INCIDENT EPORT (AEC-HSE-PM-02-01)

(Page 1)
Engineering & Construction Co. L.L.C
Client: ……………………………………………………
Report No.: ……………………………………..
Project Name: ……………………………………………
Project No.: ……………………………………………..
INCIDENT REPORT Date: …………………………………………..
Location: ………………………………………………..
Area/Activity Authority
Date and time of occurrence: / hrs Location:
TYPE OF INCIDENT
Injury Occupational illness Asset Loss/ Fire/ Environ- Radiation Other Near Miss / Dangerous occurrence
Lost Time Minor Damage Explosion mental*
Name: Asset loss/damage/affected: Near Miss Card No: …………………….
Age: yrs. I.D No.: (Copy attached)
Position: Potential loss:
Company: - Injury
Dept./Section: - Asset/Property damage
Industrial: Yes No Details of damage(s)/extent/impact - Environmental impact
- Loss of production
- Loss of manpower
To be completed by Medical Officer - Others, specify
Part of body affected:
Nature/extent of injury/illness Equipment involved:
- Fatal
- Non-Disabling (minor) Samples taken: Yes No
- Disabling (lost time) FOR VEHICLE INCIDENT
- No. of lost days: Party No. 1 (Vehicle) Party No. 2 (Vehicle)
Treatment: Type of vehicle:
Registration No.
Owner
Dept./service concerned:
Driver's name: I.D. No.:
Position/dept./serv.:
Driving license No.:
Date of issue:
Name: ………………..
Sign: …………… Additional remarks:
Brief description of incident: ( attach photos / sketches as necessary)

Comments/ Recommendations:
No. Action Action By Target Date

Witnesses: (Attach written statements)

- Name: ………………………
Position: …………………………… Company: ……………………………. Dept/Section: …………………………..
- Name: ………………………
Position: ……………………………. Company: ……………………………. Dept/Section: …………………………..
External Factors: (only tick if any factor contributed to the incident)
Ground Illumination Weather Conditions
Wet Too low Sea state: Fog Hot
Dry Too bright High Rain Cold
Swell ( ft) Humid Air condition
Manager/Supervisor's Name: Signature: Date:
Project Manager Name: Signature: Date:
Procedure No.: AEC-HSE-PM-02 Form - 01 Revisions No. 00 Effective Date:01/08/2012
 INCIDENT EPORT (AEC-HSE-PM-02-01)
(Page 2)
Engineering & Construction Co. L.L.C
CAUSE ANALYSIS
Substandard actions:
1. None 8. Wrong or worn out equipment used 15. Improper loading 22. Help not asked for
2. Defective equipment used 9. Substandard conditions not reported 16. Improper lifting 23. Gas tester not used
3. Inattention to known hazards 10. Work/move too slowly/too quickly 17. Equipment moved to wrong place 24. Horseplay
IMMEDIATE CAUSES

4.. Procedures/Instruction not followed
5. PPE not worn/worn but defective
6. Safety rule not followed / did not warn
7. Improper working position
Substandard conditions:
1. None
2. Substandard act by another person
3. Hazard previously unrecognized
4. Housekeeping, PM standard poor
5. Safety equip. unsuitable not there, not
working
6. Heat or cold exposure hazard
7. Tools, equipment, materials defective
Personal factors:
1. None
2. Not motivated
Job factors:
BASIC CAUSES
ALSA PROJECT HSE
11. Equipment, tools used wrongly
12. Lack of communication
13. Safety devices by passed, not working
14. Working, riding on operating equipment
8. Ventilation inadequate
9. Work area congestion, restricted access
10. Chemical, fume, dust exposure hazard
11. Floor uneven, slippery
12. Equipment location unsuitable
13. Guards, barriers inadequate
14. Procedure/work instruction inadequate
15. Equipment used for different process
3. Not able to do job (physically or mentally) 5. Not trained (lack of knowledge or skill)
4. Over stressed (physically or mentally)
18. Equipment use without training/permission 25. Tired
19. Take short cuts, avoid discomfort 26. Unwell
20. M edication/Intoxicant influence 27. Other
21. Using equipment improperly
16. Supervision inadequate 24. Noise exposure
17. Inadequate warning system 25. Insect, animal bite
18. Abnormal operating conditions 26. Weather (rain/wind)
19. Fire, explosion, spill exposure hazard 27. Lighting inadequate
20. Personal Protective Equipment defective 28. Radiation exposure
21. Lockout of equipment not possible 29. Other
22. Process operation conditions changed
23. Sharp edge, protrusion
7. Other
6. Unsafe work permit

1. None 5. M aintenance deficiency 8. Inadequate work standards 11. Wear and tear
2. Leadership/supervision deficiency 6. Inspection deficiency 9. Tools, equipment, materials deficiency 12. Abuse or misuse
3. Work instruction/procedure inaccurate 7. Purchasing inefficiency 10. Unsafe working conditions 13. Other
4. Engineering deficiency
Organizational factors:
1. None 7. Safety audit schedule & follow- up 13. Engineering controls 19. Task observation
2. M anagement and supervisory training 18. Incident investigation procedures 14. Planned inspection programme 20. Personnel training
3. Personnel selection or assignment 9. Purchasing requirements 15. Safety communications 21. Incident analysis
4. Job safety analysis programme 10. Personal Protective Equipment 16. Routine communications 22. Other
5. Responsibilities, accountability undefined11. Occupational safety/health programme 17. Emergency preparedness
6. Company rules and standards unclear 12. Safety procedures preparation / update 18. Normal/ emergency procedures
Type of contact:
1. Personal falls 7. Trench or excavation 13. Animal, human and biological 19. Noise
2. Falling objects 8. Cranes 14. Violence 20. Stress
3. Caught in / between 9. Wires, ropes, cables and chains 15. Environmental impact 21. Others
4. Fires and explosion 10. Confined space 16. Dangerous materials
5. M achinery, tools and equipment 11. Vehicles and transportation 17. Handling
6. Electricity 12. Scaffolding or ladders 18. Environmental conditions
Comments / Recommendations:

Actions to be Taken/ Follow-up of Action(s)

No. Action Action By Target Date Comments

COMMENTS / RECOMMENDATIONS
PROJECT
ALSA

HSE

Project/Plant /Rig HSSE, Name: ………………………………………………..

Signature: ………………………………….
COMMENTS:
MANAGER
PROJECT
ALSA

Further investigation is required: Yes No

Project Manager Name: ……………………………………………………………..
Signature: ……………………………….
Procedure No.: AEC-HSE-PM-02 Form - 01 Revisions No. 01 Effective Date:01/08/2012