HSE Incident Report Rev

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TROJAN GENERAL CONTRACTING LLC

HEALTH, SAFETY AND ENVIRONMENT


HSE INCIDENT REPORT

Project: Report No:


Contractor :- Reported By:-
Incident Date:- Incident Time:- Date & Time reported:-

Incident Type – Mark (X) for applicable category


Fatality / Disability Fire / Explosion Spill/Release/Discharge to Air
Serious Injury (*Refer Chapter 02 of DM CoP) Property Damage Spill/Release/Discharge to Land
Vehicular accident Harm to Animal Spill/Release/Discharge to Water
Near Miss Harm to Vegetation Others - Please specify

Details of Injured Person(s) ( if Applicable)


Name Age /sex
Position Nationality
Date of Joining Contact details

Name Age /sex


Position Nationality
Date of Joining Contact details

Witness Details
Name Department/ Company
Contact details Manager

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

Hospital (admitted) Doctor (Outpatient)


First aid only Not required

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?





Report Preparation Review and Approval

Name Signature Designation Date


Prepared by
Reviewed by
Approved by

TGC/FRM/HSE/031 Rev:-01

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