INCIDENT / INVESTIGATION REPORT

1. GENERAL INFO

TYPE OF REPORT * Preliminary Final

CASE TYPE * Accident Near Miss

INCIDENT TYPE * Work related Non-work related

2. WHERE AND WHAT

DATE* TIME

LOCATION* PROJECT NUMBER / NAME * EPCC-05, MS block & Octamax

RESPONSIBLE REPORTING
CLIENT*
CENTER
YES NO
INCIDENT If yes, who?
AUTHORITIES INFORMED
CATEGORISATION

DESCRIPTION OF THE INCIDENT* -

INVESTIGATION INFORMATION
CHRONOLOGY OF SIGNIFICANT EVENTS –
PRECEDING EVENTS -5 -4 -3 -2 -1 INCIDENT +1 +2 +3 +4 +5 SUB SEQUENT ACTIVITIES
-5 +1
-4 +2
-3 +3
-2 +4
-1 +5

3. CLASSIFICATION
WORK ACTIVITY *

ACTIVITY CONTRACTOR / SUBCONTRACTOR INVOLVED

ACTUAL LOST*
Harm to people (proceed to 3.1) Environment (proceed to 3.2) Occupational Illness (proceed to 3.3) Damage (proceed to 3.4)

3.1 – HARM TO PEOPLE -

ACCIDENT CATEGORY: FATALITY LTI RWC MTI FIRST AID

TYPE OF INJURY* (e.g. cut) Male Female AGE

PART OF BODY HARMED* EXPERIENCE IN POSITION (years)

EXPERIENCE ON INSTALLATION
POSITION* (e.g. pipe fitter, welder)
/SITE (months)
COMPANY* FOR LTI / RWC* (Estimate days lost)

3.2 – ENVIRONMENT-

ENVIRONMENTAL DOMAIN * VOLUME (litres) *

SUBSTANCE TYPE * DURATION (min) *

ENVIRONMENTAL INCIDENT
Major Minor Reportable Minor Non reportable
CLASSIFICATION *

DESCRIPTION *

3.3 – OCCUPATIONAL ILLNESS -

SEVERITY OF ILLNESS* AGENT / INFLUENCE (e.g. noise, gas)

TYPE OF ILLNESS ORGAN SYSTEM:

Male Female POSITION* (e.g. pipe fitter, welder)

AGE COMPANY:

3.4 DAMAGE
DAMAGE
EQUIPMENT/TYPE
DESCRIPTION
OPERATOR/SUPERVISOR COST OF REPAIR

CLASSIFICATION (€uro)
< 100.000 100.000 – 1M 1M – 2M 2M–5M >5M

4. LOSS POTENTIAL* (See attachment matrix)

POTENTIAL RECURRENCE/SEVERITY POTENTIAL RISK

Potential recurrence: A B C D E
R Low (1-8) R Medium (16-32) R High (64-256)
Severity: 1 2 3 4 5

POTENCIAL CONSEQUENCES

HARM TO PEOPLE ENVIRONMENT DAMAGE OCCUPATIONAL ILLNESS

GROUP INCIDENT REGION INCIDENT WORKSITE INCIDENT

5. IMMEDIATE CAUSES – Report immediate causes at first instance. Consult the following list and describe more as needed. Check below
which causes best indicate reason for existence of acts and/or conditions identified. Add other causes if not listed. Why it happened?
Which condition was under-standard? – Generally more than one.
PEOPLE ORGANIZATION
1P Bypassed control / defense 18O Inadequate permit / not following permit
Disabled / removed guard / warning system / safety
2P 19O Poor job plan.
device /shortcut
3P Failure to act ENVIRONMENT
4P Failure to obey / see safety systems / controls / barriers 20E Exposure to extreme / unexpected weather
5P Failure to secure 21E Exposure to extreme temperature / humidity / dust
6P Inadequate pre-task checking 22E Exposure to hazardous atmosphere
7P Inappropriate manual handling / use of equipment / tools 23E Inadequate ventilation / light / illumination
8P Inappropriate position of person(s) 24E Natural effects (flooding, landslides etc)
9P Incorrect loading / stacking 25E Slippery or uneven surface / obstruction etc
10P Lapse, mistake, omission. 26E Unprotected height risk
11P Operated without authority / permission TECHNOLOGY
12P Operating equipment / vehicle at improper speed etc. 27T Exposure to hazards e.g. fire, chemical, noise etc
13P Slips, trips, falls 28T Falling / incorrectly placed objects / materials.
Improper loading / storing / positioning of material /
14P Under influence of alcohol / drugs 29T
equipment
Ineffective guards / warning systems / safety device / PPE
15P Unsafe / inappropriate act / horseplay 30T
etc
16P Used faulty / defective tools / equipment 31T Leakage (fuel, radiation, chemical, gas) etc
17P Worked on equipment in operation / live 32T Plant / equipment status was not correct
33T Technical / mechanical failure / faulty equipment etc
34T Undetected / unforeseen hazard / failure

