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  • Incident Report Form: RPSG-IMS-F-24 Accident and Investigation Form 5A

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    Rocky Bis
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    An incident report form documents an accident that occurred on November 15, 2020 at 5:00 hrs involving Abbas Raheem, a 26-year-old cleaner with 16 months of experience. While mixing Dettol with water for cleaning at the Majnoon kitchen, some of the solution splashed into his eye. After a few hours, his eye became red, so he received first aid at the on-site clinic and then returned to work. An investigation was conducted by the KC Manager and HSE Manager, who determined the root cause was improper handling of chemicals due to human error from an unsafe body posture that allowed direct eye contact with the Dettol. Actions taken to prevent recurrence included staff training on safe chemical handling and re

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    Accident Investigation Report - FAC 15-11-2020

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    An incident report form documents an accident that occurred on November 15, 2020 at 5:00 hrs involving Abbas Raheem, a 26-year-old cleaner with 16 months of experience. While mixing Dettol with water for cleaning at the Majnoon kitchen, some of the solution splashed into his eye. After a few hours, his eye became red, so he received first aid at the on-site clinic and then returned to work. An investigation was conducted by the KC Manager and HSE Manager, who determined the root cause was improper handling of chemicals due to human error from an unsafe body posture that allowed direct eye contact with the Dettol. Actions taken to prevent recurrence included staff training on safe chemical handling and re

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    132 views2 pages

    Incident Report Form: RPSG-IMS-F-24 Accident and Investigation Form 5A

    Uploaded by

    Rocky Bis
    An incident report form documents an accident that occurred on November 15, 2020 at 5:00 hrs involving Abbas Raheem, a 26-year-old cleaner with 16 months of experience. While mixing Dettol with water for cleaning at the Majnoon kitchen, some of the solution splashed into his eye. After a few hours, his eye became red, so he received first aid at the on-site clinic and then returned to work. An investigation was conducted by the KC Manager and HSE Manager, who determined the root cause was improper handling of chemicals due to human error from an unsafe body posture that allowed direct eye contact with the Dettol. Actions taken to prevent recurrence included staff training on safe chemical handling and re

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    Doc. No.

    RPSG-IMS-F-24 Accident and Investigation Form 5A

    Incident Report Form


    Details of injured person
    Name: Abbas Raheem ID Badge number- 53008 Age: 26 Make X Female
    Date of Incident: Time of Reporting:
    Job Title: Cleaner Time of Incident:0500 hrs
    15/11/2020 0855hrs
    Number of Years in Job: 16 months Shift Hours Worked: 8 No. of Days into Trip:

    Site Name: Majnoon Contract No: MFD-IFMS-001 Site Contact Details: Majnoon PC

    Part of body Nature of Injury/Illness


    Indicate main parts of body affected: Indicate nature of injury/illness:
    Head Shoulder Multiple Injuries Amputation Dislocation Skin Disease
    Eye X Back Digestive Minor Fracture Ingestion Lung Disease
    Ear Chest None Bruise Respiratory Hearing Loss
    Neck Abdomen Other (specify) Burn/Scald Shock (Electrical) No Injury
    Hip Leg Burn/Chemical Sprain/Strain Near Miss
    Arm Foot Burn/Electrical Occupational Illness Other (specify)
    Hand
    Toe Crush Poisoning Minor fracture
    Wrist
    Finger Respiratory Cuts/Abrasions Foreign bodies

    Broad Incident Types


    Indicate what kind of incident led to the injury/illness/near miss or condition
    Loss of containment Slips/Trip/Falls Use of Machinery Radiation
    Fire/Explosion Falling Objects Exposure to or contact Other (specify)
    Fall from Height Handling Goods/Materials with harmful substances X
    Using Knives Lifting/Crane Operations Electrical
    Manual Handling Use of Hand Tool Structural/Foundation
    RPSG

    Contact with moving machinery or material being machined Exposed to, or in contact with a harmful substance X
    Hit by a moving, flying or falling object Exposed to fire
    Hit something fixed or stationary Exposed to an explosion
    Injured while handling, lifting or carrying Contact with electricity or an electrical discharge
    Slipped, tripped or fell on the same level Physically assaulted by a person
    Fell from a height Another kind of accident (specify)
    How high was the fall?
    Trapped by something collapsing
    Drowned or asphyxiated

    What action was taken with the injured person? (Tick more than one box if applicable)

    Returned to work Immediately Received First Aid X Sent to Hospital Days off Work
    Self-Treated First Aid Sent Home/Doctor Returned After

    How has the client categorized the accident? FAC


    To be Completed by Supervisor / Manager:
    Short Description of the Incident: Around 05:00hrs IP was performing cleaning job at KC kitchen. He was
    mixing the dettol with water for cleaning purpose. during mixing the dettol with water by manual, he has got
    splashed on his eye from the dettol water. At the time the IP did not feel much rash or pain on his eye and he has
    not reported to his supervisor or anyone. After few hours his eye got redness.
    Then he went to PC clinic and got treatment with basic first aid and afterwards he went to work

    Investigation Team:
    Name Position Company
    Basel KC Manager RPSG
    Niranjan Pratapsingh HSE Manager RPSG
    Injured Persons Statement
    N/A

    Witness Statements: (Use a blank sheet if necessary. Include names and addresses.)
    Uncontrolled when printed.
    This cannot be copied in whole or part without the written consent of Quality Assurance Manager
    Doc. No. RPSG-IMS-F-24 Accident and Investigation Form 5A

    Expert Report:
    After doctor washed his eye, he has been returned to work and had no issue -as per statetemnt
    Root Cause Analysis
    State the Immediate Cause:
    Improper handling of chemical -Dettol
    What are the Underlying Causes?
    Human error (body posture makes direct eye contact with Dettol)

    What are the Root Causes?

    Action Taken to Prevent a Repetition or Similar Incident:


    Action Person Responsible Target Date
     TBT had conducted with staff for their HSE officer 5-12-2020
    awareness of incident. QHSE Officer
     Employee has been re-trained to safe
    10-12-2020
    handling chemical material

    Form Completed By:


    Name: Basel Position: Dining Manager
    th
    Date: 5 Dec 2020 Signature:
    Unit: RPSG Date of Incident: 5th Dec 2020
    Verification of Action Completion:
    RPSG

    Name: Niranjan Pratapsingh Signature: HSE Manager


    Date: th
    5 Dec 2020 Date of Incident: 5th Dec 2020
    Distribution within 24 hours:
    Original copy - keep on site
    First copy to Operations Manager/COO/CEO
    Second copy to Client

    Official Use Only:


    Date received: Action Taken: Yes
    Ref No.: 5th Dec 2020 File Under: Incidents/Accidents
    Date: Investigated by: Niranjan / Basel

    Uncontrolled when printed.


    This cannot be copied in whole or part without the written consent of Quality Assurance Manager

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