TRANS ANATOLIAN

NATURAL GAS PIPELINE PROJECT

ACCIDENT/INCIDENT REPORT

Record No: - Page 1 of 2


Report No: Company Involved:
Date of Occurrence: Time of Occurrence:
Location of Occurrence:
Work Related Not Work Related
Type of Accident/Injury
Property Damage Injury Illness
Environmental Security Fatal Injury
Identifying Information
Injured s Name:
Nationality
Marital Status:
Nationality: Employers Company:
Gender: Occupation:
Age: Experience in Current Job:
Object/Equip/Subst. Inflicting Harm:
Cause Checklist
Substandard Actions Substandard Conditions

Operating equipment without authority

Inadequate PPE

Failure to warn

Inadequate guards or barriers
Failure to secure Defective material, tool, equipment

Operating at improper speed

Restricted action
Removing safety devices Fire and explosive hazards

Using defective equipment/tool

Poor housekeeping

Failure to use equipment/tool properly

Noise exposure
Failure to use PPE properly Hazardous environment conditions e.g. gases, dusts, fumes etc.

Improper loading

Inadequate ventilation
Improper lifting Inadequate or excess illumination

Horseplay

High temperature exposure

Stress

Inadequate work area standards

Lack of capability, knowledge, skill, motivation

Mis-positioned scaffolding

Abuse or misuse

Inadequate supervision
Violation of rules, procedures Others

Others


Investigation
Describe the operation in progress at the time the incident occurred (use separate sheet if necessary)






Describe how the incident occurred (use separate sheet if necessary and attach photos & sketch)






TRANS ANATOLIAN
NATURAL GAS PIPELINE PROJECT
ACCIDENT/INCIDENT REPORT

Record No: - Page 2 of 2



Witnesses: YES NO
1. 3.
2. 4.
Approved by Safety Engineer, SE/Name: Date/Time: Signature:
Signatur
Prepared by Supervisor/Name: Date/Time: Signature:
Signatur
Remedial Action Plan
Immediate actions to prevent reoccurrence or escalation Responsibility Deadline Closure Date
























Report closure
Closed by Supervisor/Name: Date/Time closed: Signature:
Signatur