FORM G1

AACM - Department of Municipalities and Transport (Building and Construction Sector)

SERIOUS OSH INCIDENT INVESTIGATION

Incident Notification Date:

Incident Investigation Report Submission Date:

Part A – Incident Information (as notified in Form G)

Reporting Entity Information

Incident No. (for official use by SRA)

Name of Entity: Nael And Bin Harmal Hydroexport Nayel Rashed Saif Alshamsi ‫ ـ‬Sole Proprietorship L.L.C.

Sector: Building and Construction Classification Code: BC-12

Registration Number: 151102000431

Address of Entity: 6th Floor 601, Al Muhairy Center Office Tower, Khalidiya Area Abu Dhabi, UAE

Authorized Contact Person: ENGR. PATRICK JASON B. NOCOS

Email Address: PJNOCOS@NBHH.AE

Telephone Number: 0551101181

Mobile Number:

Reporting on

Reporting on behalf of Non-nominated Contractor Reporting on behalf of Nominated Contractor Reporting for my Entity

Incident Information

Date of Incident / Time (24 hr):

Fatality Serious Dangerous Occurrence Serious Injury Serious Occupational Illness

Type of Incident:

Mechanism 11.0 Schedule A Mechanism 11.0 Schedule B Mechanism 11.0 Schedule C

Incident Description:

Incident Location on Site:

Incident Workplace Address:

Region where incident occurred: Abu Dhabi Al Ain Al Dhafra Other Region

Applicable Reports: Police Medical Other Investigation report and photos

Part B – Incident Investigation Summary

Incident Causes Details

Failure to secure Operating equipment without authority

Failure to warn Servicing equipment in operation

Removing / Defeating Safety Devices Using defective equipment / tools

Failure to use PPE properly Using equipment improperly

Immediate Cause(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

Other :

Inadequate guards or barriers Inadequate or improper protective equipment

Inadequate warning system or notice Inadequate or excess illumination

Inadequate ventilation Congestion/ restricted action/ poor access

Fire and explosion hazards Poor housekeeping, disorder

Immediate Cause(Unsafe
Conditions)
High / Low temperature exposure Excessive noise exposure

Hazardous gases/dusts/vapors/fumes Radiation exposure

Defective tools, equipment or materials Equipment failure

Other :

Physical Capability (Any sensory deficiency, Physical Condition (previous injury/illness, Fatigue, blood
Inadequate size or strength or physical disabilities) sugar or Impairment due to drugs)

Mental State (poor judgment, memory failure, Skill Level (Inadequate required skill, lack of coaching on
poor condition, fears or emotional disturbance) skill or infrequent performance of skill)

Root Causes(Personal factor)

Behavior (save time, avoids discomfort, Mental Stress (Frustration, confusion/conflicting directions,
improper supervisory, inadequate disciplinary emotional overload, extreme meaningless activities or
process or inappropriate aggression) concentration/judgment demands)

Human Error

Other :

Root Causes(System Factor)

 Inadequate Training / Knowledge transfer Inadequate Leadership Supervision

Inadequate / Missing Work Procedures (SoP) Inadequate Incident Investigation / Analysis

Inadequate Purchasing/Material handling Inadequate Engineering / Design / Controls

Inadequate Tools/Equipment Inadequate Maintenance

Inadequate Risk Assessment / Management Inadequate Communication

Inadequate Contractor Management Inadequate Planned Inspections

Inadequate Management of Change Inadequate Emergency Response Plan

Other :

Injuries Details

Add Injury

1.
Name: Occupation:

Relationship with Entity:

Entity Employee Contractor Employee Other Person (e.g. Visitor)

(MM/DD/YYYY)
Nationality: Date of Birth:

Passport Number: Length of Service: Years Months

Contact Phone Number: Gender: Male Female

Emirates ID:

Injury Severity known at the time of Incident The actual severity and consequences of the notified injury based on diagnosis by licensed health care professional and
supported by medical report shall be reported in the incident investigation report to the SRA (Form G1) as well as in the entity performance report to the respective SRA
(Form E/E2).

Permanent Total Permanent Partial Lost Workdays Lost Workdays Occupational

Fatality Disability Disability Injury Illness

Nature of Injury/Illness:
Abrasions / Bruising Amputation - Traumatic

Bite / Sting Burn

Concussion Crush / Internal Injury

Cuts/ Laceration / Open Wound Hearing Loss / Deafness

Dislocation Electric Shock

Foreign Body under Skin Fracture

Foreign Body in Eye Infectious Disease

Hernia Heat Related Illness

Occupational Illness / Disease Musculoskeletal Disorder - Chronic / RSI

 Nerve / Spinal Cord Injury Psychological (Stress)

Poisoning / Toxic Effect - Ingestion Poisoning / Toxic Effect – Inhalation

Strain / Sprain Respiratory Disease

Skin Irritation / Disease

Other :

Bite / Sting Biological Factors

Cave-In or Collapse Chemicals / Substances / Radiation

Drowning / Submersion Dust / Fumes / Gases

Extreme Temperature / Fire Electricity

Equipment / Property Damage Hit by Moving Object / Crush / Vehicle

Mechanism of Injury/Illness:
Manual Handling Fall from Height

Occupational Violence Penetrating Injury (needle stick, puncture wound)

Mental Stress Repetitive Motion

Slip, Trip and Fall Sound / Pressure

Struck by Falling Object

Other :

Animal / Human Confined Space

Environmental Conditions Fixed Machinery / Plant

Infectious Agent Materials or Chemical Substances

Mobile Plant / Equipment Non-Powered Equipment / Tools / Appliances

Agency/Source of Injury:

Powered Equipment / Tools / Appliances Road Transport / Vehicles

Scaffolding or Ladders Sharps / Scalpels / Needles / etc.

Trench or Excavations

Other :

Bodily
Location: Cervical Spine Ear Eye

Head /
Face (excluding eye) Forehead Mouth
Neck

Neck Nose Scalp / Skull

Abdomen Back Genitals

Trunk
Pelvis Spine Thorax

Upper
Clavicle (Collar Bone) Elbow Fingers (other than Thumbs)
Extremity
 Forearm Hand Shoulder

Thumb Upper Arm Wrist

Ankle Buttocks Foot

Lower
Hip / Groin Knee Lower Leg
Extermity

Thigh Toes

Arteries Brain Heart

Internal
Intestines Kidney Liver
Organs

Lungs Spleen Stomach

Heat Related Occupational Illness

General
Other :

Additional Information : (additional information to complete the investigation as required by clause 5.4 of OSHAD-SF Mechanism 11.0
- to include information not already covered by Form G1.)
Other information can be added to the investigation report with maximum 200 words

Actions Taken Immediately after the Incident

No. Actions Responsibility Status Date Completed

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

Incident Root Cause(s)

Add Item

Corrective Actions to Prevent Recurrence

Add Item

No. Actions Responsibility Target Date Completed Date

 Incident Cost

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)

5 Asset Cost (Property, Machinery, Equipment, Structure, Material, Vehicle, etc. – Replacement)

6 Enforcement Action (Penalty Issued by Authority etc.)

7 Incident Scene / Area Restoration Cost (arrangements to make safe, cleanup, etc.)

8 Other Cost relevant to / associated with the Incident

Total Cost 0

Risk Assessment

Probability : Rare Possible Likely Often Frequent

Severity of Consequence : Insignificant Minor Moderate Major Catastrophic

Level of Residual Risk : Low Moderate High Extreme

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