ACCIDENTINCIDENT

INVESTIGATIONREPORT

INVESTIGATIONREPORT
Thepurposeofcompleteinvestigationistoidentifyallofessentialandcontributingfactorswhereled
accident/incidentoccurredanddeterminecorrectiveactiontopreventreoccurrence.

I. PROJECTDATA
Projectname/No :
ProjectManager :
ProjectLocation :

ACCIDENT/INCIDENT
DateofOccurrence : / / Day : Time : :

DETAILS
Locationdetails :
Workrelated : Shiftworked : Overtime :
Company :
Department :
Contractor :
AreaCoordinator :

II. INVESTIGATIONTEAM

No InvestigationTeamMember Position




III. LOSSINFORMATION

Completeattachment1detailsoflossinformation

IV. WITNESS
No Name Position Department

AttachWitnessstatement
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Filename IncidentInvestigationReport Issuedate August15,2011

DocumentNo GBEHSE_00202_FIIR_2011 Rev.No. A0

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INVESTIGATIONREPORT

ACCIDENT/INCIDENTDESCRIPTION
V. CHRONOLOGY

Note:Attachadditionsheetwhereappropriate

VI. IMMEDIATECAUSE

VII. BASICCAUSE

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Filename IncidentInvestigationReport Issuedate August15,2011

DocumentNo GBEHSE_00202_FIIR_2011 Rev.No. A0

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VIII. INJURYDETAILS
BodyPartInjured
Head/Neck Arms Hands Back Chest

Abdomen Feet Legs Skin Eyes

Internal Other:..(Explain)

TypeofInjury
Amputation Concussion Fracture Crush Burn

Sprain/strain Bruising Abrasion Laceration Dermatitis

Exposure Other:..(Explain)

MechanismOfInjured
Knocked Chemicals Manualhandling FlyingObject Electricity

FallingObject Vehicles Hands Tool Knife

Trip/Slip/Fall Machinery Other:..(Explain)

ProtectiveClothing&Equipment
ProtectiveClothing&EquipmentwasbeingwornatthetimeofIncident
SafetyShoes SafetyStandardAchieve Yes No

SafetyHelmet SafetyStandardAchieve Yes No

SafetyGlass SafetyStandardAchieve Yes No

HandGloves SafetyStandardAchieve Yes No

Respirator SafetyStandardAchieve Yes No

SplashGoggles SafetyStandardAchieve Yes No

HearingProtection SafetyStandardAchieve Yes No

FaceShield SafetyStandardAchieve Yes No

Other:(Described)

Note:AttachSketchorphotographswhereappropriate

Filename IncidentInvestigationReport Issuedate August15,2011

DocumentNo GBEHSE_00202_FIIR_2011 Rev.No. A0

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IX. ROOTCAUSEOFACCIDENT
ReviewandticktheboxbelowthosearecontributingtothecauseofIncident

EQUIPMENT WORKER ENVIRONMENT MANAGEMENT

Ambientconditions Hazardouswork
Poorlighting Fatigue/Stress
(Wind,dust,rain,etc) methodspecified

Physicaldisability
ExcessiveNoise affecting Excessivenoise LackOfSupervision
performance
Difficultyin Provisionofcorrect
operating CulpableAct Terrain safetyequipment
(Tool&Equipment) andclothing

Skylarkingor Inadequatetraining
ManualHandling Temperatures
Misconduct provided


CongestedWork Possiblepersonal Poorhousekeeping
PoorHousekeeping
Area problem standard

BuildingSurface
HazardousMachine, Inexperienceintask Poorlymaintained
conditions(Stair,
toolorEquipment beingperformed equipment
floors)
Malfunctionor Suitableplant/
Failuretousesafety Storage/stackingof
defectinmachine/ equipment
clothing material
equipment unavailable
Unsuitablesafety Exposureorcontact Inadequateorno
Hazardouswork
clothingor chemicalsorother document
methoduse
equipment harmfulmaterial procedures
Inadequate
Possibleinfluenceof Exposuretoinfectious
Difficulttomaintain instructionor
alcoholordrugs sickness/diseases
information

