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CAS1969-2G00-01-124-008 Final Investigation Report Form

This document is a final investigation report of an incident that occurred on a project. It provides details of the incident such as the location, date and time of occurrence, and injured party information. The report analyzes the causes of the incident, which included unsafe actions and conditions as well as personal and work factors. Root causes are identified and prevention/corrective actions are recommended, including descriptions, responsibilities, target dates, and statuses.

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49 views3 pages

CAS1969-2G00-01-124-008 Final Investigation Report Form

This document is a final investigation report of an incident that occurred on a project. It provides details of the incident such as the location, date and time of occurrence, and injured party information. The report analyzes the causes of the incident, which included unsafe actions and conditions as well as personal and work factors. Root causes are identified and prevention/corrective actions are recommended, including descriptions, responsibilities, target dates, and statuses.

Uploaded by

lab cnc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DOCUMENT NO: CAS1969-2G00-01-124-008

REFERENCE PRO: CAS1969-2G00-01-109-014


FINAL INVESTIGATION
DATE: 28-12-2021
REPORT
REV: A
Page 1 of 3

Name of Project: Date:

Location of Project: Country:

Exact Location of Incident: Date & Time of Occurrence:

Report Prepared By:


Consortium HSE Manager (Name)
Details of Incident
Incident Type:

 Fatality
 Lost Time Injury (LTI)
 Restricted Workday Case
 Medical Treatment Case
 First Aid
 Property Damage
 Near miss
 Fatality

Summarize the incident and describe how it occurred.


DOCUMENT NO: CAS1969-2G00-01-124-008
REFERENCE PRO: CAS1969-2G00-01-109-014
FINAL INVESTIGATION
DATE: 28-12-2021
REPORT
REV: A
Page 2 of 3

Name of Injured party (IP) if any ID No.

Home address of Injured party City /Country

Lost Time (Days):

Description of Injury/ Illness sustained and / or extent of damage or pollution

Injury Map Injury Category

 Head  Abrasion / Bruising Burns /


 Eye  Scalds Lacerations / Cuts
 Torso / Back  Stab / Penetrating Wound
 Arm / Wrist  Strain / Sprain
 Hand  Internal Injury
 Leg  Other(fracture)
 Ankle / Foot N/A
N/A

Details of Dangerous Occurrence

 Collapse of formwork or load bearing structure  Fire or explosion


 Collapse of scaffold or false work (Shoring Systems)  Failure of radiography equipment
 Collapse, failure or misuse of lifting equipment /accessories  Malfunction of breathing
apparatus
 Collapse of excavation  Vehicle / plant collision or damage
 Flooding of excavation or confined space  Falling objects outside of exclusion zones
 Contact with overhead / underground services  Flying or moving objects
 Electrical short circuit or overload causing a fire  Misfire of explosives
 Failure of compressed gas cylinders  Other (Add Details)

Details of Plant, Tools and Equipment involved in the Incident (if any)

Analysis of Causes
Immediate Cause (refer to SCAT Method)
1. Unsafe Action:
1.1
1.2
2. Unsafe Condition
2.1
2.2
Basic Cause
1. Personal Factor
1.1
1.2
2. Work Factor
2.1
2.2
DOCUMENT NO: CAS1969-2G00-01-124-008
REFERENCE PRO: CAS1969-2G00-01-109-014
FINAL INVESTIGATION
DATE: 28-12-2021
REPORT
REV: A
Page 3 of 3

Root causes (what are the root causes behind the incident?)
1.
2.
3.
Prevention / Recommended Corrective Actions
Action by Target
No Description Status Remark
(PIC) Date

Report Completed by: Name:


Consortium HSE Manager Date:
Approved by: Name:
Consortium Project Manager/Deputy Project Date:
Manager
Actions

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