Form No : SAF – 01/ Rev.

02
INCIDENT / INJURY OCCURRENCE REPORT Date Prepared : 29 / 09 / 08

Part B:
Plant : Report No:

Date of Incident : Title:

1. PLEASE TICK THE BASIC ACTIVITY IN PROGRESS AT THE TIME OF INCIDENT

Normal Operation Plant Startup Plant Shutdown Lifting (Mech.) Chemical Handling
Commissioning Cleaning Material Handling Lifting (Manual) Others
2. PLEASE TICK WHAT IS CONSIDERED TO BE THE CAUSE OF INCIDENT:

PEOPLE RELATED EQUIPMENT/MATERIAL RELATED

Lack of Communication Careless Act Judgment Design Maint. / Inspection
Lack of Training PPE Manufacturing Defect Operation

3. SUPERVISION AT TIME OF INCIDENT: Installation Housekeeping

Directly Supervised Indirectly Supervised Failure
Not Supervised Supervision not feasible
4. PLEASE TICK WHAT YOU CONSIDER TO BE THE RELATED CAUSE

PROCEDURE RELATED PERMIT RELATED

Not Available Not Followed Incorrect Permit – Not raised Inadequate

Inadequate Not Clear Violated

5. PLEASE TICK THE PSM/s VIOLATED

Risk Analysis,
Incident Reporting
Safe Operations Program Personal Safety Assessment &
Analysis & Follow-up
Management
Operations & Maintenance Reliability of Critical Control of Defeat of
Management of Change
Procedures Systems & Devices Critical Systems & Devices
Emergency Facilities Design &
Work Permit System Inspection & Maintenance
Preparedness Construction
Process & Facilities Employees Qualification &
Information & Documentation Training
6. PLEASE TICK THE RESULTANT HEALTH AND ENVIRONMENT EFFECT (if applicable)

Air Water Land Noise

Ingestion Eye Skin Inhalation
7. DESCRIPTION / DETAILS OF THE INCIDENT
(Give as much detail as required for complete clarification. Use additional sheet if required.)
 Form No : SAF – 01/ Rev. 02
INCIDENT / INJURY OCCURRENCE REPORT Date Prepared : 29 / 09 / 08

8. CONCLUSION

What has been done / need to be done to prevent recurrence?

Action By Completion Date
(To be filled in concerned Supervisor / Section Head)

Comments / Recommendations by Department Manager:

Do you recommend further Investigations? Yes No Approved
Do you have concurrence of responsible individual on action items completion dates? YES NO
Date of occurrence of Incident: Report B due on (Based on 7 working days):

Report C will be due on :

NAME : (Section In-Charge / Section Head) SIGNED DATE

NAME : (Section In-Charge / Section Head) SIGNED DATE

Categorization of Recommendations:
1) S : Simple (to be completed within a week)
2) P : Procedural (to be completed within 2 months)
3) SJ : Simple Job ( to be completed within 3 months)
4) EJ : Engineering Job (to be completed within one year. Follow Management of Change Procedure)
5) T/A : Turnaround Job (to be completed at FAO / during T/A)

NOTE : PART B OF THIS REPORT SHOULD REACH THE SAFETY UNIT WITHIN SEVEN WORKING DAYS OF THE INCIDENT