Revision : 02

AL FUTTAIM ENGINEERING Issue : 03

INCIDENT / NEAR MISS INVESTIGATION REPORT Doc No : HSEMS FR 04

NAME OF THE ENTITY: AL FUTTAIM ENGINEERING (AFE) LOCATION:

INCIDENT REPORT NO: Name of Project / Div. / Camp: Job No:
Date: Time: Location of the Incident:
Type of the Incident: Choose an item. Severity of the Choose an item.
Incident:
Classification of the Choose an item. Job Supervisor:
Incident:
Health & Safety (details needed if the incident is related to Health and Safety)
Name of the effected person: Staff No: Emir ID:

Age of the effected person Experience in his current

role
Designation Who reported the
incident
Note: Enter the details under the ‘description of the incident’ if more than one injury cases are there.

AFE / subcontractor Choose an item. Name of the

subcontractor
Witness of the Incident Contact no of the
witness
Classification of Injury / illness Choose an item. No of effected persons Choose an item.
case
Affected Part Choose an item. Side Effected Choose an item.

Nature of Injury / illness Choose an item. Others

Injury / Illness Agent Choose an item. At the time of the Choose an item.
incident the employee
was
Fire (details needed if the incident is fire related)

Material Involved N/A Intensity of the fire Choose an item.

What was the extinguishing

media applied?
Was the civil defense / police Choose an item. Was building Choose an item.
informed? evacuated?
Potential cause of the Fire
(fill in detail in description
section)
Unsafe Act / Unsafe condition
noticed
Preventive action proposed

Cost Involved (Approx.) Were material / place Choose an item.

insured?
If Yes Name, address and contact

AFET-IMS-F291 | HSE | Incident Investigation | Issue 2 | Rev 0 | Jun '17

 Revision : 02
AL FUTTAIM ENGINEERING Issue : 03
INCIDENT / NEAR MISS INVESTIGATION REPORT Doc No : HSEMS FR 04

number of Insurance Company

If No ; Justify the reasons for not
being insured
Present state of material / place

ENVIRONMENTAL (details needed if the incident is environmental / property related) (Not applicable)

Duration of the spill / release Name of the

chemical/substance
release
Approx. quantity of spill Wind condition

Description of the incident: ( Attach photographs if required)

Immediate action taken:

Corrective action taken:

Is detail investigation required? This is determined by the potential worst possibility consequences as a
Choose an item. Details Investigation report.
Name Designation Signature & Date
Prepared By: Site supervisor

Approved By: Project Manager / Div.

Manager / CM/ Engr. in
charge

AFET-IMS-F291 | HSE | Incident Investigation | Issue 2 | Rev 0 | Jun '17

 Revision : 02
AL FUTTAIM ENGINEERING Issue : 03
INCIDENT / NEAR MISS INVESTIGATION REPORT Doc No : HSEMS FR 04

Event Employee(s) Location

Details involved

Date
Time

Injuries or ill health

effects, if any

Investigation Details
Include details such as
 Overview of the event
 Activities performed
 Equipment used
 Working conditions
 Safe work procedures
 Maintenance
 Competence for people involved
 Workplace layout
 Safety equipment used
 Any other conditions which may
influence the event

AFET-IMS-F291 | HSE | Incident Investigation | Issue 2 | Rev 0 | Jun '17

 Revision : 02
AL FUTTAIM ENGINEERING Issue : 03
INCIDENT / NEAR MISS INVESTIGATION REPORT Doc No : HSEMS FR 04

Cause of the event

Immediate event Underlying cause Root cause

Which risk assessment control measure should be implemented to prevent recurrence?

Risk Control Planned completion date Actual completion date Manager responsibility

Which risk assessment and safe work procedure to be reviewed and updated?

Risk Control Planned completion date Actual completion date Manager responsibility

AFET-IMS-F291 | HSE | Incident Investigation | Issue 2 | Rev 0 | Jun '17

 Revision : 02
AL FUTTAIM ENGINEERING Issue : 03
INCIDENT / NEAR MISS INVESTIGATION REPORT Doc No : HSEMS FR 04

Are there any further

details that should be
mentioned?

Member of the Name Position Name Position

investigation team

Signed on behalf of the investigation team

Name Position Date Signature

Report accepted by
Name Position Date Signature

The findings of the investigation need to be communicated to the following people

Name Position Date Signature

AFET-IMS-F291 | HSE | Incident Investigation | Issue 2 | Rev 0 | Jun '17