Doc. No.

:HSE/FRM-32
Rev. 00
Date of Rev: June22, 2016:
FINAL INCIDENT REPORT Page : 1 of 6

PART – 1: INCIDENT BRIEFING

PROJECT TITLE: PROJECT NO.:

REPORT NO: DATE :

INVESTIGATION TEAM:

1) Name: Deptt : Designation:

2) Name: Deptt : Designation:

3) Name: Deptt : Designation:

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INVESTIGATION LEADER:

Name: Deptt/ Area: Designation:

INCIDENT DETAILS:

TYPE: ________________________ INCIDENT LOCATION: _______________ DATE & TIME: _____________

COMPANY: DESCON SUBCONTRACTOR SUBCONTRACTOR NAME: ____________________

PERSON INVOLVED OR INJURED:

1) Name: Deptt : Designation:

2) Name: Deptt : Designation:

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NATURE See IRAM

HUMAN LOSS:

SEVERITY: LOW MEDIUM HIGH

PROPERTY LOSS: LOW MEDIUM HIGH

SEVERITY

ENVIRONMENTAL LOSS: LOW MEDIUM HIGH

SEVERITY

PART II: a) OVERVIEW OF INCIDENT

 Doc. No.:HSE/FRM-32
Rev. 00
Date of Rev: June22, 2016:
FINAL INCIDENT REPORT Page : 2 of 6

b) DESCRIPTION OF INCIDENT

c) SEQUENCE OF EVENTS

TIMINGS EVENTS

d) KEY FINDINGS

e) DIRECT IMPACT (e.g. FINANCIAL, HUMAN, TIME AND PRODUCTION):

f) INDIRECT IMPACT (e.g. WORKFORCE MORAL AND COMPANY IMAGE):

g) IMMEDIATE CORRECTIVE ACTIONS TAKEN

 Doc. No.:HSE/FRM-32
Rev. 00
Date of Rev: June22, 2016:
FINAL INCIDENT REPORT Page : 3 of 6

PART III: (ATTACHMENTS)

Yes No Ref. No.

a) Photographs
b) Video
c) Communication
d) Documentary Evidence
e) Sketches / Drawings
f) Supervisor statement
g) Witnesses Statement
h) Injured Person Statement

PART IV : CONCLUSIONS (CAUSE ANALYSIS)

a) IMMEDIATE/APPARENT CAUSE/S:

b) BASE / LATENT/ ROOT CAUSES:


FINAL INCIDENT REPORT
IMMEDIATE / APPARENT CAUSES
SUBSTANDARD ACTIONS
 1.Operating equipment without authority
 2. Failure to secure
 3.Failure to warn
 4.Operating at improper speed
 5.Making safety device inoperable
 6.Using defective equipment
 7.Using equipment improperly
 8.Failure to properly use PPE
 9.Improper loading/placement/lifting
 10.Improper position for task
 11.Servicing equipment in operation
 12. Horse play
 13. Any Other Cause (Specify:
BASE / LATENT / ROOT CAUSES
PERSONAL FACTORS
 1.Inadequate capability
 2.Lack of knowledge/training
 3.Lack of skill
 4.Stress
 5.Improper motivation
[] 6.Fatigue
[] 7.Mental absence
8. Any Other Cause (Specify:
Doc. No.:HSE/FRM-32
Rev. 00
Date of Rev: June22, 2016:
Page : 4 of 6
SUBSTANDARD CONDITIONS
 1.Inadequate guard or barriers
 2.Improper protective equipment
 3.Defective tools, equipment
 4.Conjection or restricted action
 5.Inadequate warning system
 6.Fire & explosion hazards
 7.Poor housekeeping
 8.Environmental conditions
 9.Noise/Radiation exposures
 10.Inadequte ventilation
 11.High or low temperatures
 12.Inadequate illumination
 13. Any Other Cause
) . Any Other Cause
(Specify: )
JOB FACTORS
 1.Inadequate leadership supervision
 2.Inadequate engineering
 3.Inadequate purchasing
 4.Inadequate tools/equipment
 5.Inadequate maintenance
 6.Inadequate work standards
 7.Wear & tear
)  8.Abuse or misuse
9. Any Other Cause
(Specify: )
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Rev. 00
Date of Rev: June22, 2016:
FINAL INCIDENT REPORT Page : 5 of 6

PART V: (RECOMMENDATIONS & FOLLOW-UP)

a) RECOMMANDATIONS & FOLLOW UP:

Sr. RECOMMENDATIONS ACTION BY TARGET DATE FOLLOW-UP 1 FOLLOW-UP 2

b) REMARKS BY PM / SM / FACILITY MANAGER

c) REMARKS BY HOD

c) REMARKS BY HEAD QHSE

 Doc. No.:HSE/FRM-32
Rev. 00
Date of Rev: June22, 2016:
FINAL INCIDENT REPORT Page : 6 of 6

INCHARGE SITE HSE/CORPORATE HSE PM /SM

HEAD QHSE HOD

REPORT DISTRIBUTION:

1.
2.
3.