iRISE/HSMS/RRII REV#00 EFF DATE:01/04/2021

iRISE INDIA PVT. LTD

REPORTING, RECORDING AND INVESTIGATING INCIDENTS

PART -- A

Supervisor's Initial Investigation Report

(SIIR)
GENERAL INFORMATION:

1. Department: 2.Vendor: #

3. Date of Incident: 4. Time of incident:: .

5. Date Reported: 6.Time Reported:

7. Hours worked before incident: 8.Supervisor :

INCIDENT CLASSIFICATION:

�Injury/Illness � Property Damage � Near Miss � Observation

POSSIBLE CONSEQUENCE
�First Aid � Fire �Toxic Release � Derailment
� Medical Case (Existing illness) �For gain Body � Equipment / Property Damage
�Lost Time � Fatality

INCIDENT RATING: To ensure proper reporting and investigation, this incident is rated below
considering the potential severity and probability of recurrence:
1. CRITERIA-1 2. CRITERIA- 2-5
EMPLOYEE INFORMATION:

9.Name of employee:……………………… 10.RFID Number

11. Designation: ………………………12.Rate of pay:

13. Address…………………………………………………………………………..City:…………………………………….

State:……………………………………………….Pin……………………14. Phone…………………………………..

15.MaritalStatus: �Married �Widowed �Divorced �Single

16. Spouse Name: 17.Number of Children: …

18. Birth date/Age: ……………… 19.Experienceyrs./months

20.Sex:√�M � F 21.ESI Number

22. Subcontractor: ………………… 23.SiteContactPhone#

24.On Company Property: Yes� No� 25.Date of Hire:

26. Incident Location:…………………………………………………………

iRISE/HSMS/RRII REV#00 EFF DATE:01/04/2021
iRISE INDIA PVT. LTD

INJURY
(If more than one work was injured as a result of the incident, complete additional SIIR forms describing those injuries and attach)

27.Part of Body: Indicate “R” for right, “L ”for left,“B” for both n/a

�Abdomen �Ankle �Arm �Back �Chest/Ribs

�Ear �Elbow �Eye �Finger/Hand � Leg/Groin/Thigh

�Foot/Toes �Head/Face/Skull �Hip �Knee �Wrist

�Mouth �Multiple Injuries �Neck �Shoulder

�Other (please specify)………………………………………………………………………………………………………..

28.Natureof injury:

�Abrasion �Amputation �Burn Chemical �Burn Thermal

�Contusion �Fracture �Electric Shock �Heat Disorder/Stress

�Frostbite �Hernia �Ingestion/Poisoning �Irritation/Infection

�Inhalation � Laceration �Joint Dislocation �Puncture

�Strain/Sprain �Occupational Disease �Particleonsurface �Particle/splinter imbedded

�Musculoskeletal Disorder(Repetitive Strain/Tendonitis)�Other (please specify

29.Contact/Event:
�Struck Against (Running or Bumping) �Struck By (Hit By Moving Object)

�Fall on Same Level (Slip and fall, Trip Over) �Equipment Failure

�Fall from Elevation to Lower Level �Caught In (Pinch and Nip Points)

�Caught Between or Under (Crushed or Amputated) �Caught On(Snagged, Hung)

�Environmental Release �Overstress/Overexposure/Overexertion

�Contact With (Electricity, Heat, Cold, Radiation, Caustics, Toxics, Biological, Noise

30.Sourceof Incident:(Employee activity at time of incident)� On Job � Off Job

�Climbing �Driving-Car/Truck �Material Installations �Hand Tool Use

�Innocent victim �Material handling �Standing �Operating Crane/Hoist/forklift

�Operating machine �Walking �Operational/maintenance work

31.Person treating injury (physician/hospital lname and address)………

32.Rescuer’s Name:…………………………………..
iRISE/HSMS/RRII REV#00 EFF DATE:01/04/2021
iRISE INDIA PVT. LTD

PROPERTY/MATERIAL/ENVIRONMENTAL DAMAGE

33. Does Material belong to Tata Steel…………………………………………………………………………………….

34. What was damaged?………………………………………………………………………………………………..

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35. Nature of damage:…………………………………………………………………………………………….………..

