Incident Investigation & Reporting HSE Procedure

Initial Incident Report

(This report will describe and indicate the initial facts related to the scene, IP, incident environment and any involved equipment)

NEAR MISS INJURY ROAD TRAFFIC E&S SECURITY INCIDENT

DATE: TIME: REPORT# LOCATION: INCIDENT TYPE:

If no IP tick the box (Double click to check/uncheck the box)
NAME: AGE/SEX:
COMPANY: LOCATION:
BODY INJURED PART: TRADE:
ID No. OTHER:
Description:
Direct Cause(s)
Management System:

Immediate Medical Treatment Given:

If no IP tick the box

Evacuation required? If yes, please specify. IP was evacuated from scene of incident, to Site Clinic
If no IP tick the box
Apparent causes
Direct causes Surface causes Management System Deficiencies
Improper Work Technique Poor Workstation Design or Layout Lack of Written Procedures or Safety Rules
Improper PPE, Not Used or Used Incorrectly Fire or Explosion Hazard Safety Rules Not Enforced
Safety Rule Violation Congested Work Area Hazards Not Identified
Operating Without Authorization Hazardous Substances PPE Unavailable
Failure to Warn or Secure Inadequate Ventilation Insufficient Worker Training
Operating at Improper Speeds Improper Material Storage Insufficient Supervisor Training
By-Passing Safety Devices Improper Tool or Equipment Improper Maintenance
Guards Not Used Insufficient Job Knowledge Inadequate Supervision
Improper Loading or Placement Slippery Conditions Insufficient Job Planning
Improper Lifting Poor Housekeeping Inadequate Hiring Practices
Servicing or Adjusting Machinery in Motion Excessive Noise Poor Process Design
Horseplay Inadequate Guarding of Hazards Inadequate Workplace Inspections
Drug or Alcohol Use Defective Tools/Equipment Inadequate Equipment
Unsafe Act(s) of Others Insufficient Lighting Unsafe Design or Construction
Unnecessary Haste Inadequate Fall Protection Unrealistic Scheduling
Other: Other: to be identified Other:
Others If yes specify: Lack of daily inspection, and proper maintenance
Immediate Action Taken:

Reference photos:

NE1-00-HS-SEC-PRO-OOO(G)-00005 Rev 05
 Incident Investigation & Reporting HSE Procedure

Situation Fixed Need Further Actions? if yes please specify: Action proposed to be re-discussed
Investigation required? Yes No
Reporting party
(Name/Company/Designation)
Reviewer
(Name/Company/Designation)

NE1-00-HS-SEC-PRO-OOO(G)-00005 Rev 05