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NOTICE OF INCIDENT
NOI No. : _________________ Date of Incident: March 14, 2018_______
Incident : _________________ Time / Shift : _______1:30 AM________
INCIDENT CLASSIFICATION

Personnel Accident X Property Environmental Fire / Explosion

Damage Incident
Force Majeure Other ESH related incident: ________________________________

Project / Facility : Restoration of Parapet, Faulty Concrete and River Bridges

Exact Location : 5th – R.Papa Station
Specific Activity : Hauling of Tools and Materials
RELEVANT PERSONNEL
Dept. Head / Project Manager / PIC,: __________________ Witness 1: ____________________
Supervisor / Foreman : Juan Bolofer / Ricky Paclibar____ 2: ________
LIST BELOW ALL PERSONNEL INVOLVED:
Consecuti
Yrs of
Name Company Title/Designation ve Days
Service
Worked

COMPLETE BOXES BELOW IN CASE OF PERSONNEL ACCIDENT:

Nature of Injury / Severity
Nature of Accident Body Part Affected Accident Source
Illness of Injury

BRIEF DESCRIPTION OF ACCIDENT/INCIDENT:

At the Time and Date mentioned above. The Civil Group was given the task cutting of
old parapet at under the supervison of Juan Bolofer(Supv. During hauling of tools and
materials using Boom Truck No. 2004-55. Mr. Ryan Elardo (rigger) was using 1x6 web
sling basket hitch system which attached into the Hilti Cutting Machine #3 trolley lock
rubber lug hoisting at the Via Duct. On the process, unfortunately the machine fell down
into the ground from the height of aprproximately 4.7 meters which fully barricaded. No
was injured on the incident

INITIAL ACTION TAKEN TO MITIGATE RISK, PREVENT ESCALATION or REOCCURRENCE:

Details of Immediate Action Actionee Date of Action Status

NOTIFICATIONS MADE:
Entity Persons Time Date Manner of Notification

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INCIDENT SEVERITY:(Refer to Severity Matrix on the next page)
Actual : Potential :

Prepared By: Position:

signature over printed name
Approved By:
Dept. Head / PM /PIC
signature over printed name

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SEVERITY CRITERIA POTENTIAL INCIDENT SEVERITY LIKELIHOOD

Responsible Actual 1 2 3 4 5
Impact on Supervisor / Incident
Personnel Asset Environmental Very Very
Reputation Manager Severity Unlikely Possible Likely
Unlikely Likely

( 1 ) Slight≤ P 50T, <24 ( 1 ) Slight (< = 5 gals / 20 ltrs, Foreman /

( 1 ) First Aid enviromental damage is self ( 1 ) Local 5 1 2 3 4 5
hrs disruption) Supervisor
healing)
( 2 ) Medical ( 2 ) Minor (≤ P 100T, ( 2 ) Minor (< = 50 gals / 155 ltrs, ( 2 ) Provincial
Contruction
10 2 4 6 8 10
Treatment <72 hrs disruption) impact contained to site) Manager

( 3 ) Restricted Work ( 3 ) Medium (≤ P 500T, ( 3 ) Medium (< = 500 gals / 1,555 ltrs, ( 3 ) Regional Project Manager 15 3 6 9 12 15
Injury <120 hrs disruption) localized effect contained off-site)

( 4 ) Lost Time Injury ( 4 ) Major (≤1 M, <168 ( 4 ) Major (< = 5,000 gals / 15,500 ( 4 ) National Operations Head 20 4 8 12 16 20
hrs disruption) ltrs, uncontained off-site)

( 5 ) Single / Multiple ( 5 ) Extensive (> 1 M, ( 5 ) Extensive (>5,000 gals / 15,500 ( 5 ) Internationa

ltrs, irreversible environmental President & COO 25 5 10 15 20 25
Fatality >168 hrs disruption) l
damage)
SEVERITY MATRIX (use matrix to describe the actual and potential severity levels below)

1 – 6 = Low Severity 8 – 12 = Medium Severity 15 – 25 = High Severity

(Indicate all types of loss applicable to the incident by indicating the actual and potential severity ratings using the matrix above. All incidents having actual
severity rating of 10 and above and or with potential severity of 8 and above shall merit full investigation and full report submitted )

TYPES OF LOSS/DAMAGE ACTUAL SEVERITY POTENTIAL SEVERITY

PERSONNEL INJURY 0 4X
ASSET DAMAGE COSTS 1 5=

ENVIRONMENTAL SPILL DAMAGE 0 1

(include volume spilled and cleanup costs)
DAMAGE TO COMPANY’S REPUTATION(include any
fines/penalties)

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INVESTIGATION TEAM (List all personnel to be involved in the investigation based on the highest actual or potential severity rating listed above)
1. ProjectESH Specialist 1. Project ESH Supervisor/ 1. Site ESH Sr. Supervisor/ 1. Project Manager/ 1. Corporate ESH Head
2. Immediate Supervisor Manager Assistant ESH Manager Department Head 2. Investigation Committee
2. Construction Manager 2. Construction Manager 2. Corporate ESH Manager 3. Qualified Individual Independent of the
Operations Unit where the incident
occurred appointed by FB Operations
(Rating 1-25 Severity) (Rating 1-25 Severity) (Rating 7 or greater Severity) (Rating 15 or greater Severity) Head / President
(Rating 20 or greater Severity)

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