APPENDIX A

KATA GENERAL ENGINEERING SDN.BHD(196843-V) Lot 35, 1st and 2nd Floor, Block F, Grace Square, Sembulan, 88100, Kota kinabalu, Sabah. Tel: 088-255050 Fax: 088-255051 Email: kata_eng@yahoo.com INCIDENT INVESTIGATION REPORT
(To be completed and submitted to SAFETY DEPARTMENT after an incident) 1. TYPE OF INCIDENT *(Tick and delete where appropriate) Struck by falling/flying/moving/against object Fall/slip on same/different level Contact with electricity/heat Exposed to fire/explosion/contact with harmful substance or radiation

Others (please specify) : Noncompliance to HSE Regulation.

2. (a)

*DAMAGE STATUS

(b)

* DAMAGE CONDITION

Repairable Unrepairable

Fair (RM1000>) Bad (RM1000 RM5000) Serious (>RM5000)

3. (a)

THE DAMAGED PROPERTY Description Section :No property damage involved :Operations Dept

Ref. / Serial No.:Nil Model No. Date of Incident Time of Incident Location of Incident :Nil :Mar 28, 2012 :1800hrs 2100hrs____________ :Laydown Area 1, SAMUR Project Site ____________

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APPENDIX A CONTINUED (b) WITNESS TO THE INCIDENT

(i) REKIND H.S.E S/I

_____ Signature

(ii)

AZMI FAUZI KATA H.S.E

Signature

4. (a)

INCIDENT DESCRIPTION Nature of Damage : NONE

5.

DESCRIPTION INCIDENT (Use sketch overleaf if necessary) (i) What job was being carried out (include type of tools, machinery, etc.)? Lifting of Water Crossing Culvert. Machineries/ equipment/tools use for activity :a) Truck Crane x 1 nos b) Loading trailer x 2 nos c) 4 ton Sling x 1 nos (ii) How did property damage? NON (iii) What are the unsafe condition / act?

No information to Consortium for approval to work beyond normal hours. No PTW was applied for work. No JSA was produce for the task. No Lifting Plan for lifting work. No proper PPE for work activity (No rigging glove used for slinging and rigging activity). No Sufficient Lighting for night activity work. Incompetent rigger to handle task. No pre job briefing / toolbox before commencing activity. Involving Local Authority Vehicle (Truck Crane used are from MDS) Webbling Sling used are in ill condition ( No certificate was produce for sling) No PMA permit for crane used for lifting activity ( Crane Not Certified by JKKP) Crane used for lifting activity was not inspected for approve to work by H.S.E Dept.

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(iv) What was defective, unsafe condition or wrong with job method?

No Proper information was relay to H.S.E Dpt. Inexperience/ no knowledge in handling job / task Lack of preparation for the task.

(v) What safeguards/mitigation should be used?

To educate all personnel involved. All construction activity on site is to be properly reported/inform to H.S.E Dpt. before commencing. To be prepared before commencing activity.

APPENDIX A CONTINUED 6. (a) REPORTED BY : Name: AZMI FAUZI ID No.: Position: H.S.E SUPERVISOR Date: Mar 29, 2012.

Signature (b) REPORT ACKNOWLADGE BY (Section Head): Name: RAJIED HENRY ID No.: Date: Position: PROJECT MANAGER Mar 29, 2012.

Signature Name: ABDUL SALIM BIN HAJI AWANG TENGAH ID No.: Date: Position: SENIOR SUPERVISOR Mar 29, 2012.

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Signature

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