INCIDENT

INVESTIGATION REPORT
This form must be used for all incidents that have caused harm
or damageor had the potential to cause significant harm or damage
Facility name
Date & time of incident
Full name of injured party
Job title
Department
Line manager

Injured party's status

First Aid
16/2/15 11:00am
Umeshpal
usk( Kanhaiyya)
Vanish Mfg
Aman Singh
Employee
Temp/Agency
Contractor
Visitor
Public

Yes

Nature of Incident

Accident with injury

Accident with damage
Dangerous occurrence
Illness

If the incident resulted in injury,

what level of medical treatment
was required?

On-site 1st aid

On-site medical
Off-site medical

Did the incident result in any Lost Work Days?

Did the incident result in any restricted work?

No
No
No
No
check one
yes
no
no
check one

No
No
delete as appropriate

check one
Injured party'scontact
details

Pradeep

Factual description of the incident. Include as much details as possible. Avoid including personal opinions. Use additional sheets if necessary,. Include
photographs and any sketches of the incident location etc as attachments
Today at 11 AM in Vanish Powder Mfg Area , during spraying of oxo-alcohol ( 6 mins of spray in a batch directed downwards), spray nozzle got loose and
dropped causing the oxo-alcohol stream to direct towards the unskilled person attending the batching process. The unskilled was wearing Goggles and
thus escaped from the casualty. However, when he removed his goggles for lunch , he complained of redness in eyes which was immediately addressed.

Nature of any injury or property damage. Include details of which parts of the body/building infrastructure were harmed/damaged, and details of any
medical treatment provided.

Redness in eyes
List any witnesses to the
incident

Name
Title

Have witness statements been

collected and attached? If no, why not?

Incident investigation
team

Name
Title
Role
Name
Title
Role

Nirmal
Chemist
No

Aman Singh
Executive
SO

Coding of immediate causes (or contributing factors): CHECK ALL APPLICABLE

SUBSTANDARD BEHAVIORS / ACTS

yes

1. Operating equipment without authority

2. Failure to warn
3. Failure to secure
4. Operating at improper speed
5. Making safety devices inoperable
6. Using defective equipment
7. Failing to use personal protective equipment properly
8. Improper loading
9. Improper placement
10. Improper lifting
11. Improper position for task
12. Servicing equipment in operation
13. Horseplay
14. Under influence of alcohol and/or other drugs
15. Unsing equipment improperly
16. Failure to follow procedure/policy/practice
17. Failure to identify hazard/risk
18. Failure to check/monitor
19. Failure to react/correct
20. Failure to communicate/coordinate

SUBSTANDARD CONDITIONS
Yes
Yes

1. Inadequate guards or barriers

2. Inadequate or improper protective equipment
3. Defective tools, equipment or materials
4. Congestion or restricted action
5. Inadequate warning system
6. Fire and explosion hazards
7. Poor Housekeeping; disorder
8. Noise exposures
9. Radiation exposures
10. High or low temperature exposures
11. Inadequate or excess illumination
12. Inadequate ventilation
13. Hazardous environment conditions: gases, dusts, smoke, liquids, vapor
14. Inadequate instructions/procedures
15. Inadequate information/data
16. Inadequate preparation/planning
17. Inadequate support/assistance
18. Inadequate communications: hardware/software/process
19. Weather conditions
20. Surface conditions floor/road/platform

Coding of basic (or root ) causes: CHECK ALL APPLICABLE

1. Inadequate physical capability
2. Inadequate mental capability

1. Inad. Leadership/supervision
2. Inadequate Engineering

yes

3.
4.
5.
6.
7.

Physical stress
Mental stress
Lack of knowledge
Lack of skill
Improper motivation

Yes

8. Abuse or misuse

3.
4.
5.
6.
7.
8.

Inadequate Purchasing
Inadequate Maintenance
Inadequate Tools/equipment
Inadequate Work standards
Wear and tear
Abuse or misuse

Cause analysis. List oll the findings of the investigation. Causes should match the ticked boxes in 'Coding of causes.' Any risk assessment associated with
the activity must be reviewed as part of this analysis.

Informed Engineering team of this glitch in spraying process, Counselled USK to wash hands after batching process is over.

Corrective action plan (continue on a separate sheet if necessary)

Responsible
person

Due date

Sign off as completed

0. Activity risk assessment reviewed and amended as necessary.

2. Spraying Nozzles maintenance to included in PM

Kaushal

3
4
5
6
Sign off (review and investigation complete)
Site H&S Manager/Coordinator
Line Manager
Department Manager
Senior Site Manager/Director

Signature

Name

Date

1.

Struck against

1.

Electricity

2.

Struck by

2.

Heat

3.

Caught in

3.

Cold

4.

Caught on

4.

Radiation

5.

Caught between

5.

Solid object

6.

Rubbed/Abraded

6.

Noise

7.

Fall on same level

7.

Chemical substance

8.

Fall to below

9.

Overexertion/stress

10.

Environmental Release