FORM XII

REPORT OF ACCIDENT OF DANGEROUS OCCURRENCE

To be sent to the Inspector, Dock Safety

Address:

[Required by Regulation 91 of the Dock Workers (Safety, Health and Welfare) Regulations, 1989 in pursuance of Sec. 22 of the Dock Workers (Safety, Health and Welfare) Act, 1986].

(See Instruction Overleaf)

• Name of the Employer
• Address of the Employer
• Ship or other exact place where accident or dangerous occurrence happened.
• Date, Shift and hour of accident or dangerous occurrence

  Date

  Shift

  Hour

• • Name and address of injured person

    Sex

    Age

    Year

    Occupation No.

    Experience in the trade

  • Nature and extent of injuries, (e.g. fatal, loss of finger, fracture of legs)
  • By whom treatment was given?
  • Was the injured person disabled for more than forty-eight hours?
  • Type and name of cargo handled.
• Hour at which the injured person started work
• Cause of accident or dangerous occurrence
• Accident:
  
  • If caused by machinery, state:
    
    • Name of machine and part causing the accident
    • if moved by mechanical power at the time
  • State exactly what the injured person was doing?
• Dangerous occurrence:
  
  • Nature of collapse or failure of lifting appliance.
  • Nature of the breakage of rope, chain or other appliances.
  • Name of collapse or failure of means of access to or from a ship.
  • Nature of any other dangerous occurrence as counted under Regulation 90 other than 9 (a), 9 (b) and 9 (c) above.

Signature......

Dated......

(to be filled in by Inspector)

Port.......

Date of receipt........

Accident/Dangerous Occurrence No.....

Causation........

Sex......

Remarks.......

INSTRUCTIONS

REPORTING OF ACCIDENTS AND DANGEROUS OCCURRENCES

Reporting of accidents:

• Notice of any accident in dock which either:
  
  • Causes loss of life to a dock worker, or
  • disables a dock worker from work on which he was employed for the rest of the day or shift in which the accident occurred, shall forthwith be sent by telegram, telephone or special messenger within four hours of the occurrence to
  • the Inspector;
  • the relatives of the workers when the accident causes loss of life to the dock worker or is likely to disable the dock worker from work for more than ten days; and
  • in the case of fatal accidents only, the officer-incharge of the nearest Police Station, and the District Magistrate or if the District Magistrate by order so directs the sub-divisional Magistrate.
• In cases of accidents falling under Cl. (b) of sub-regulation (1), the injured person shall be given first-aid and thereafter immediately conveyed to a hospital or other place of treatment.
• Where any accident causing disablement, results in the death of dock worker disabled, notice in writing of the death shall be submitted to the authorities mentioned in sub-regulation (1) within 72 hours after the death occurs and acknowledgment obtained.
• The following classes of dangerous occurrence shall be reported to the Inspector, whether death or disablement is caused or not, in the manner prescribed in sub-regulation (1):
  
  • collapse of failure of lifting appliance or breakage or failure of ropes, chains or loose gears, including slings, lifting beams, container supreaders, etc. or over turn or displacement of cranes used in dock work, falling of hatchboards or beams or cargo slings, displacement of hatch beam resulting in the fall of hatch beams or coverings;
  • collapse or subsidence of any wall, floor, gallery, roof, platform, staging or means of access;
  • explosion of a receiver or vessel used for the storage, at a pressure greater than atmospheric pressure, of any gas or gases (including air) or any liquid or solid resulting from the compression of gas;
  • explosion or fire causing damage to any place in the docks in which dock workers are employed;
  • failure, capsizing, toppling or collision of transport equipment;

  (j) spillage or leakage of dangerous cargoes or damage to their containers

  (g) breakage, buckling or damage of freight containers.

• If a failure of lifting appliance, loose gear or similar other gears and transport equipment has occurred, the concerned shall as far as practicable be kept undisturbed until inspected by an Inspector.
• In addition every notice given under sub-regulation (1) and sub-regulation (4), shall be confirmed within seventy-two hours of the occurrence by submitting a written report to the Inspector in Form XII provided that in case of an accident under Cl. (b) of sub-regulation

(1) such written report need be submitted only when the dock worker is disabled from work on which he was employed for more than forty-eight hours from the time of the accident.