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Incident Investigation Report

The Incident Investigation Report details a short circuit incident classified as Level One, with no environmental damage reported. Immediate actions taken included stopping work and barricading the area, while the probable cause is believed to be voltage variation. Proposed corrective actions are to be assigned to Mr. Suresh D, with follow-up evaluations planned to ensure effectiveness.

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33 views3 pages

Incident Investigation Report

The Incident Investigation Report details a short circuit incident classified as Level One, with no environmental damage reported. Immediate actions taken included stopping work and barricading the area, while the probable cause is believed to be voltage variation. Proposed corrective actions are to be assigned to Mr. Suresh D, with follow-up evaluations planned to ensure effectiveness.

Uploaded by

SURE TECH
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Incident Investigation Report

Section A

Reference No
ESCON/IIR/001

Project Name

Location

Date of Incident
Time of Incident

Names of person
involved

Names of Witnesses

Type of incident Short circuit Environmental Property Damage Near Miss

Body Part affected NIL Upper Limbs Lower Limbs Torso


(If applicable)

Investigation Type Level One Level Two


(See below for descriptors) (See below for descriptors)
√

Reported to HSE Advisor √ Line Manager √ Local Manager √ PMC √

Investigation Type (if in doubt, please contact your HSE Advisor)


Level Safety Environment Dangerous incident (near miss)
One Short circuit incident happen due to voltage No environmental damage. An incident where a person is exposed to
variation a risk that could have resulted in a First
. Aid Injury or Medical Treatment Injury
only.

OBSERVATION / INITIAL CAUSE


Incident Investigation Report
Describe clearly how the incident occurred, including details of the extent of injuries and/or property
damage/environmental impact as appropriate:

IMMEDIATE ACTION
State what was done immediately after the incident. eg: stopped work, barricading, etc.

BACKGROUND INFORMATION
Provide some back ground information (In bullet points) related to the incident that may have contributed eg: work
conditions, time on shift.
Based on collected information, the investigation team is of opinion that the probable cause of the
incident is.

Section B (Only to be completed when advised by HSE Advisor)


ANALYSIS
What act(s) and/or omission(s) if any, or any other factors or conditions contributed to this incident?
Contributing Factor Job Factors Human Factors Environmental or
Organisational Factor

ROOT CAUSE (Using the analysis state what was the root cause of the incident one paragraph)

Section C
EVALUATION (State what caused the incident)
Proposed Corrective Actions Person Date
(actions that will prevent the incident re-occurring in the future) Responsible Completed
1. Mr. Suresh D
2. “ “
3. “ “
4. “ “
5. “ “

SIGNATURES
Incident Investigation Report

Investigating Officers Mr. Position


Name
Signature Date
Investigating Officers Mr. Suresha D Position EHS M
Name
Signature Date

Section D
FOLLOW UP Comments of Project Manager or Investigating Officer
(PM to allow a minimum of a week to pass before conducting a review that corrective actions are effective on site)

SIGNATURES
Investigating Officers Position Project manager
Name
Signature Date

Reviewed by senior management

Reviewed by PMC Safety Manager

Reviewed by PMC Project Manager/Lead

Safety/Environmental Alert or other information released to all relevant staff

Details: Date Completed:

ATTACHMENTS
(Supporting documentation including induction records, WMSs, training records, qualifications, medical certificates,
witness statements, etc.)
A. …..
B. …..

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