Immediate CAUSES - Report the immediate causes and describe more if needed

6. UNDERLYING CAUSES – Which specific human factor or work factor have leaded to immediate causes (at least one for each immediate
cause)? – Why that act or condition was present? – The root causes shall be removed by an action plan.
PEOPLE ORGANISATION
P1 Deliberate infringement / violation / action O24 Conflicting objectives / goals / standards
P2 Extreme work demands / fatigue O25 Financial, resource constraints / purchasing / procurement
P3 Followed usual custom & practice O26 Inadequacies in shift handover
 P4 Illness / injury O27 Inadequate correction of prior hazard / incident / condition
P5 Inadequate reaction to changing circumstances O28 Inadequate leader knowledge, ability/supervise./decision
P6 Lack of attention / due care / poor work practice O29 Inadequate planning / risk assessment
P7 Lack of awareness / perception of risk O30 Inadequate safety controls / warning systems / signs.
P8 Lack of knowledge of task / procedure / permit O31 Inadequate training / guidance provision / qualifications
P9 Lack of skill / knowledge / experience / training O32 Inadequate work planning / programming
Miscommunication / inadequate communication of Ineffective auditing / inspection / monitoring
P10 O33
instructions
Not following / incorrect following of standards / Ineffective identification of hazards
P11 O34
procedures
P12 Not using / incorrect use of PPE O35 Ineffective management of change
Physical / mental capability / stress problems / fatigue Ineffective standards/ enforced/procedures/guidelines/
P13 O36
instruct.
P14 Poor decision-making / judgment O37 Lack of / ineffective job plans (toolbox talks etc.) / ptw.
Poor team relationships / dynamics / tensions (social / Lack of accountability / responsibility
P15 O38
cultural)
TECHNOLOGY O39 Lack of means of communication
T16 Design deficiencies O40 Missing or inadequate job safety analysis.
T17 Excessive wear & tear of tools / equipment O41 Poorly controlled contractors / external people
T18 Improper identification of hazardous materials O42 Security breach
T19 Improperly prepared tools / equipment O43 Unclear / conflicting lines of responsibility
T20 Inappropriate equipment / vehicle for not fit for purpose ENVIRONMENT
T21 Ineffective adjustment / repair / maintenance E45 Inappropriate construction / layout
Ineffective fire / explosion / radiation / chemical / electrical Insufficient / restricted access & exits
T22 E46
protection
T23 Lack of correct tools / equipment / power E47 Poor housekeeping / disorder

Underlying CAUSES - Report the Underlying causes and describe more if needed

2.

7. ROOT CAUSES– Report the Root Causes selecting the basic categorization and detailing describing the root causes identified during the
investigation.
P People O Organization
T Technology E Environment

Root CAUSES - Report the Root causes and describe more if needed

8. CORRECTIVE ACTIONS

CORRECTIVE ACTION PLAN TO BE EXECUTED BY DUE-DATE

9. FINAL CLASSIFICATION (Please follow the progressive number as per Site Incident Register)
 Fatality LTI RWC MTI First Aid NM DI EI

10. ATTACHMENTS - Photos, Witnesses statement, medical report, Other

NO TITLE DOCUMENT NAME

11. APPROVAL

0
WRITTEN BY CHECKED BY APPROVED BY
REV. DATE STATUS
(name) (name) (name)