees namely Joemar Parañal, Alvin Loberiano , Edwin
Silang, John Aldrel Soliman Romualdo Also and Edward Gallardo was placing the submersible pump at sumpit
vacant slot. They used 1.5T capacity chain block that was connected to the custom made chain block stand. While
descending the said submersible pump, suddenly the chain block stand became unstable and imbalance that causes
it to suddenly fell down and hit the head of Edward Gallardo, who was holding a lighting to provide additional
illumination.

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

Around 9:20AM, of tperform suture to the laceration on his head.

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

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

IDENTIFY THE CONTRIBUTING FACTORS:

MANPOWER MACHINE
Manpower took overtime to complete the task NA
( fatigue), lack of manpower to perform task, NO
Hard Hat during activity, Poor Risk assessment, NO
EHS Officer on time of incident at the work area. Lack
of safety awareness on lifting activity. No proper risk
assessment done

MATERIALS
The chain block equipment was first time to use by
our team, Chain block stand footing is not wide
enough to balance the load. Custom made chain
block stand was provided by client and was endorsed
only to used. No counterweight to support the
balance the between the load and equipment.
METHOD
No documented procedure to perform the task, NO risk
assessment conducted, NO safety briefing prior to
activity. No orientation regarding safe use of chain block
and its component

ENVIRONMENT
Insufficient lighting of the work area.

ROOT CAUSE OF ACCIDENT/INCIDENT:

The chain blocked stand became unstable due to heavy weight of the pump, the team unable to support the chain
block stand to prevent collapsed. The footing of chain block stand is too small and no counter weight installed.
___________________________________________________________________________________________

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

cause(s) of an incident and to prevent recurrence)

To Strictly wearing of Hard Hat of all Technicians for low May 13, Safety Officer On-going
clearance and over activity at all times. Violators of using PPE 2024
will be given disciplinary action and sanction for violating safety
rules and protocols on site.

For discussion of correct and appropriate use of Personal

Protective Equipment training to all technicians for refresher May 24-25, Safety Officer Open
2024
Conduct training regarding use of safe mechanical lifting
equipment ASAP

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 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)

Risk Assessment will be conduct by Facility Engineer, Technical May 13, Facility Engineer, On-going
Supervisor and Safety officer before the start of any activity. To 2024 Supervisor, and
identify the risk and hazard and will provide control measures Safety officer
to prevent any accident or incident to happen.

Specific safety briefing should be done prior to the activity.

Work permit must be accomplished, reviewed and properly

assessed.

Prepared by:

Roland Mago
Corporate EHS Officer