36. Source object inflating damage:………………………………………………………………………………………..

37.Estimatedcost of repair/replace:……………………………………………………………………………………….

38.Who discovered damage:…………………………………………………………………………………………………

VEHICLE DAMAGE

39. What was damaged:……………………………………………………………………………………………………….

40. Nature of damage:………………………………………………………………………………………………………..

41. Source–object inflicting damage…………………………………………………………………………………………

42. Name of operator(s)……………………………………………………………………………………………………….

43. Estimated cost of repair/replace:…………………………………………………………………………………………

44. INCIDENT DESCRIPTION (describe what happened–who was involved–where–when–how)………………………

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iRISE/HSMS/RRII REV#00 EFF DATE:01/04/2021
iRISE INDIA PVT. LTD

REPORTING, RECORDING AND INVESTIGATING INCIDENTS

PART-B
INCIDENT ANALYSIS
1. Department: 2.Vendor:

3. Date of Incident: 4.Time of incident:

5.Date Reported: 6.Time Reported:

7. Hours worked before incident: 8.Supervisor:

INCIDENT CLASSIFICATION:

�Injury/Illness � Property Damage � Near Miss � Observation

POSSIBLE CONSEQUENCE
�First Aid � Fire �Toxic Release � Derailment
� Medical Case(Existing illness) � For gain Body � Equipment / Property Damage
�Lost Time � Fatality

INCIDENT RATING: To ensure proper reporting and investigation, this incident was rate done the
Supervisor’s Initial Investigation report (SIIR).Upon further review, the incident as
now been rated as follows,

1. CRITERIA-1 2. CRITERIA-2-5

8. : Identify immediate causes Substandard conditions

�Inadequate guards or barriers �Inadequate or improper tools, equipment, material or PPE

�Defective tools, equipment, material or PPE �Inadequate access or workplace

�Inadequate warning systems �Fire and explosion hazards

�Poor housekeeping, disorderly workplace �Hazards from working environment

�Noise exposure �Radiation (heat or ionising) exposure

�High or low temperature exposure �Inadequate or excessive illumination

9. Identify immediate causes Substandard Acts

�Operating equipment without authority �Failure to create or secure a safe environment

iRISE/HSMS/RRII REV#00 EFF DATE:01/04/2021
iRISE INDIA PVT. LTD

�Operating at improper speed �Defeating or removal of safety devices

�Using defective equipment �Using equipment improperly

�Failing to use appropriate PPE in correct manner �Improper method of loading or positioning load

�Improper mechanical lifting or handling �Improper manual lifting or handling

�Improper body position for task �Horseplay / assault

�Under the influence of alcohol and/or other drugs �Failure to comply with instructed safe method of work

10. Identify underlying causes Job / system factors

�Lack of written procedures or policies �Inadequate work procedures / standards

�Inadequate job planning �Inadequate supervision

�Inadequate engineering �Inadequate purchasing

�Inadequate maintenance �Inadequate tools, equipment, materials

�Wear and tear �Abuse or misuse

11. Personnel factors

�Inadequate capability (physical or physiological) �Inadequate capability (mental or psychological)

�Lack of knowledge �Lack of skill

�Stress (physical or physiological) �Stress (mental or psychological)

�Improper motivation (incorrect or inadequate)

12. Identify root causes

�Leadership and accountability �Competent people

�Hazard identification �Compliance assurance

�Health and safety planning �Risk management

�Asset management �Management of change

�Managing contractors’ �Operational control

�Communication �Emergency preparedness

�Learning from events �Measuring performance

�Audit and review

iRISE/HSMS/RRII REV#00 EFF DATE:01/04/2021
iRISE INDIA PVT. LTD

13. RECOMMENDEDCORRECTIVEACTIONS

Action Category Responsibility Target Date Status

Fail safe/Fool Proof/
Fail soft

Analysis Completed by:

(Name and signature of investigator)