Revised DOLE/BWC/OHSD/IP-6A, 2013 Republic of the Philippines

Department of Labor and Employment

REGIONAL OFFICE No ___
GOVERNMENT SAFETY ENGINEER’S ACCIDENT
INVESTIGATION REPORT
(This report shall be accomplished and attached to the Labor Laws Compliance Assessment Checklist after the conduct of Accident Investigation)

ORIGIN
1. X Establishment Police Other (Name)
2. Telephone Telegram Messenger, Other
(NOTICE)
Other
3. Establishment Petron Corp. - Refining Division Nature of Business Refinery
4. Address Brgy. Alangan, Limay, Bataan
EMPLOYER
5. Manager Petron Corp Nationality Filipino
6. Employees & Workers M 693 F 94 Total 787

7. Name Gian Karlo A. Bambo Age 26 Sex Male Civil Status Single
8. Address No. 208 A. Bambo St., Tubuan, Pila, Laguna No. of Dependents
FATALITIES 9. Occupation Average Weekly Wage P
10. Length of service prior to accident 2.6 years Accident Record
(Use another sheet if necessary)
11. Name Age Sex Civil Status
12. Address No. of Dependents
INJURED
13. Occupation Average Weekly Wage P
14. Length of service prior to accident Accident Record
(Use another sheet if necessary)
15. Date of Accident June 26, 2020 Time 1430H
16. This accident involved: No. of Fatalities 1 No. of Injured N/A Property Damage N/A
17. Description of accident: (Given full details on how accident occurred) :
See attached accident report
THE
ACCIDENT 18. Activities performed before accident siphoning of accumulated water at F7702 via pneumatic pump
Was this part of regular job? Yes If not, why?
19. No. of similar accidents in the past 2 years None
20. No. of injuries in the past 12 months
Total Non-Disabling Disabling Fatal 1

21. Extent of injury: Fatal Permanent Total

INJURY 22. Nature of Injury:
23. Part of body affected:
24. Department involved Production B Block 2 Maintenance
25. Section Involved SE Maintenance
CAUSE 26. Unsafe mechanical or physical condition F7702 was maintained under inert environment using nitrogen
27. Accident Type Cardio-Respiratory Arrest probably Secondary to Hypoxia
28. The Unsafe Act Entering a confine space without appropriate work permit
29. Contributing Factor Short cutting of work
30. Describe kind and extent of damage to equipment, materials, machinery and tools
PROPERTY
N/A
DAMAGE

PREVENTIVE 31. Preventive measures taken: Immediately ordered suspension of the activity and secured the area.
MEASURES
32. Supervisor/Foreman (Name)
WITNESS 33. Worker (Name)
34. Others (Name Contractors Personnel: Orlando Dayao and Jose Bacquian
REMARKS 31. See attached accident report
RECOMMENDATION
Investigation conducted in the presence of:
Nicanor M. Bantog / Michael H. Sevilla Mark Francis D. Bagang / Gaylord A. Galope
Name and Position Labor Laws Compliance Officer
June 29, 2020
Date