Lepanto Consolidated Mining Company Doc. No.

FRM-SLC-001
Lepanto Mine Division Revision No. 00
Lepanto, Mankayan, Benguet Date Effective Feb. 1, 2020
Page 1 of 2

SAFETY INCIDENT REPORT

LOCATION OF INCIDENT DEPARTMENT DATE AND TIME OF INCIDENT DATE AND TIME OF REPORT

INJURED PERSON’S NAME: DAMAGED PROPERTY:

Chapa No: Age:

PART OF BODY INJURED: NATURE OF DAMAGE:

DESCRIPTION OF INJURY: ESTIMATED COST:

OBJECT/EQUIPMENT/SUBSTANCE INFLICTING THE INJURY: OBJECT/EQUIPMENT/SUBSTANCE INFLICTING THE DAMAGE:

OCCUPATION / DESIGNATION: LENGTH OF SERVICE: PERSON IN MOST CONTROL and DESIGNATION:

DATE HIRED:
EVALUATION OF LOSS LOSS SEVERITY POTENTIAL: PROBABILITY OF REOCCURRENCE:
POTENTIAL Major Serious Minor High Moderate Low
IF NOT CORRECTED:
BRIEF DESCRIPTION OF THE INCIDENT:

IMMEDIATE CORRECTIVE ACTION TO FIX THE EXISITNG PROBLEM:

ANALYSIS OF ROOT CAUSE (WHY-WHY ANALYSIS):

WHY 1:

WHY 2:

WHY 3:
 Lepanto Consolidated Mining Company Doc. No. FRM-SLC-001
Lepanto Mine Division
Revision No. 00
Lepanto, Mankayan, Benguet
Date Effective Feb. 1, 2020
Page 2 of 2
CORRECTIVE ACTION (LONG TERM) TO FIX THE PROBLEM:

DUE DATE:
REVIEWER’S REACTION TO THE ROOT CAUSE ANALYSIS AND THE CORRECTIVE ACTIONS INDICATED:

PREPARED BY: REVIEWED AND NOTED BY:

Immediate Supervisor Group / Department Head

Safety Engineer/Inspector
SKETCH OF THE INCIDENT SITE:

FOLLOW-UP OF CORRECTION (REMARKS / STATUS): SAFETY INSPECTOR: DATE:

1.

2.

3
 SAFETY INCIDENT REPORT

Loss Severity Potential

• Major – Loss of life, permanent disability, loss of process, major cost

• Serious – Lost time injury, no disability, disruption t process, significant cost
• Minor – Minor injury with no lost time, partial disruption to process, minor cost