Inadequateguarding Actoromissionof Production
Visibility
orprotection anotherperson pressure








Filename IncidentInvestigationReport Issuedate August15,2011
DocumentNo GBEHSE_00202_FIIR_2011 Rev.No. A0

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X. PERSONALDETAILS
(Performinseparatesheetifmorethan2peopleinvolves)

Person Name

DateofBirth: / / Age : Female Male

GBEEmployee SubContractorEmployername

Position

Damaged Fataloccurred LosttimeIncident NonLosttimeIncident

injury Disease Datesymptomswerefirstrecognized

Work Work Work
Initial Initial Consequences Consequences Consequences
treatment Prognosis Immediate After24hours After3days

Returntopre Returntopre Returntopre
Hospital Class1
injuryduties injuryduties injuryduties


Restricted
Medical Class2 Restrictedduties Restrictedduties
duties


FirstAid Class3 OffWork OffWork OffWork

Thisdamageisconsideredtobe:

Aggravationofpreviouspersonal
Thesourceofthepersonaldamage
damage

XI. DIRECTCAUSE(S)ENVIRONMENTALFACTOR

FactsFinding : 1
2
3
4
5
6
7
Filename IncidentInvestigationReport Issuedate August15,2011
DocumentNo GBEHSE_00202_FIIR_2011 Rev.No. A0

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8

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XII. CONTRIBUTINGFACTOR(S)ENVIRONMENTALFACTOR

FactsFinding : 1
2
3
4
5
6
7
8


XIII. CORRECTIVEACTIONTAKENTOPREVENTREOCCURRENCE
SHORTTERM(Immediateactiontoaddressdirectcauses)
PERSON
CORRECTIVEACTIONTAKEN TARGETDATE
INCHARGES










LONGTERM(Toaddresslongtermcorrectiveaction)
PERSON
CORRECTIVEACTIONTAKEN TARGETDATE
INCHARGES

Filename IncidentInvestigationReport Issuedate August15,2011

DocumentNo GBEHSE_00202_FIIR_2011 Rev.No. A0

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XIV. MANAGERIALSTATEMENTS:

SUPERINTENDENTCOMMENTS

Signed: Date:
SUPERINTENDENT

HEADDEPARTMENTCOMMENTS

Signed: Date:
HEADDEPARTMENT

PROJECTCOORDINATORCOMMENTS

Signed: Date:

Filename IncidentInvestigationReport Issuedate August15,2011

DocumentNo GBEHSE_00202_FIIR_2011 Rev.No. A0

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PROJECTCOORDINATOR

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XV. THISPARTDESCRIBETOPERSONNELWHOWILLENSUREANDCONTROLTHECOMPLETION
OFCORRECTIVEACTIONTAKEN
INVESTIGATIONTEAM
InvestigatorI InvestigatorII Acknowledgeby

SITESAFETYOFFICER SITEDEPARTMENTHEAD SITECOORDINATOR

SAFETYMANAGER/HSECOORDINATOR

YUSRI
CompleteAction Signed: Date:
HSEDEPARTMENTHEAD

XVI. CLOSEOUTOFACCIDENTINCIDENT

To be completed once all relevant sections have been completed. This accident/incident
report, including investigation and corrective actions, has been adequately closed out.
The effectiveness of the corrective actions has been evaluated.

Name : Signature :

Position : Date :

Filename IncidentInvestigationReport Issuedate August15,2011

DocumentNo GBEHSE_00202_FIIR_2011 Rev.No. A0

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INVESTIGATIONREPORT

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Filename IncidentInvestigationReport Issuedate August15,2011

DocumentNo GBEHSE_00202_FIIR_2011 Rev.No. A0