Incident Details

Name of person involved in the incident: Date of Incident:

19 year old Male Operator September 25, 2019
Location of Incident:
Production 2 Factory 2.2 / Sew-Cutting Process
Incident Investigation Team:

What task was being performed at the time of the incident?

Team member runs Auto carry Cutting Machine Lectra 3

What happened? (e.g. ‘employee tripped over box’ o ‘forklift hit wall’)
During process at 40th layer, cutting blade suddenly stop/clogged because of material’s stacking
wrinkled/crumpled. Team member tried to tidy up position of material stacking. At the same time, after
material tidied up, cutting blade moved forward carry on the process, and tip of T/M’s right Ring finger
slashed by cutting blade.
What factors contributed to the incident?
Environment: Equipment/materials:
□ Wrong equipment for
□ Noise □ Layout / Design □ Equipment Failure
the job
□ Inadequate □ Material / Equipment
□ Lighting □ Dust / Fume
Maintenance too heavy / awkward
□ Inadequate Training
□ Vibration □ Slip / Trip Hazard □ Inadequate guarding
Provided
□ Damaged / Unstable
□ Other □ Other
Floor
Work Systems: People:
□ Procedure not
□ No / inadequate risk
□ Hazard not identified followed / no □ Drugs / alcohol
assessment conducted
procedure exist
□ No / Inadequate safe □ No / inadequate □ Time / production
□ Fatigue
work procedure controls implemented pressure
□ Inadequate training / □ Distraction / personal
□ Hazard not reported □ Change of routine
supervision issues / stress
□ Lack of
□ Other □ Other
communication
Corrective Actions:
Contributing factor What are we going to
Who When Completion Date
(from above list) do to fix the problem?
Equipment/materials, 1. Safety All
Work System and awareness reminder for Operators
people all operators
2. Change cutting
process system, if
cutting process stop,
cutting blade back to
home position.
3. Additional area
sensor
4. Yokoten to
other 2 machines
Incident Details
Name of person involved in the incident: Date of Incident:
48 years old male associate with 1 month September 17, 2019
experiences
Location of Incident:
101 Plant (on the sidewalk in the premise)
Incident Investigation Team:

What task was being performed at the time of the incident?

During going to work the night shift and walking on the sidewalk in the premise, a pedestrian was
walking on the left side towards IP so IP moved to the right side of sidewalk.
What happened? (e.g. ‘employee tripped over box’ o ‘forklift hit wall’)
Right ankle was twisted at the step of sidewalk (slope part in front of crosswalk)
Person didn’t notice the step because it was dim around the sidewalk.
What factors contributed to the incident?
Environment: Equipment/materials:
□ Wrong equipment for
□ Noise □ Layout / Design □ Equipment Failure
the job
□ Inadequate □ Material / Equipment
□ Lighting □ Dust / Fume
Maintenance too heavy / awkward
□ Inadequate Training
□ Vibration □ Slip / Trip Hazard □ Inadequate guarding
Provided
□ Damaged /
□ Other □ Other
Unstable Floor
Work Systems: People:
□ Hazard not □ No / inadequate risk □ Procedure not followed
□ Drugs / alcohol
identified assessment conducted / no procedure exist
□ No / Inadequate
□ No / inadequate □ Time / production
safe work □ Fatigue
controls implemented pressure
procedure
□ Hazard not □ Inadequate training / □ Distraction / personal
□ Change of routine
reported supervision issues / stress
□ Other □ Lack of communication □ Other
Corrective Actions:
Contributing factor What are we going to
Who When Completion Date
(from above list) do to fix the problem?
1. Re-instruct to walk Management As soon Within the month
Equipment/materials with watching your own as
and people steps fully. possible
2.Confirm if there are
any places which it’s
hard to see the step of
sidewalk in the premise
because of darkness and
consider installing
street light, indicating
remarkable marking or
flatten the step if needed.
Incident Details
Name of person involved in the incident: Date of Incident:
26 year old female associate with 6 month September 26, 2019
experiences
Location of Incident:
Power Card No.3 Line
Incident Investigation Team:

What task was being performed at the time of the incident?

While the injured person was exchanging the tool of wire bonding device, she dropped the part in the
carrier device in front. Trying to pick up the part※1, she removed the fixed cover※2 on the upper carrier
device without permission and put her hand into the device without turning off the switch※3. Then, she
got her right hand between the carrier device which was moved from the right side and equipment
cover.
What happened? (e.g. ‘employee tripped over box’ o ‘forklift hit wall’)
She was not allowed to treat trouble, but she wanted to take action quickly and put her hand abruptly
worrying about mixing foreign objects. She did not learn the correct procedure for releasing temporary
safety device. So she thought it was OK to remove the cover if the machine stopped. She was
convinced that she pushed the emergency stop switch.

What factors contributed to the incident?

Environment: Equipment/materials:
□ Wrong equipment for
□ Noise □ Layout / Design □ Equipment Failure
the job
□ Inadequate □ Material / Equipment
□ Lighting □ Dust / Fume
Maintenance too heavy / awkward
□ Inadequate Training
□ Vibration □ Slip / Trip Hazard □ Inadequate guarding
Provided
□ Damaged / Unstable
□ Other □ Other
Floor
Work Systems: People:
□ Procedure not
□ No / inadequate risk
□ Hazard not identified followed / no □ Drugs / alcohol
assessment conducted
procedure exist
□ No / Inadequate safe □ No / inadequate □ Time / production
□ Fatigue
work procedure controls implemented pressure
□ Inadequate training / □ Distraction / personal
□ Hazard not reported □ Change of routine
supervision issues / stress
□ Lack of
□ Other □ Other
communication
Corrective Actions:
Contributing factor What are we going to
Who When Completion Date
(from above list) do to fix the problem?
 1. Correct trouble All September September 26, 2019
Work System and shooting procedure ※ Operators 26, 2019
people for the target and
Leaders
person
a)Do you know the
trouble you are allowed
to handle with?
Appointed trouble
shooter
b)Implement “Stop,
Call, and Wait” in
accordance with the
following cases such as
“the trouble are not
allowed to handle
with” or “happened
for the first time“
when trouble occurs.
All members
c)Implement “3S + D”
for the first priority at
trouble-shooting
Appointed trouble
shooter
2. Correct
handling by passing
safety device
a)Prohibit to remove
the safety device
(including fixed cover)
whenever equipment
stops or not.
b)In case of the
necessity to remove the
safety device, ask to
team leader or assistant
manager at first. Team
leader or assistant
manager apply to
bypass the safety
device