Rev. No.

:00

Date: 13.02.2024

Page 1 of 194

ISO 9001:2015, 14001:2015 & 45001: 2018

ACCIDENT INVESTIGATION REPORT F-23

(The purpose of the investigation is to find out the causes of accident and to take
preventive measures)
PERSONAL PARTICULARS

1 Name of the Injured Person:

2 Employment No. 3 Sex: Male / Female 4. Age

5 Department 6 Designation

7 Contractor (if) 8 Years of service:

9 Experience in present job (yrs)

ACCIDENT PARTICULARS

10 Date of Accident 11 Time

12 Date of Accident 13 Affected Body Part

14 Nature of Injury (disabled-Temporarily / Partially/

Permanently)
15 Time lost

16 Brief description of accident:

17 Accident sequence (Describe in reverse order of occurrence of the events that

preceded the accident/ injury)
a. d.

b. e.

c. f.
 Rev. No. :00

Date: 13.02.2024

Page 2 of 194

ISO 9001:2015, 14001:2015 & 45001: 2018

CAUSE ANALYSIS

Immediate causes Basic causes

18 What the employee failed to do 19 a) Why was it done or not done?

that contributed accident?
20 What condition of equipment,
machinery or structure or work
area contributed to accident?
b) Were relevant safety rules
enforced?
c) Whether job hazard analysis is
being prepared?
21 a) Why did these conditions exist.
b) Were you aware of the unsafe
condition.
c) Whether job hazard analysis is
being prepared for the job?

Signature of Supervisor:

Name:

Comments of Project-In-Charge

Signature of Supervisor:

Name:

FOLLOW UP ACTION

22 Action plan to prevent similar accident

By Whom Date Remarks

23 Are there any other similar exposure in the said project.

Signature of Supervisor

REVIEW BY SIGNATURE
 Rev. No. :00

Date: 13.02.2024

Page 3 of 194

ISO 9001:2015, 14001:2015 & 45001: 2018

Project-In-Charge

Safety Manager

Safety Committee