PPL - HSE / FM / IIR / 03

Rev : 01

INCIDENT INVESTIGATION REPORT (IR 03)

Dept. / Field / Location:

Area:

__________________________

_______________________

Type of incident investigated: (check below)

Fatality

Lost time
injury or
illness

Occupational
injury or illness
without lost time

Restricted
Work
Case

Fire /
explosion

Property
damage

Near
Miss

Environmental

incident

Exact location of incident: (area, building, floor, department)

Person(s) involved:
Full name:

Employee Number:

Department:

Occupation:

Witnesses:

Name(s):

Department:

Incident date:
Investigation Team:
Name:

Shift:

Occupation:

Time:

Department:

Occupation:

Date of Investigation:
Details of incident: (Who was involved, what happened and why, actions taken at the time etc. (attach additional
information if necessary)

Number of work days lost (calendar days):

PPL - HSE / FM / IIR / 03

Rev : 01

Investigation Findings (Immediate and underlying causes and contributory factors)

Actions to prevent re-occurrence (Attach additional information if necessary)

Primary or Underlying Cause:
Action:
Responsible:

Compiled by:
(Sectional Head)
Name:
Designation:
Date:

Reviewed by:
(HSE
Representative)

Approved by:
(Dept. Head /
Field / Location
Incharge)

Completion Date:

Report distribution:

Summary of Action Review:

Date of Review, Name and Signature:

All incidents must be reported to HSE at HO within 5 days on IR 03 with copy to all concerned. In case of unavailability of victim for
investigation purpose report may be submitted on his arrival as soon as possible.