HSE Incident Report Rev
HSE Incident Report Rev
HSE Incident Report Rev
Witness Details
Name Department/ Company
Contact details Manager
Injury Details
Please indicate body part injured on chart below
Strain / sprain Cut /laceration
Scratch Bruising
Fracture Dislocation
Burn Foreign body
Sting / bite
Other
Treatment Given
Consequences of Incident
Work Closure
Lost Time Injury
Restricted work case
Medical Treatment case
TGC/FRM/HSE/031 Rev:-01
TROJAN GENERAL CONTRACTING LLC
HEALTH, SAFETY AND ENVIRONMENT
HSE INCIDENT REPORT
Incident details
Describe in detail what happened – what, where, who, when, why and how. Include diagrams images and use additional pages if required
Cause Analysis – Mark ‘X’ against the factors which are thought to have contributed to the cause of the incident
Task Environment Organizational Human factors Equipment
Lifting Housekeeping Poor communication Lack of experience Faulty equipment
Carrying Slippery conditions No policy/ procedures Lack of competence Lack of proper
equipment
Repetitive Excessive noise Poor job design Stress / fatigue Poorly maintained
movement
Twisting Weather conditions Hazards not identified Procedures not followed Wrong for task
Driving Heat / cold Lack of staff / budget Improper technique Lack of signage
Walking Lighting /visibility Lack of training Physical limitations
Working on Surface conditions Lack of supervision Skylarking / horseplay
elevation
Maintenance and Pressure to complete task
Cleaning
Other
Please specify
Corrective Action
What action is required to prevent the incident from happening again? By who? By when?
TGC/FRM/HSE/031 Rev:-01
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