Document No.

SATURN TRADING & CONTRACTING

Rev. No. Rev. Date
HSES ACCIDENT / INCIDENT REPORTING AND INVESTIGATION
PROCEDURE
Page
HSES INCIDENT / ACCIDENT INVESTIGATION REPORT 1 of 5
`

Disease Illness Death

HEALTH (Category 3) (Category 1)
Report No:-
(Category 1)

Near Minor Reportable / Fatali Property

SAFETY ty Fire
Miss Injury Major Injury (Categor (Category 2) Damage
(Category 3) (Category 3) (Category 1) (Category 2)
y 1)

Complaint
From Env Major
Relea
ENVIRONMENTAL Authority / Hazard – Minor Release
se
Neighbour Near Miss (Category 2)
(Categor
hood (Category 3)
y 1)
(Category 4)

3rd Sup
EMPLOYER / SECC Sub-
Part plie
Empl contr
COMPANY SATURN TRADING & CONTRACTING PROJECT: y r
NAME:
LOCATION: Department /
(where Accident / Incident
occurred) Section:
Date of Accident / Time of Accident / Date & Time
Incident:(DD/MM/YYYY) Incident: (hh:mm) Reported: @

Name of affected / Employee

Injured Person: Coy. No.:
Designation / Employee
Job Title: Age: (YY)
Expected time off work:-
Date Employed: - (excl. day of accident) Tick appropriate
Duration of Employment:- Industry Experience:-
A (DD/MM/YY)
0 days ≤ 3 days > 3 days Perm.

yrs: mths: yrs: mths:

Accident / Incident Government / Police: No Date:

reported to: Labor Ministry/Government : No Date:

Machine / process involved /

type of work performed:
Description of Incident
(A detailed report together with diagrams, photographs and any witness statements should be attached where necessary, in case of Environmental

B spillage mentioned the amount of the spillage (in liter) ):-

Type of Accident (Indicate what kind of accident led to the injury or condition – tick ONE box)

Contact with moving machinery or material being machined. Drowning or asphyxiation.

Struck by moving, flying, or falling object. Exposure to or contact with harmful substance.

Struck by moving vehicle. Exposure to fire.

C Struck against something fixed or stationary. Exposure to an explosion.

Injured whilst performing manual handling, lifting or

Contact with electricity or an electrical discharge.
carrying.

Slip, trip or fall on same level. Injury by an insect or animal.

Fall from height. Violence, physically assaulted by a person.

Trapped by something collapsing. Other kind of accident. ( __________________)

Immediate action(s) taken after occurrence of accident:

 Document No.
SATURN TRADING & CONTRACTING
Rev. No. Rev. Date
HSES ACCIDENT / INCIDENT REPORTING AND INVESTIGATION
PROCEDURE
Page
HSES INCIDENT / ACCIDENT INVESTIGATION REPORT 2 of 5
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1.
2.
3.
4.
D 5.
6.
7.
Supervisor’s Name: Sup. Sign: Date:

Overview of Events Prior to the Time of Accident / Incident: (Tick appropriate) YES NO N/A
Did the accident / incident occur during normal working hours?
Was the PSTB conducted with the injured person(s) prior to commencement of work?
Was the hazard(s) identified during the PSTB review process?
Was the injured person authorized to carry out the job / task?
Was the injured person trained for the specific job / task?

E Was the job / task supervised by a competent supervisor at the time of accident / incident?
Did the injured person make use of the correct tool(s) / equipment / material at time of event?
Was the correct PPE worn by the injured person at the time of the accident / incident?
Were the correct machine guards in place at the time of the accident / incident?
Were all energy sources to the machinery / equipment isolated?
Was the injured person working in an elevated position at the time of the accident / incident?
Was the height of the elevated position 2.0 meters or more?

What was the procedure taken during the occurrence of the accident / incident? (Tick appropriate)
First aid provided at location?
Injured employee transferred to hospital for medical treatment?
F Injured employee transferred to home?
Injured employee returned to place of work?
Injured employee moved to perform other job / task?
Other (Specify):

Environmental Conditions at place of incident / accident:

ATMOSPHERE: LIGHTING: WORK SURFACE: HOUSEKEEPING:

Wet Natural Levelled / even Good / controlled

Dry Artificial Unlevelled / uneven Poor / uncontrolled

Hot Good / sufficient

G Cold Poor / insufficient

Storm – Sand None

Storm – Rain

Mist

High wind / Gust

Other

H Injury, Disease & Environmental Analysis:

BODY PART TYPE OF INJURY CAUSE OF INJURY DAMAGE

AFFECTED
 Document No.
SATURN TRADING & CONTRACTING
Rev. No. Rev. Date
HSES ACCIDENT / INCIDENT REPORTING AND INVESTIGATION
PROCEDURE
Page
HSES INCIDENT / ACCIDENT INVESTIGATION REPORT 3 of 5
`

