Details needed to enter a report into synergi web application

Note:the fields that are marked in green are mandatory

Case Type
Incident Title
Date Of Incident
Time (24 hrs clock)
Port /CIS Location
Vessel/Site

Near Miss
Truck 137 hit Truck 48
7/10/2014
23:15:00 PM
Port Said
Under QC12

Vessel/Site(If other please specify)

Detailed Location
Shipping Line
Master/Supervisor at time of incident
Operating Office
Reported By
Name Of Company, if 3rd party
Incident Description (with details)

Under QC12
Truck driver
OPS
TSV

While Truck 137 enter under QC12 for

loading hit truck 48 which lead to hit truck
56 and making damage in Truck 48 bumper
and minor scratch in both tail.

Equipment involved
Equipment number
1- inform Safety Supervisor.
2- informed Eng team.

immediate action taken

weather condition
road condition
visibility
suggestion for improvement
Injured persons details
Employee number
National ID
First Name
Surname
Home address

Clear
Dry
Good

Phone
TWIC No./ID No.
Work address
Social Security Number
Date Of Birth
Gender
age
Employment category
company
Unit/Department
3rd party type
job title
marital status
Involved Person/Witness details(if any)
Employment Category
first Name
Surname
Person Involved as
Telephone Number
Job Title
Social Security Number
Home/work Address
If Over the road driver, drivers license no.
and state

gi web application

Actual event type

A.]People
B.]Asset damaged
C.]Environment
D.]Reputation

A.]People (If any)

Accident category
Course of events
Detailed course of events
Type of injury
Part of body harmed
Estimated workdays lost
Actual workdays lost
Estimated workdays restricted
Actual workdays restricted
Is The container able to move out via vessel/rail/chassis
Does The container need M&R to take action

Department
Explain Damage
Damage caused by
Pre-existing damage
Forpre-existing damage,(if cargo/container) eter the ship
name/gate number/date/cargo type.
Must track repair expenses.

Operating office in charge of case

Person in charge

Loss Potential

Potential Event type

People
Asset
Environment
Reputation
Most probable recurrence frequency

Contractor
Customer
Employee
Full-time employee
Government Authorities
Hired
Others(Please Specify)
Over the road/external driver
Port employee
Shipping Line/Vessel crew
Substitute
Vendor
Visitor
Involved
Witness

Clear
Fog
Ice/Snow
NA
Overcast
Rain
Sun
Thunder storm
Windy

CHE
1.Chassis/Trailer
2.Empty Handler
3.Mobile Crane
4.Rail-Mounted Gantry(RMG)
5.Reach Stacker
6.Rubber-Tired Gantry(RTG)
7.Ship Crane
8.Ship-To-Shore-Crane
9.Shuttle Carrier
10.Straddle Carrier
11.Terminal Tractor
12.Top Loader
CONTAINER
1.Dry
2.Flat rack

3.Open Top
4.Reefer
5.Tank
MISCELLANEOUS
1.Building/Facility
2.Cargo
3.Chassis Flipper
4.Lashing Gear
5.Leakage Trailer
6.Others(please specify)
7.Over Height Frame
8.Rail Chassis
9.Safety/Lashing Cage
10.Spreader
11.Tug/Boat
12.Vessel
VEHICLE
1.3rd party vehicle
2.Bus
3.Car
4.Emergency Vehicle
5.Fork Lift
6.Fuel Truck
7.Man Lift
8.Pick up
9.Sweeper.

No
Yes
Undetermined
Cargo
Chassis
Container
No
Yes
Observation
Near Miss
Incident

slip/trip/fall
squeezed
struck against
struck by
struck down by

Building
Dock/Quay
Gate
Inspection Area/CFS
Off-Site
Other(Please Specify)
Parking
Rail

APL
CMA CGM
COSCO
CSAV
China Shipping(CSCL)
Eimskip
Evergreen Marine Corp
Hamburg Sud

Vessel
Warehouse
Workshop(M&R)
Yard

Hanjin
Hapag Lloyd
Horizon Lines
Hyundai(HMM)
Item2
K-Line
MSC
Maersk
Mol_group
NYK
OOCL
Others(Pl Specify)
PIL
Shandong
UASC
Wanhai
Yang Ming
ZIM

Dry
Flooded
Ice/Snow
Muddy
NA
Oil/Grease
Sandy
Uneven
wet

AOM/Shift Manager/Ops
Clerk/Checker
Driver:3rd Party
Driver: Company Vehicle(Bus,Car,Pickup,Motorbike)
Driver: Container Handling Equipment
Driver: Forklift
Driver:UTR/Terminal Tractor
Flagman/Signalman/Wharf Controller
Foreman/Supervisor
Gearman/Lasher(Vessel)
Line Handler/Mooring Crew
MESC
Mechanic/Engineer/Technician
OCU
Others-3rd party(please specify)
Others-Employees(please specify)

