Incident Notification Form FORM COR HSE 105 E R04

Doc. no.
FORM-COR-HSE-105-E
FORM
Rev.04 12/07/2016
INCIDENT NOTIFICATION Page 1
Ref. Doc. no. STD-COR-HSE-116-E
TO BE COMPLETED WITHIN 24HRS

1. GENERAL INFORMATION Report no: 01 Date: 02-04-2019 Event title: NEAR MISS REPORT
2. PROJECT/SITE DETAILS
Project (contract) Worksite activity Operating Company
Worksite (e.g. construction, installation, Job code Client Country
Name maintenance, drilling, etc) / Branch
HAWYIAH GAS
HGP PLANT CONSTRUCTION SNAMPROGETTI HO2755 SAUDI ARAMCO SAUDI ARABIA
EXPANSION
3. EVENT DETAILS
Date: Hour:
INCIDENT
REPORTED TO Discipline Supervisor Site Management HSE Other
ACCIDENT Outcome : Personal injury Property/ Asset Damage Environmental Damage
TYPE OF INCIDENT NEAR MISS Possible outcome Personal injury Property/ Asset Damage Environmental Damage
OTHER (specify)
4. INCIDENT BRIEF DESCRIPTION
(PROVIDE A BRIEF DESCRIPTION OF INCIDENT)
FOUND THAT ONE TRAILER IS PASSING THROUGH THE PRE CAST AREA,
WITH A OVER SPEEDING. I TRIED TO INFORM HIM, TO GO SLOWLY. ALSO
THE MATERIALS WAS NOT SECURED( OR) LASHED. HE IS CARRYING
SOME RE-BARS ON HIS VEHICLE. SUDDENLY SOME OF THE REBAR FELL
DOWN FROM VEHICLE. FORTUNATELY NO VEHICLES (OR) PERSONS IN
SURROUNDING AREA. IF ANYONE PASSING NEAR THIS TRAILER THE
CONSEQUENCES WILL BE VERY HIGH, LIKE SEVERE INJURIES SOMETIMES
DEATH MAY OCCUR. NAME OF TRAILER DRIVER:ABDEL
WAHAB MOHAMED ABDALLA
IQAMA NUMBER:2413003902
VEHICLE REGISTRATION NUMBER: 2570 JRA
DRIVING LICENSE NUMBER: 2413003902
INJURED PERSON: NO ONE INJURED
Name:
Badge no.
Role Company:
Nationality:
ATTACHMENTS
Pictures: ATTACHED
Sketches
Other (specify)
Doc. no. FORM-COR-HSE-105-E
FORM
Rev.04 12/07/2016
INCIDENT NOTIFICATION Page 2
Ref. Doc. no. STD-COR-HSE-116-E
5. IMMEDIATE ACTIONS TAKEN
I TOOK THE DRIVER IDENTIFICATION DETAILS LIKE IQAMA,DRIVING LICENSE,VEHICLE DOCUMENTS.INFORMED TO ARE CONCERNED SUPERVISOR
AND SAFETY DEPARTMENT INCHARGE IMMEDIEATLY.
Real outcome (from Sections 1 & 2):

Incident Severity(1 to 5):_1__ Inv. level for real consequence (A/B/C):__A_
6. Incident Classification:
Incident Potentiality and Investigation Level Potential outcome (from Sections 1 & 3):
Indicate Inv. level for potential
(the investigation level shall be chosen based on the the Potential Severity Probability
highest ranking between real outcome and potential consequence
(1 to 5):__1__ (1 to 5): ___
outcome) (A/B/C):___
 Investigation level (A/B/C): ___
SECTION 2 SECTION 3: INVESTIGATION LEVEL FOR

SECTION 1: CONSEQUENCE
INVESTIGATION POTENTIAL CONSEQUENCE
LEVEL FOR
Incident Harm to Environment Damage to REAL 1. 2. 3. 4. 5.
Severity People Effect Assets CONSEQUENCES
Very unlikely Unlikely Possible Likely Very Likely
Slight injury or
1 Health effects Slight damage
Negligible A A A A A B
Negligible (First Aid) No interruptions
Minor injury or Minor damage

2 Local environmental
Health effects
damage. Within the Short interruption (cost A A A A
(Medical Treatment B B
of Work Restricted perimeter and systems €10K-€100K, work stopped
Low 1 day)
Case)
Contamination
Local damage
3 Major injury or damage that effects
Health effects the environment. No Partial shut-down (cost B A A B B C
permanent effect to the €100k-€500k), work stopped
Medium (Lost Time Injury) environment 1-7 days
Loss limited discharge Serious Damage

4 Single fatality with known toxicity.
or Permanent Affects surrounding Partial service loss (cost C B B B C C
High Total Disability villages €500k-€3M) work stopped 2

weeks
Severe environmental Extensive damage

5 damage. Major
intervention required Total or substantial C C C C
Multiple fatalities B B
Major for decontamination of operating loss (cost €3M-
environment €10M), work stopped over 2
weeks
Prepared by: RAJESH THORATI Signature: Date:02-04-2019
COMPLETE THE FORM: FORM-COR-HSE-106-E, for incident with level of investigation A.
COMPLETE THE FORM: FORM-COR-HSE-047-E, for incident with level of investigation B or C and for fatality, lost time injury,
work restricted case, medical treatment case, high potential near miss.

Incident Notification Form FORM COR HSE 105 E R04

Uploaded by

Copyright:

Available Formats

Incident Notification Form FORM COR HSE 105 E R04

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Incident Notification Form FORM COR HSE 105 E R04

Uploaded by

Copyright:

Available Formats

Doc. no.

TO BE COMPLETED WITHIN 24HRS

REPORTED TO Discipline Supervisor Site Management HSE Other

ACCIDENT Outcome : Personal injury Property/ Asset Damage Environmental Damage

4. INCIDENT BRIEF DESCRIPTION

(PROVIDE A BRIEF DESCRIPTION OF INCIDENT)

VEHICLE REGISTRATION NUMBER: 2570 JRA

DRIVING LICENSE NUMBER: 2413003902

INJURED PERSON: NO ONE INJURED

5. IMMEDIATE ACTIONS TAKEN

Real outcome (from Sections 1 & 2):

SECTION 2 SECTION 3: INVESTIGATION LEVEL FOR

Minor injury or Minor damage

Loss limited discharge Serious Damage

High Total Disability villages €500k-€3M) work stopped 2

Severe environmental Extensive damage

Prepared by: RAJESH THORATI Signature: Date:02-04-2019

COMPLETE THE FORM: FORM-COR-HSE-106-E, for incident with level of investigation A.

You might also like