Incident Investigation Report

GENERAL INFORMATION				Rig:
				Report No.:
Date of Accident:		Time of Accident :		Place of Acc.:
Category of Accident : Injurious [ ]     Occupational Illness [ ]     Near Miss Case [ ]
Property/Environmental Damage [ ]     Road Traffic Acc-Roll Over [ ]     Road Traffic Acc-Non Roll Over [ ]
Short Description of Incident :

DETAILS OF INJURED PERSON   -
Surname :		Initials :		Sex: Male [ ], Female [ ], Others [ ]	Date of Birth :
Occupation :		Job at Incident :		With SGD: yrs In Present Job: yrs Total Industry Experience : yrs
SGD Staff : [ ]	Subcontractor : [ ]	Other : [ ]
SGD Pers. No.:		Name :		Name :
Department :		Employer :		Employer :

Time into Duty :		Work Schedule :
Shift :	Hours     Trip: days	Report Date :	Report Time :	Leaving Date :	Leaving Time :

First Treatment By (Position):

Name :

Date :

Part of Body Injured (√) :			Nature of Injury (√) :
[ ] Skull	[ ] Leg/Ankle		[ ] Loss of Consciousness	[ ] Sprain/Strain
[ ] Head/Neck	[ ] Foot/Toes		[ ] Loss of Sight	[ ] Effects of Chemicals
[ ] Eyes	[ ] Arm/Wrist		[ ] Amputation	[ ] Concussion
[ ] Back	[ ] Hand/Fingers		[ ] Fracture	[ ] Dislocation
[ ] Torso	[ ] Multiple		[ ] Burns	[ ] Open Wounds
[ ] Lungs	[ ] Other :		[ ] Cuts/Grazes	[ ] Bites & Stings
			[ ] Crushing/Bruises	[ ] Other :

SUPERVISORS INITIAL ASSESSMENT OF INCIDENT AND ACTION

Estimate Cost (√) : 1. Less Than INR 10,000 [ ] 2. INR 10,000 to INR 50,000 [ ] 3. INR 50,000 to INR 1,00,000 [ ] 4. Greater than INR 1,00,000 [ ] Remarks:	Injury Class (√) : [ ]    FTL      Fatality [ ]    LTI       Lost Time Incident [ ]    RWC    Restricted Workday Case [ ]    MTC     Medical Treatment Case [ ]    FAC      First Aid Case
a)    Potential Severity Rating :
b)    Incident Actual Severity :

Level of Investigation : Level 1 (SV) [ ],   Level 2 (TP/RM) [ ],   Level 3 (DS) [ ],   Level 4 (HO) [ ]

Immediate Action Taken: (Reference from FIR)
Supervisor's Immediate Action to contain Incident and prevent Recurrence :
Actions	Responsible	Status	Target Date
Job Category :	Name :                          Date :

Identification of Root Cause (5 Why-Why Analysis)
Why's	Cause

Investigation Level      Confirmed [ ]   or Amended To Level 1[ ]   Level 2 [ ]   Level 3 [ ]   Level 4 [ ]

Investigation Initiated - Assigned Lead Investigator (Name):

Investigator Designation :

Client Informed: Yes [ ]     No [ ]     Client Representative Participation:
Endorsed by (Name) :          Department/Position :
Date of Endorsement :

FULL DESCRIPTION OF INCIDENT   ( Attach photograph/sketch of incident )

WITNESSES
Name	Address	Employer
Name :	Address:	Employer :
Name :	Address:	Employer :

Other Witnesses (if any) :

Attach Witnessed Form (if applicable) :

CONTROL OF WORK
Did the Job Require a Permit : Yes [ ]     No [ ]	Was a Permit Raised Yes [ ]                     No [ ]
Were the Permit Conditions Correct for the Job? :	Yes [ ]      No [ ]
Were the Permit Conditions Complied With ? :	Yes [ ]      No [ ]
Comment on any Irregularities Associated with the Permit :

RESULTS OF INVESTIGATION :

FINDINGS

IMMEDIATE CAUSES

Investigator Name (printed) :                                          Sign :                                          Date :

RECOMMENDED CORRECTIVE ACTIONS :
Description of Action Recommended :	Assigned To:	Target Date:	Action Initiated by ATR No.:

INVESTIGATION APPROVAL (SITE MANAGEMENT)
COMMENTS (Rig Manager ) :
Date :	Job Title :	Name (Rig Manager):	Sign :
COMMENTS (Tool Pusher) :
Date :	Job Title :	Name (Tool Pusher):	Sign :

INVESTIGATION APPROVAL BY HO HSE DEPT.
Approval of Recommended Corr. Action : Yes [ ] No [ ]
Is Change required in Procedures : Yes [ ] No [ ] Doc. No. :
COMMENTS :
Date :	Job Title :	Name :	Sign :

SENIOR MANAGEMENT REVIEW / ENDORSEMENT
COMMENTS (CEO):
Date :	Job Title :	Name :	Sign :