Allergic reaction
Asbestosis
Cancer
Cardio logical
Contagious Disease
Cumulative trauma
Diseases caused by biological agents
Diseases caused by chemical agents
Diseases caused by physical agents
Hearing loss
Heat Prostration/Heat stroke
Mental stress
Non Occupational
Not selected
1.Poisoning

Pinman/Coneman/Lasher(Quayside)
Security
White Collar

2.Radiation
3.Respiratory
4.Silicosis

Abdomen/stomach
Ankle
Back/spine
Buttock/hip/groin
Chest
Ear
Elbow
Ear
Eye
Face/head
Hand/wrist
Knee
Left arm
Left foot
Leg
Lower arm
Mental/emotional
Neck
Nose
Right arm
Right foot
Shoulder
Skull
Throat
Thumb
Toe/nail
Upper arm
Whole body
Finger
Forehead
Others (please specify)

Abrasion/Bruise/Contusion
Amutation
Burn
Burn/Scald
Cardiac/respiratory
Concussion
Contusion/Bruising/contact skin
Crushing
Cut/Open wound
Cut/Laceration/scratched/punctured
Damage caused by electricity
Dislocation
Electric shock
Emotional Stress
Exposure
Fatal
Foreign body in wound
Foreign object Invasion
Facture
Fracture/sprain
Hernia
Illness
Injury to internal organ
Internal ache/pain
Jostling
Multiple injuries
Muscle Strain
Pass-out
Poisoning
Reaction to Chemical
Skin Irritation
Smash/Trauma
Soft Tissue Injury
Sprain
Stress
Superficial Injury
Swelling
Traumatic Amputation
Twist/Bend
Unknown

Overstrain/exertion
Caught in/by/between
Caught up in
Contact with
Contact with(elec./temp./col/etc)
Fall to lower level
Fall to same level
Foreign object in eye
Hit against

Jostled/shock by
Other(Please Specify)
Pressure related
slip/trip/fall
squeezed
struck against
struck by
struck down by

Good
NA
Poor
Satisfactory
Very good
Very Poor

Man
Woman

divorced
domestic partner
living together
married
registered partners
separated
single
unknown
widowed

Building
Container handeling Equipment
Container repair & maintenance
Dock/Quay
Gate
Inspection Area/CFS
Non- Containerised Cargo
Off - Site
Other Inland Services
operations(Ware house,CFS..etc)
Other Terminal Ops Labour
Parking
Rail
Reefer handeling
Transport
Truck/tractor driver
Vessel
Warehouse
Workshop (M & R)
Yard

Contractor
Customer
Government Authorities
Others(Please Specify)
Over the road/external driver
Port employee
Shipping Line/Vessel crew
Vendor
Multiple fatalities
single fatality
LTI
Days away from work
Restricted work
Medical treatment only
first aid only

yes
no

Other type of fire

5.Multiple Fatalities-resulting from injury or occupational health

4.Single Fatality or permanent total disability
3.Major injury or health impact-affecting work performance for more than 5 days
2.Minor injury or health impact-affecting work performance upto 5 days
1.Slight injury/health impact-not affecting work performance/daily life activity

5.More than 1.0 milloion USD

4.Between 100,000 USD and 10,00,000 USD
3.Between 10,000 USD and 100,000 USD
2.Between 1,000 USD and 10,000 USD
1.Lower than 1,000 USD

Electrical fire
Fire in solid materials
Fluid fire
Hydrocarbon fire
Metal Fire

others(Please Specify)
Auto Sprinkler dry pipe
Auto Sprinkler-wet pipe
Dry Chemicals
Fire water monitors
Fire Truck
Foam system
Halon Release
Hand extinguisher
Overpressure/ventilation fans
Permanent CO2 system
Shutdown
Smoke and Fire doors
Water
Water mist
Water spray-AFFF
water wall
Others(Please Specify)
3rd party
Terminal

A.Never heard in industry

B.Heard of in industry but not heard of in APMT
C.Has happened more than once in the indusrty or has happened at the location
D.Has happened more than once in APMT or has happened at the location
E.Has happened more than once at the location
5.Massive impact-Persistent,severe environmental damage
4.Major impact-Severe environmental damage that requires extensive measures.
3.Moderate impact-limited env damage that persists and requires cleaning up
2.Minor impact-minor environmental effect but no lasting damage
1.Slight impact-slight env damage that contains within the premise

5.Massive impact-on APMT reputation,-Govt/International public/NGO concern

4.Major impact-Likely to escalate and affectAPMT reputaion
3.Moderate impact-significant impact in country.local stkhldrs are concerned
2.Minor impact-Local public concern or local media coverage
1.Slight impact-local public awareness but no discernable concern/media coverage

ational health

ormance for more than 5 days

formance upto 5 days
rformance/daily life activity

has happened at the location

appened at the location

t requires extensive measures.

ts and requires cleaning up
lasting damage
hin the premise

national public/NGO concern

cal stkhldrs are concerned

rnable concern/media coverage