SISTEMA DE GESTIÓN DE SEGURIDAD, SALUD Y MEDIO AMBIENTE / Code: HSE-REG-000

HEALTH, SAFETY ANDA ENVIRONMENT MANAGEMENT SYSTEM Revision: 01

Date: 6/1/2022
PRELIMINARY REPORT Project:

GENERAL DATA
Incident Incident with First Aid Dangerous Incident Occupational disease
EVENT
Mild accident Disabling Accident Mortal accident Others:____________________
AREA - SG Safety at Work Occupational health Environment Operational
TYPE OF IMPACT / DAMAGE Staff Materials Environment Process Social
WORK/PROJECT Construction of the Operation Zone (ZOP) and the Entrance Complex (CI) of the Chancay MultipurCUSTOMECOSCO SHIPPING Ports Chancay Perú S.A.
DATE 04.09.2023 Hour 11:30:00 AM PLACE ZOP - North Beach Z1.2
EVENT Own (Consorcio+CHECSAC-CCCC4TH) Contractor.- JD

NAMES AND SURNAMES OF THOSE DIRECTLY INVOLVED Occupation AREA

PETER ALVAREZ CRUZ Roustabout Operations

DESCRIPTION OF THE EVENT

What happened? entry of dust particles into the eye Type of contact: Contact with

At 11:30 a.m. on 09.04.2023, the worker Peter Álvarez Cruz identified with DNI N•48712815 with charge roustabout and Peruvian nationality, was carrying out
the activity of meshing mailboxes (covering mailbox holes), when suddenly Suddenly the dust, as a consequence of an earth movement located about 20 meters
from the mesh, some dust particles enter the left eye, causing slight irritation.

PROBABLE IMMEDIATE OR DIRECT CAUSES

Inappropriate_use_of_PPE

CHRONOLOGICAL DETAIL OF THE DEVELOPMENT OF THE EVENT

N° Date Time Detail Responsible

1 04.09.2023 8:00 The roustabout receives the order to mesh the mailboxes. Chen Xuemei - Foreman JD

2 04.09.2023 11:30 The incident happens Chen Xuemei - Foreman JD

3 04.09.2023 15:15 Report event to HSE Supervisor. Dr. Santiago Hidalgo - Occupational Physician
HSE personnel refers the worker in the topic ZOP

4 04.09.2023 15:30 Start of investigation of events. Jorge Triveño - Supervisor HSE

IMMEDIATE ACTIONS
N° Description Responsible

1 Primary care for worker. Dr. Santiago Hidalgo - Occupational Physician

ILLUSTRATIVE / PHOTOGRAPHIC PANEL

Mailbox meshing process Primary care for a worker in the

topic ZOP.

OBSERVATIONS / RECOMMENDATIONS

First aid incident under investigation.

INFORMANT Ing. Jorge Triveño DATE 04.09.2023

 SISTEMA DE GESTIÓN DE SEGURIDAD, SALUD Y MEDIO AMBIENTE / Code: HSE-REG-000
HEALTH, SAFETY ANDA ENVIRONMENT MANAGEMENT SYSTEM Revision: 00
Date: 9/1/2021
PRELIMINARY REPORT Project:

GENERAL DATA
Incident First Aid Incident Hazardous Incident Occupational Illness
EVENTO
Slight Accident Incapacitating Accident Fatal Accident Other:____________________
AREA - SG Safety at Work Occupational Health Environment Operational
TYPE OF DAMAGE Personal Materials Environment Process Social
SITE / PROJECT Construction of the Operation Zone (ZOP) and the Entrance Complex (CI) of the Chancay MultipuCLIENT COSCO SHIPPING Ports Chancay Perú S.A.
DATE 04.09.2023 TIME 11:30:00 AM LOCATION ZOP - South Beach
COMPANY Own (Consortium+CHECSAC-CCCC4TH) Subcontractor..- JD

NAMES AND SURNAMES OF THOSE DIRECTLY INVOLVED POSITION AREA

Javier Polo Carhuayano Operator Operations

EVENT DESCRIPTION

What happened? Instep blow of the left foot Type of Contact: Contact with

At 5:30 p.m. on 06.07.2023, the worker Javier Polo Carhuayano identified with DNI No. 48178553 as an Operator of Peruvian nationality, carried out the
activity, unloading UPVC pipes, the instant in which a pipe slips and makes contact with the foot of the worker in question. The worker reports the event on 06-
08-2023 at 3:30 p.m. The time the FLASH REPORT is sent

PROBABLE IMMEDIATE OR DIRECT CAUSES

Improper storage

CHRONOLOGICAL DETAIL OF THE DEVELOPMENT OF THE EVENT

N° Date Time Detail Responsible

1 06.06.2023 9:00 The laborer receives the order to clean the water tanks for concrete curing Zhong Xue - Capataz JD

2 06.06.2024 15:20 After finishing cleaning the 4th pond, he proceeds to pump out the water that Zhong Xue - Capataz JD
was left from cleaning all the walls.

3 06.06.2025 15:30 Report event to HSE Supervisor. Dr. Santiago Hidalgo - Occupational
HSE personnel refers the Peon to Topico to be evaluated by a doctor. Physician

4 06.06.2026 16:50 Start of event investigation. Donato Sacramento G. - HSE Supervisor

IMMEDIATE ACTIONS
N° Detail Responsible
Dr. Santiago Hidalgo - Occupational
1 Primary care for workers.
Physician

ILLUSTRATIVE / PHOTOGRAPHIC PANEL

Unloading process Worker is hitted by the square pipe Worker receives attention from doctor

COMMENTS / RECOMMENDATIONS

First aid incident under investigation.

REPORTER Ing. Jorge Triveño DATE 04.09.2023