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Incident Report Form: RPSG-IMS-F-24 Accident and Investigation Form 5A
Incident Report Form: RPSG-IMS-F-24 Accident and Investigation Form 5A
Site Name: Majnoon Contract No: MFD-IFMS-001 Site Contact Details: Majnoon PC
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
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)