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 :