Document No:
Issue Date:
OHS INCIDENT REPORT Rev:
Revision:
App:
0
Page 1 of 2
Part A – Incident Information
Report No : Project Name :
Location:
Who was involved? (Tick as appropriate)
1. Incident Type:
Serious incident: (Tick as appropriate) Non-Serious incident: (Tick as appropriate)
Fatality Restricted Work Case
Permanent Total Disability Medical Treatment case
Lost Time Injuries Permanent Partial Disability First Aid Injury
Lost Workdays Injury Equipment/Property Damage
Lost Workdays Occupational Illness Near Miss
Other Other
2. Incident Details
Brief description of the main
circumstances leading to the Incident:
(Attach additional pages if required)
Incident Location on Site:
Applicable Reports: Police Medical ✘ Other (Specify)
Attached: Yes ✘ No
Yes No Yes No
Part B – Incident Investigation Summary
3. Incident Causes Details: To be supported with the incident investigation report
Failure to secure Operating equipment without authority
Failure to warm Servicing equipment in operation
Removing / Defeating safety
devices Using defective equipment / tools
Immediate Cause Failure to use PPE properly Using equipment improperly
(Unsafe Act) Operating at improper speed Improper lifting/ loading/ placement
Lack of awareness / knowledge Improper position for task
Lack of attention / concentration Horseplay (practical joke with harmful impacts)
Violation / taking shortcuts Others
Physical Capability Physical Condition
(Any sensory deficiency, inadequate size or (Previous injury/illness, Fatigue, blood sugar or
strength or physical disabilities) Impairment due to drugs)
Mental State Skill Level
(Poor judgement, memory failure, poor condition, (Inadequate required skill, lack of coaching on skill or
fears or emotional disturbance) infrequent performance of skill)
Root Causes
(Personal factor) Behavior Mental Stress
(Save time, avoids discomfort, improper (Inadequate required skill, lack of coaching on skill or
supervisory, i n a d e q u a t e d i s c i p l i n a r y p r o c e s s o r emotional overload, extreme meaningless activities or
inappropriate aggression) concentration/judgment demands)
Human Error Others
Document No:
Issue Date:
OHS INCIDENT REPORT Rev:
Revision:
App:
0
Page 2 of 2
4. Key Actions Taken Immediately after the Incident:
No. Actions Responsibility Date Completed:
1.
7. Incident Cost: (Approximate / Best Estimate)
No. Item / Area Amount (Dhs.)
1. Injury Cost (Treatment, Hospital, Transport, Insurance, etc.)
2. Legal Cost (Compensation claims, judicial prosecutions, etc. – Federal Law No. 8)
3. Productivity Cost (Business disruptions, Delays, Production loss / day, Material, Salaries, etc.)
4. Asset Cost (Property, Machinery, Equipment, Structure, Vehicle, etc. – Repair & Maintenance)
Unknown
5. Asset Cost (Property, Machinery, Equipment, Structure, Material, Vehicle, etc. – Replacement)
6. Enforcement Action (Penalty Issued by Authority)
7. Incident Scene / Area Restoration Cost (arrangements to making safe, cleanup, etc.)
8. Other Cost relevant to / associated with the Incident
9. Total Cost
5. Risk Assessment: (considering / implementing the post incident corrective actions and controls):
Refer to AD EHSMMS RF Technical Guideline on Process of Risk Management
Probability: Rare Possible Likely Often Frequent
Severity of Consequence: Insignificant Minor Moderate Major Catastrophic
Level of Residual Risk: Low Moderate High Extreme
6. Declaration by Reporting Project/Site:
I declare that all information provided in this document is true, correct and complete.
Incident Investigation Status: Ongoing Report attached
Official
Stamp:
Signature of the Sr. Construction
Manager/ Project Manager:
Official
Stamp:
Signature of the HSE Manager:
Date :
Investigation Team
Name Position Signature Date
Evidence Photos
