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    Incident Investigation Report Format No: HSE Format - 03 Rev. E Page 1 of 2

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    Nibha
    This document is an incident investigation report template that can be used to document workplace incidents. It collects information about the date, time, location and type of incident. It also documents details of any injuries or property damage. The template guides the investigator to identify the immediate, basic, and root causes of the incident. It provides checklists to help determine the direct causes and any failures in the company's occupational safety and health management system. Recommended remedial actions are suggested to prevent similar incidents.

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    Incident Investigation Report Format No: HSE Format - 03 Rev. E Page 1 of 2

    Uploaded by

    Nibha
    82 views2 pages
    This document is an incident investigation report template that can be used to document workplace incidents. It collects information about the date, time, location and type of incident. It also documents details of any injuries or property damage. The template guides the investigator to identify the immediate, basic, and root causes of the incident. It provides checklists to help determine the direct causes and any failures in the company's occupational safety and health management system. Recommended remedial actions are suggested to prevent similar incidents.

    Original Description:

    Safety notes

    Original Title

    Safety notes

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    This document is an incident investigation report template that can be used to document workplace incidents. It collects information about the date, time, location and type of incident. It also documents details of any injuries or property damage. The template guides the investigator to identify the immediate, basic, and root causes of the incident. It provides checklists to help determine the direct causes and any failures in the company's occupational safety and health management system. Recommended remedial actions are suggested to prevent similar incidents.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    82 views2 pages

    Incident Investigation Report Format No: HSE Format - 03 Rev. E Page 1 of 2

    Uploaded by

    Nibha
    This document is an incident investigation report template that can be used to document workplace incidents. It collects information about the date, time, location and type of incident. It also documents details of any injuries or property damage. The template guides the investigator to identify the immediate, basic, and root causes of the incident. It provides checklists to help determine the direct causes and any failures in the company's occupational safety and health management system. Recommended remedial actions are suggested to prevent similar incidents.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    MALLAVARAM-BHOPAL-BHILWARA-VIJAIPUR NATURAL

    GAS PIPELINE PROJECT – RFCL CONNECTIVITY

    Format No: HSE Format - 03


    INCIDENT INVESTIGATION REPORT
    Rev. E Page 1 of 2

    DATE AND TIME OF INCIDENT LOCATION OF INCIDENT AREA OF INCIDENT

    ROAD TRAFFIC  INJURY  ILNESS  FIRE / EXPLOSION


     PROPERTY DAMAGE  DANGEROUS OCCURANCE  LEAKAGE / SPILLAGE  OTHER

     INJURY / ILLNESS  PROPERTY DAMAGE OTHER POTENTIAL LOSS

    NAME OF INJURED EQUIPMENT DETAILS DAMAGE DETAILS

    - -
    NATURE OF INJURY COST ESTIMATED NO OF DAYS LOST

     MINOR
     MAJOR

    DESCRIPTION – HOW THE EVENT OCCURED

    IMMEDIATE CAUSES (ATTACH ANNEXURE IF REQURIED)

    BASIC / ROOT CAUSES ( ATTACH ANNEXURE, IF REQURIED)

    SUGGESTED REMEDIAL ACTIONS


    MALLAVARAM-BHOPAL-BHILWARA-VIJAIPUR NATURAL
    GAS PIPELINE PROJECT – RFCL CONNECTIVITY

    Format No: HSE Format - 03


    INCIDENT INVESTIGATION REPORT
    Rev. E Page 2 of 2

    DIRECT CAUSES CHECKLIST OSHEMS FAILURE

    SUBSTANDARD ACTIONS SUBSTANDARD CONDITIONS


    Operating equipment without authority Inadequate guards Safety Policy
    Failure to warn Inadequate or improper PPE Safety Work Practices
    Failure to secure Defective tools, equipment or Safety Training
    materials
    Carelessness / Recklessness
    Operating at improper speed Congestion or restricted action Safety Meeting
    Making safety devices inoperable Inadequate warning system Incident Investigation
    Using defective equipment Fire & explosion hazards In-House Safety Rules &
    Regulations
    Using equipment improperly Poor housekeeping; disorder SAFETY Promotion
    Failure to use personal protective Hazardous environmental conditions; Control of Sub-Contractors
    equipment properly gases, dusts, smokes, fumes, etc.
    Wrong working method
    Improper loading Noise exposures SAFETY Inspections
    Improper placement Radiation exposures Maintenance Regime
    Improper Lifting High temperature exposure Risk Assessment
    Improper position for task Inadequate illumination Control of Hazardous
    Substances
    Servicing equipment in operation Inadequate ventilation Emergency Preparedness
    Horseplay Occupational Health
    Under influence of alcohol/drugs Environmental Control
    Programs
    ROOT CAUSES CHECKLIST

    HUMAN FACTORS WORK FACTORS

    Inadequate capability Inadequate supervision Inadequate tools/equipment


    Lack of knowledge Inadequate engineering Inadequate work standards
    Lack of skill Inadequate purchasing Wear and tear
    Stress Inadequate maintenance Abuse or misuse
    Improper motivation

    NAME AND 1. FOLLOW UP ACTION


    SIGNATURE OF 2. DATE
    INVESTIGATOR/S 3.

    FOLLOW UP ACTION COMPLETED NAME AND SIGNATURE OF REVIEWER

    DATE: DATE :

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