KUNAL STRUCTURE (I) PVT.LTD.

DJC-PROJECT,IIT-KHARAGPUR,
Incident Investigation Report

Incident Investigation Report: LTI / Fatal / PD /HIPPO

Location: CRF /NANO BUILDING Date of Investingation:18/08/2018

Reference Number: Location- CRF/NANO, Year-2018 Report No-0002

___________________________________________________________________________
Index
Sr. No. Particulars Page no.

1. Executive summary

2. Details of incident

3. Investigation team member

4. Chronology of Events(Timeline)

5. List of Interviewees

6. Details of the IP

7. Cause(s) of the incident

8. Root cause(s)

9. Contributory cause(s)

10. Recommendations
11. Photographs
12. Witness statements
 KUNAL STRUCTURE (I) PVT.LTD.
DJC-PROJECT,IIT-KHARAGPUR,
Incident Investigation Report

1. Executive Summary : ( Brief description, Root cause & Recommendations)

 Brief Description: - Due to Overloading in the lift bucket a brick has overturned and
fall down from the 4th floor.
 Root Cause: - No proper supervision of the load that has to be taken by the lift
bucket at site during work. Hazard communication not made at site before work
activity.
 Recommendations: - Recheck the load in the lift bucket before operation and
TPI Certificate & load chart. Daily tool box meeting to be made before job.
Availability of job supervisor at site during work. Hazard communication to be
discussed with worker as per the work activity on regular basis.

2. Details of Incident : ( Due to overloading in the lift bucket a brick has fallen from 4 th floor
and No injuries, No Accident happened)

3. Investigation Team member :

Name Designation Name of Company Signature
R.Sahadeo Reddy HSE ASST- KSIPL
Manager

4. Chronology of Events (Timeline):

Date Time Description Information

Source

02/08/18 15:15 Incident happed at site.

5. List of Interviewees :

Name Company Description

 KUNAL STRUCTURE (I) PVT.LTD.
DJC-PROJECT,IIT-KHARAGPUR,
Incident Investigation Report

Sintu KSIPL Operator

8. Details of the IP (if applicable) :

Full Name
Date of Birth
Full Address

Name of Contractor
Date of Joining in
KSIPL
Total Experience
Educational
qualification
Training Details
Nature of Injury
Body Part Involved

9. Cause(s) of the Incident :

a) Contributory cause (s):

b) Root cause(s): Incompetency of work. Poor supervision.

10. Recommendations:
 KUNAL STRUCTURE (I) PVT.LTD.
DJC-PROJECT,IIT-KHARAGPUR,
Incident Investigation Report

Sr. No. Recommendations Action By Proposed completion

Date
Daily tool box meeting to be
1 Site
made before job. Supervisor/
Engineer

2 Availability of job supervisor at Supervisor/

site during work. Engineer

3 Hazard communication to be Supervisor/

discussed with worker as per Engineer
the work activity on regular
basis.
Proper PPE arranged for
4 HSE Dept.
workers for job.

(Signature) (Signature ) (Signature)

Sr.Project manager Construction Manager Site Engineer

Attachment 1: Photographs

Attachment 2: Witness Statements