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Report No. Contract No. UI-61917-PGCC-HSSE-IAF…3.1

Short Description of Incident

Where did the incident occur?

Specific Zone/

When did the incident occur?

Date & Time of
Date & Time of Incident

Who or What was involved?

Name of Involved Person(s) Emp. No: Job Title: Contact Details:

Name of Responsible Emp. No: Job Title: Contact Details:

Supervisor (PGCC)

Name of Responsible Emp. No: Job Title: Contact Details:

Supervisor ( EL)

Name of Witness(es) Emp. No: Job Title: Contact Details:

Vehicle/Equipment Involved: (if


What were the conditions like?

Weather: Road Surface:

Lighting: PPE Used :

Event Type:
Near Miss Incident (NMI) Road Transport Incident

Potential Incidents (Unsafe Acts & Conditions) Asset / Property Damage

First Aid Case (FAC) Environmental Incident / Spills

Medical Treatment Case (MTC) Reputation Impact

Restricted Workday Case (RWC) Non-Accidental Death

Lost Time Injury Case (LTI Case) Fires and Explosions

Permanent Total Disability (PTD) Occupational Illness

Fatality Case Asset Rules / Security Violations

Third Party Fatalities Life Saving Rules Violations

High Risk Incident (HRI) Others:__________

Full description of the incident:

Form No: PGCC-HSSE-AIR-001 Page 1 of 3

Root cause of Accident/Incident

Lack of job training/knowledge/experience

Using defective equipment/tools
Inaccessible or poorly maintained PPE Others(Specify)________
Lack of Supervision
Poor working conditions
Congested work environment
Safety rules not clear or understood
Missing guard
Ignoring instructions
Inadequate communication
Horse play
Inadequate/no inspection system
Known hazards not corrected
Deliberate unsafe act
Inadequate design of engineering
Inappropriate method of work
Lack of attention/ focused on the job
No access/platform/scaffold

Enter any Immediate corrective actions(Correction) taken:

Corrective action/ Preventive action proposed to prevent recurrence:

Actual Severity Rating (as per RAM matrix) Potential Risk Rating

Fountain reported by: Fountain ID No: Date/Time:

Investigation Team Members

Prepared by: Designation: Signature: Date:

Reviewed by (HSSE): Designation: Signature: Date:

Reviewed by (Concern Dept.): Designation: Signature: Date:

Follow-up Review (to be completed by HSSE Department) Report closed: Yes No

Form No: PGCC-HSSE-AIR-001 Page 2 of 3

Follow up reviewed by: Designation: Signature: Date:

Form No: PGCC-HSSE-AIR-001 Page 3 of 3

Form No: PGCC-HSSE-AIR-001 Page 4 of 3