Malaysian Resources Corporation Berhad (Company No : 7997-D) Form No.

: MESB-HSE-IAR-21
MRCB Engineering Sdn Bhd (Company No : 81777-T)
Ver. : 0.0

HEALTH, SAFETY AND ENVIRONMENT

INCIDENT and ACCIDENT INVESTIGATION REPORT

PROJECT

JOB CODE
REPORT NO

DATE OF EVENT

TIME OF EVENT
EXACT LOCATION

REPORT DATE

REPORT TIME

Incident and Accident Classification

Fatality Dangerous Occurrence Body Injuries

First Aid Property Damage Health
Chemical Fire / Explosion Near Miss

STATUS OF REPORT Initial Final

Details of Injured Person

Name

NRIC / Passport

Nationality

Address

Company Name

Team - Stressing, Grouting,

Segment Erection, Supv. etc

Date Of Birth Age

Sex Male Female

Category Direct Sub-contractor Visitor

Public Other (specify___________________)

Details of Injured Person

Name

NRIC / Passport

Nationality

Address

Company Name

Team - Stressing, Grouting,

Segment Erection, Supv. etc

Date Of Birth & Age Age

Sex Male Female

Employment Direct Sub-contractor Visitor

Public Other (specify___________________)
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 Malaysian Resources Corporation Berhad (Company No : 7997-D) Form No. : MESB-HSE-IAR-21
MRCB Engineering Sdn Bhd (Company No : 81777-T)
Ver. : 0.0

HEALTH, SAFETY AND ENVIRONMENT

INCIDENT and ACCIDENT INVESTIGATION REPORT

Action Taken

Injured Person Sent To Hospital Clinic Others

Name of Hospital or Clinic

Others (specify)

Loss Time - Estimated

Immediate Return to Work Hospitalised for 3 Days or Less

Hospitalised for 1 Day Hospitalised for more than 3 Days

Loss Time - Actual (state total no. of days Injured Person away from work)

Actual Man Days Lost

Description Of Incident or Accident

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Malaysian Resources Corporation Berhad (Company No : 7997-D) Form No. : MESB-HSE-IAR-21
MRCB Engineering Sdn Bhd (Company No : 81777-T)
Ver. : 0.0

HEALTH, SAFETY AND ENVIRONMENT

INCIDENT and ACCIDENT INVESTIGATION REPORT

Immediate Causes Of Incident or Accident

Recommended Preventive Measures

Page 3 of 6
 Malaysian Resources Corporation Berhad (Company No : 7997-D) Form No. : MESB-HSE-IAR-21
MRCB Engineering Sdn Bhd (Company No : 81777-T)
Ver. : 0.0

HEALTH, SAFETY AND ENVIRONMENT

INCIDENT and ACCIDENT INVESTIGATION REPORT

Type Of Injury

Abrasion / Scratches Amputation Asphyxia / Drowning

Burns Dermatitis (skin rash) Contusion (local swelling)

Concussion Laceration / Cuts Animal / Insect Bite

Fractures / Dislocation Electric Shock Poisoning

Puncture Wounds Sprains / Strains Others (specify)

Eye Crushed

Location of Body Injury

Head Arms Feet Others (Specify)

Eyes Legs Toes

Ears Knees Ankles

Neck Hand Back

Shoulders Fingers Abdomen

Chest Wrists

Substandard Acts
Operating Equipment without Authority Removing Control Devices Improper Lifting

Failure to Warn Using Defective Equipment Improper Position or Task

Failure to Secure Failing to Use PPE Properly Servicing Equipment in Operation

Operating at Improper Speed Improper Loading Horseplay / Behaviour

Making Control Devices Inoperable Improper Placement Others ______________________

Substandard Conditions
Inadequate Guards or Barriers Inadequate Warning System Radiation Exposure

Inadequate Protective Equipment Fire & Explosion Hazard Temperature Extremes

Defective Equipment or Materials Poor Housekeeping Inadequate or Excess Illumination

Congestion or Restricted Action Noise Exposure Inadequate Ventilation

Inadequate Maintenance Others _________________________________________

Human Factor Work Factor

Inadequate capability Inadequate supervision Inadequate work standards

Lack of knowledge Inadequate engineering Wear and tear

Lack of skill Inadequate purchasing Abuse or misuse

Stress Inadequate maintenance None

Behaviour Inadequate tools/equipment

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 Malaysian Resources Corporation Berhad (Company No : 7997-D) Form No. : MESB-HSE-IAR-21
MRCB Engineering Sdn Bhd (Company No : 81777-T)
Ver. : 0.0

HEALTH, SAFETY AND ENVIRONMENT

INCIDENT and ACCIDENT INVESTIGATION REPORT

Details of Witness

Name

NRIC / Passport

Nationality

Company Name

Team - Stressing, Grouting,

Segment Erection, Supv. etc

Designation

Date Time

Statement

I declare that this statement is an accurate and complete account of what I witnessed in relation to the referenced
incident / accident case.

Witness, Interviewed by,

Signature Signature

Date Date

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 Malaysian Resources Corporation Berhad (Company No : 7997-D) Form No. : MESB-HSE-IAR-21
MRCB Engineering Sdn Bhd (Company No : 81777-T)
Ver. : 0.0

HEALTH, SAFETY AND ENVIRONMENT

INCIDENT and ACCIDENT INVESTIGATION REPORT

Prepared By

Name Signature

Company

Designation

Date & Time

Approved By

Name Signature

Company

Designation

Date & Time

Attachment

Sketch / Photograph of accident Police Report

NRIC / Passport and Work Permit of Injured Person Medical / Doctor Report / Medical Cert.

NRIC / Passport and Work Permit of Witness Machinery / Operator Report

CIDB Others

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