Head / Scalp Abrasion (graze) Act of violence Buildings

Face Amputation Caught in between / trapped Plant / Machinery
Eye Asphyxiation Collapse – structure Equipment
Neck Burn / Scald Contact – Electrical Tools
Shoulder Burn – Chemical Contact – hot metal / flash Vehicles
Chest Contusion (bruise) Contact – with machinery Product
Back Cut / Laceration Climate – heat stress Other
Abdomen Dislocation Explosion
Arm – Upper Electrical Shock Exposure – Haz. Substance
DISEASE / ILLNESS
Elbow Foreign Object Fall – from height
Arm – Lower Foreign Body – in eye Fall – same level / slip / trip Skin
Wrist Fracture / crush Fire Respiratory
Hand Multiple Injury Flying / striking object Muscular
Finger Poisoning Handling / use – electr. Tools Skeletal
Leg – Upper Puncture / Penetration Handling / use – hand tools Endemic
Knee Sprain / Strain Handling – manual Hearing
Leg – Lower Unconscious / faint Handling / lifting – mech. Neurological
Foot Other(___________) Horse play Psychological
Ankle Moving machinery Other
Toe Stepping on
Internal Struck – against
ENVIRONMENTAL
Multiple Struck – by moving plant
Struck – by falling object from
Soil Pollution
height
Struck – by falling object same
Water Pollution
level
Transportation / RTA Air Pollution
Bite / Sting – Snake, Insect,
Toxic Gas Release
spider, scorpion, etc.
Other(___________) Other(___________)

ESTIMATED COST (Specify Local Currency):

SUB-
Medical Salary / Wages Damages Repairs Other
TOTAL
Doctor Injured Pers. Equipm. Labour Machine hire
Ambulance Investigator Property Supervision Cont. Product
I Hospital Witness Material Material
Replacement Machinery

Local Currency: TOTAL:

 Document No.
SATURN TRADING & CONTRACTING
Rev. No. Rev. Date
HSES ACCIDENT / INCIDENT REPORTING AND INVESTIGATION
PROCEDURE
Page
HSES INCIDENT / ACCIDENT INVESTIGATION REPORT 4 of 5
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ROOT CAUSE ANALYSIS

WHAT WAS THE DIRECT / IMMEDIATE CAUSE AND THE BASIC / ROOT CAUSE OF THE INCIDENT
(Indicate with (X) where inadequate controls contributed to cause of the incident.)
Direct / immediate Cause of Incident?
Sub-standard Practices / Unsafe acts Sub-standard Conditions / Unsafe Conditions
A Operating Equipment Without Authority AA Inadequate Guards / Barriers

B Failure to Identify Hazard BB Inadequately Guarded / Unguarded

C Failure to Secure or Contain CC Inadequate Protective / Control Equipment

D Failure to Follow / Apply Control Mechanisms DD Improper Protective / Control Equipment

E Operating in Improper Manner – e.g. Speed EE Defective Tools, Equipment or Material

F Making Safety or Control Devices Inoperable FF Congestion or Restricted Movement

G Removing Safety or Control Devices GG Inadequate Warning Systems

H Using Defective / Unsafe Equipment HH Fire and Explosion Hazard

I Using Equipment Improperly or Incorrectly II Poor Housekeeping / Disorderly Workplace

J Failure to use PPE JJ Hazardous Environment / Arrangement

K Improper / Unsafe Loading KK Noise Exposure

L Improper / Unsafe Placement LL Radiation Exposures

J1 M Improper / Unsafe Lifting MM High or Low Temperature Exposures

Taking Up Unsafe Position / Improper Position for
N NN HCS Exposure (Dust, Fume, Vapour, etc.)
Task
O Servicing Equipment in Operation OO Dust Exposure

P Under the Influence of Alcohol or Drugs PP Inadequate or Excessive Illumination

Q Improper Resource Use or Disposal QQ Inadequate or Improper Ventilation

R Act of Violence RR Inappropriate / Unsafe Design or Construction

S Distracting / Teasing / Horseplay SS Fall / Slip / Trip

T Ignoring Safety Regulations TT Falling / flying object

U Other – UU Ergonomics

VV Poor / lack of maintenance

WW Moving Machinery

XX Defective machinery

YY Unsafe clothing

ZZ Poor layout

AAA Other –
BBB
None
B
C

J2 Personal Factors
BASIC / ROOT CAUSE / INDIRECT CAUSES OF INCIDENT?
Job Factors

A Unsuitable Physical / Physiological Capability AA Inadequate Leadership and / or Supervision

B Unsuitable Mental / Physiological Capability BB Inadequate Engineering / Planning

C Physical Stress CC Inadequate Purchasing

D Lack of Knowledge DD Inadequate Maintenance

E Lack of Skills EE Inadequate Tools or Equipment

F Improper Motivation FF Inadequate Work Standards / Procedures

G Improper Attitude GG Wear and Tear

H Lack of Attention / Concentration HH Abuse or Misuse

 Document No.
SATURN TRADING & CONTRACTING
Rev. No. Rev. Date
HSES ACCIDENT / INCIDENT REPORTING AND INVESTIGATION
PROCEDURE
Page
HSES INCIDENT / ACCIDENT INVESTIGATION REPORT 5 of 5
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Corrective & Preventative Action to be Taken to Prevent a Re-occurrence:

Legend Legend Follow up –
Responsible Target of of section Signed Off
Corrective & Preventative Actions
Person Date section J2
J1
1
.
2
K .
3
.
4
.
5
.
6
.

Lessons Learnt:
1.
2.
L 3.
4.

Statements (Attach ALL statements (i.e. witnesses) including statement(s) from injured person(s)):
Statement Obtained
Name Designation / Job Title Company
Yes No

Report Completed By
Job Title Name Signature Date

Report Approved for Submission and Distribution

Job Title Name Signature Date

Accident Close-out
Job Title Name Signature Date
Site HSE Manager / HSE Representative
:
Construction Manager
Operation Director/ Project Director/
Project Manager /
SHEQ Director/ Sr. HSE Manager:

Distribution: (Strike through if NOT applicable)

Operations Operations Project Project Construction Sr. HSE Consultant

General Manager Client Rep.
Director Manager Director Manager Manager Manager Rep.