•

INCIDENT/ ACCIDENT REPORT

J;'IAME OF INVOLVED EMPLOYEE:
A.) Gerald Cinco
SUMISETSU PHILIPPINES, INC.

AGE:
20 yrs old
I
PROJECT NAME:
FORM SF-001
PMM B and EC Building 20Q1
B.) John Paolo Tolentino 25 yrs old
■
Project
JOB CLASSIFICATION: HOURS: DATE REPORTED:

□
AM
A.) Safety Aid 1030H July 10, 2019
PM
8. ) Qc testing & commissioning group
NAME OF EMPLOYER: SCOPE OF WORK: ROUTE TO:
SUMISETSU Phil. INC. Sorting & Hauling
EXACT LOCATION OF ACCIDENT:
PMM A&B Safety Office
DESCRIBE THE INJURY/DAMAGE OR LOSS: None
DESCRIBE THE ACCIDENT (BE SPECIFIC, GIVE COMPLETE DETAILS)
NARRATIVE OF THE CASE
• Resting while working hours.
FACTS OF THE CASE
A.) Between 081OH same date above, the safety team instructed to conduct sorting and proper material segregation at
warehouse, stockyard and expansion areas by SPI Inhouse together with the Sub-Contractors from indifferent workplaces.
B.) Between 081OH, QC team are preparing materials used for panel improvement inside PMM building.
A.) At around 0855H, Mr. Gerald Cinco, instructed by the undersigned to haul the new fabricated base and stand sign board
of Temporary Staging area situated at 2nd floor PMM building Bin three (3) different locations.
B.) At around 0830, Mr. John Paolo Tolentino together with other QC team, instructed to prepare and sort all card holder for
panel improvement work at PMM building.
A.) At around 10:12H, Mr. Gerald Cinco, instructed to haul back alone the existing stand of Bus duct temporary staging area
signage to place at the new stockyard ongoing construction area due to the undersigned was conducting routine inspection
at West Machine room, North & South Core area 2nd floor to maintain safe work practices.
B.) At around 0950H, Mr. John Paolo, after finishing sorting and preparing the card holders, while waiting for his coworkers,
he decided to go inside at safety office to wait for his coworkers because he is not yet familiar to PM M building hence he
is a new worker at PMM project.
• At around 1030H same date above they were seen by the SPI Managers while ongoing safety & Quality Patrol at Temporary
Safety office.
SPECIFICALLY, WHAT WAS UNSAFE ABOUT THE VEHICLE, MACHINE, TOOL EQUIPMENT OR PREMISES?

- Resting at undesignated resting area

UNSAFE -
CONDITION WHY, IN YOUR OPINION , DID UNSAFE CONDITION EXIST?

□ •
DID NOT ANTICIPATED HIS REPUTATION
A. B, HIDDEN DEFECTS
AS AN REGULAR EMPLOYEE
C.
□ Imprnp1:r instrm:tilm
SPECIFICALLY, WHAT DID ANYONE DO, OR FAIL TO DO, THAT LED TO THIS ACCIDENT?
UNSAFE
- Resting at the safety office area during working hours

•
ACTION

SPECIFICALLY IN YOUR OPINION, WHAT IS THE REASON FOR UNSAFE ACT?

•
•□
A. DISREGARD OF INSTRUCTIONS F. INATTENTION

REASON FOR B. FAILURE TO UNDERSTAND INSTRUCTIONS G.

□ INDIFFERENCE (LACK OF INTEREST)

UNSAFE ACT C. DID NOT KNOW THE NEEDED METHOD H.

□ MENTAL OR PHYSICAL CONDITION (EXPLAIN)
D.
□ UNSKILLED I.
□
E.
□ NOT CONVINCED ABOVE UNSAFE ACT
WHAT SPECIFIC ACTION HAVE YOU TAKEN TO CONTROL THE ABOVE UNSAFE ACT, UNSAFE CONDITION AND REASON?
CORRECTIVE
ACTION
- Recommended for reorientation of duties and responsibilities of their designation.
- Hard copy of duties and responsibilities signed the management and worker.
REPORTED BY: DATE: DATE: " RECElVED BY· DATE:
'\"'I'-- I"'-
RR
t .
Y: _,;2 - (
v1?
Diosdado S. Ygot 07/10/2019 I B .A c ) 07/10/2019 QM DIV. MANAGER
IM PO RTA , BE SU M f /J ;wD WITHIN 24 HOURS

I Safety Officer H Project In-Charge I Project tvfitrn(g / 1 President

H QC Engr. (For Filing)
I QSA-F-6401, 0
 . ' .
A o -pc -.ei _ger Id Onco ·. S1>l it'\hoose. oi 0
1 n"'f°' A.5i Vl '1 .

Seilf' o.ic ; a c, to O'\;/ ric:11 i-f-q 03) (-1 '\ rvto.W" e-r.s, s s0ire½. f l{..e, '-;;;o-- I

f e.ro b0\-9:o) 'fO Ol\cO noi}<.itoi 01\<.e> 'D"'lin SO\ Goo.b _9\>V'l1P\ O\V\.tit sq Se60 dfloov-
l<o fO °''J n dod C1\ n_0 Vh3'0\ to "'}o
io)l'lq0 et I Vl f; olo, M trc-,b Yl()
- U \'\'l Q , h n09 "'9 10 : 1--1 t r .\,=q-te11ro..s \c'o Y? VV\ odo. (9·s. VI O\
· °''J \'(\\),-0,SO.'() Yo c,l<o rn C0iff.t'y '1 + n"' hct+:-u-ti(l Cit\9 Tetr1ror:
:+"-£>·'"'-' ..S! o5i e, 1>e\ \ _b cr.t" I fo'3\< +°'F \cO rcm<3 yY\ V\qfo-t ato re °'Y
fuV\1uV\"tO\ Cl\ Sotf{/;-/ °rric t"rO\ fV\Cll9zoo.\,.\- m,,r=o'fyY) d h,· \ b V\ SQ r
<11t {\C\_O). C\-\oi o ,? ; po vie, duMO.O.\') Jtl\Y\9 e½ f°'+ro.l oifo fo o-.y MY iiO\ l oob 1

-i"G\r-e or,ricQ, 1) f\ Ol \)t (), hiYld e, fO 0\ \<'O n h hl lo9 \.c'.C1 ?'+1 ·::> \<o ( q t' )
pc) \"O'fl, f\_3) br I rlV\s ilq ?).f UMVV\i "'' ti .
!
. n 11M ihiV1';'.) ,?°, ot\<d-i1 (J(ilai\l i Sc\ 'ft0!'\1) 1,1t\' 1 Vli Ae M 1" v 11 1r1i "I''
r'. ' '('nC1rnt1 d1 Y1°'1 1° frJ cJ o,