without loss of
resulting in Loss
LTI - Personnel
Injury resulting in
Unable to do any
work next day
(8hrs or more)
Number of Off Hires this year
Number of Stoppages this year (without off hire)
General Comments : (Please provide brief reason / total hrs / date of the of Injuries, off hires - for the reporting month)
Accumulated LTI - (How many cases of Lost Time
Injuries - LTI this year ?)
How many accidents this year?
Operating days without Accident
Last accident occurred on:
How many Incidents this year?
Key Performance Indicator (KPI) of events for the Calendar Year (From 01 January to 31 December)
1. List brief details of above events occurred this month . For personal injury list how many working hours lost. If he did light work ,then it is not treated as
2. Lost Time Injuries (LTI) : Lost Time Injuries are the sum of Fatalities, Permanent Total Disabilities**, Permanent Partial Disabilities and Lost Workday
Cases. (LTIs = Fatalities + PTD + PPD + LWC)
Ple refer to guide lines given on subsequent pages of this form regarding definition of LWC,PTD, PPD and LTI.
Root cause analysis of the Events for the reporting month (Skip this if no events this month)
The counts and comments are to be recorded for the current month only.
Count: Always mark count as 1 for each event, if relevant. E.g.: If accident happened due to People-skills, and Equipment-Design then the count will be 1
divided by the no of causes (i.e 1 divided by 2) which means 0.5 for each cause. If we have more than one incident/accident etc on board during the
month due to the same cause then it has to be counted once for each event. E.g.: 2 accidents in the month due to Equipment- Design. Count is 1+1 = 2.
MONTHLY SAFETY AND QUALITY REPORT
Number of Undesirable Events for the reporting month
(Ref Form SHE-27)