Project Site/ Office: ……………………….

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INCIDENT INVESTIGATION REPORT

WHERE AND WHEN Incident investigation Report No: …..………………

Fatal Injury Reportable LTI

Location of the Incident Dangerous Occurance Near miss

Building/ Tower:
Floor No.:
Area/ Exact location: PERSON INVOLVED

Date & Time Type of person involved

Date: …… / …… / ………… Time: …… : …… am/ pm Ambuja Staff Visitor Outsider
Contractor's Person : Contractor's Name: ……………………………

INCIDENT DESCRIPTION Details of Person involved/ affected

Name:

Brief description of Incident (facts only - attach sketch seperately) Gender: Age: DoB:
Designation: DoJ:
Address:

INJURY DETAILS

Category of Injury
Part of Body Injured: ……………………………… Left Side Right Side

Abrasion Cut/ laceration

Amputation Sprain/ strain

Bruise Swelling

Burn/ scald Eye injury

Fracture/ dislocation other (please specify below)

Type of Incident Puncture …………………………………

Fall from height/ stairs Near miss incident

Slip/ trip/ fall - same level Property loss/ damage

Contact with electricity Cut with sharp object TREATMENT

Struck by falling material Fire

Hit/ run over by mobile eqpt Person to person assault Type of Incident
Contact with hot object/ flame Others (please specify) None Required First Aid
Equipment failure/ misuse …………………………… External Medical Aid

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INJURY DETAILS

* Shade all the body parts injured for better understanding

Remarks

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INVESTIGATION

Was the location of equipment or person authorised Yes No NA Was the activity of person authorised Yes No NA

Were safe work prcatices being in place and followed Yes No NA Regular Tool-box talks conducted Yes No NA

Whether regular EHS inspections carried out Yes No NA Periodic checks/ tests of eqpt involved done Yes No NA

Whether HIRA/ JSA being carried out for the job Yes No NA HIRA/ JSA communicated properly Yes No NA

CAUSES OF INCIDENT

Sequence of Accident Direct Causes:

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Root Cause:
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Unsafe Conditions Unsafe Acts

No guard Working/ operating without permission

Inadequate guard Failure to wear PPE
Lack of safety device Working removing guards
Defective safety device Bye passing/ tampering safety devices
Lack of tool/ equipment Using tool/ equipment in wrong way
Defective tool/ equipment Failure to use provided tool/ equipment
Inadequate illumination Using defective equipment
Improper ventillation Teasing/ Horseplay
Lack of adequate PPE Entering protected/ barricaded area
Inadequate training Intentionally throwing material from height
Slippery floor Operating equipment at unsafe speed
Improper housekeeping Drawing unauthorised electrical connections
Unsafe electrical connections Failure to follow work instructions
Unprotected openings Overloading of equipment/ staging etc.
Lack of overhead protection Smoking in prohibited areas
Inadequate fall protection Operating equipment in unsafe condition
Other: ……………………………..………………………. Other: ……………………………..……………………….

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PRECAUATIONARY MEASURES

Recommended corrective action Action by whom

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Preventive action
Whether similar jobs being carried out at the project Yes No If yes, whether communicated to concerned Yes No NA

List of persons communicated for preventive action:

Report Prepared by: Signature: Signature of In-charge:

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