INCIDENT REPORT

Incident Ref No

Incident Date Time

Reported by Dept. / Site

Descriptions of Incident: Electrical cable Damaged

What Acts or conditions led to the incident?

Why the unsafe act was committed, or why was the unsafe condition present?

What steps have been / will be taken to prevent a similar incident?

Person responsible for follow up actions:

Expected completion date Actual completion date

Evaluation of Risk

Potential Consequences Probability of Reoccurrence

 Catastrophic  Probable
 Critical  Occasional
 Marginal  Remote
 Negligible  Improbable

Dept. Head / Project Manager Safety Officer