INJURY INVESTIGATION REPORT

Part A The Injured Person

Accident reference number

Ftco-A005

(H&S Team only)

Name: Murtuza

DOB:

Address: FTCO Camp,Madinah.ksa

Part B - Investigating Officer

Name: Hossam/walid

Designation: HSE Engineer

Address: DAHP - MADINA

E-mail: oncechance73@gmail.com,hosssam_khaled2010@live.com
Post Code: AL Madinah -274

Telephone no: 0599633212,0506187104

Part C - Information Gathering

1. Where did the accident happen?
The Incident happened at Building b 11, Basement Level -3while Housekeeping the piece of steel rod falling
from height.
2. Who was injured or suffered ill-health?
Al Fouzan Worker Mr.Murtuza file no 27364 iqma no 24015134622 has got minor cut at back side of neck part.

3. What injuries or ill-health effects were caused?

Minor cut at back side of neck part.

4. How did the Incident happen?

At Around 1; 50am the plumbing team working at top floor of building b11 the pices
of steel rod falling from height in the basement-3.

5. What activities/tasks were being carried out at the time of the accident?
A group of workers doing housekeeping.

6. Was the injured person trained and competent to carry out activities?
As per our investigation we found the person was doing unsafe work.

Part D - Analysis and Further Action

7. What were the immediate, underlying and root causes of the accident?
a) Immediate causes: When the Worker fired the Hillti Gun the Nail got missed from the target and it hit to the
concrete and it got reversed and also hit to the victim shoulder and passed away resulting in minor injury.
b) Underlying causes: Lack of safe work system.

c) Root causes: unsafe work practice.

81. What additional risk control measures are required to prevent recurrence?
1. Competent Person should be assigned for this activity.
2. TBT Awareness Meeting should be given for the group of workers involved in this activity.
3. Re induction for all team.
9. Do similar risks exist elsewhere?
Not Confirmed

Print Name: Hossam Khalid

Signature:

Date: 19jan2017

FOR OFFICE USE ONLY (Health & Safety Team)

Date Received (stamp)

Data entry date

Data entry by (initial)

Note:
Medical report pending from hospital.
We will submit on 22jan2017.

WITNESS STATEMENT:
Name of Witness
Jafar
Telephone Number(s)
Work:
Cellular:0593696874
Home:
Injury Date
19/1/2017

Job Title/Employer
General foremen
E-Mail Address(es)
Time the witness arrived at the scene
1:50 p.m

Address of Employer (if other than BNL)

FTCO - 8944
Home Address
Pakistan
Time the witness left the scene
2:00 p.m

1. Other persons the witness saw at the scene while the witness was there?
Yes the other person saw him while he was on the scene.
2. Describe where the witness was located in relation to the incident/accident scene.
The witness was near accident area.
3. Did the witness note anything unusual prior to or during the incident/accident? If yes, please describe what
the witness noted and why the witness thinks it was unusual.
No
4. What was the witnesss role in the incident/accident sequence?
He was doing housekeeping.
5. What conditions influenced the incident/accident? (Weather, time of day, etc.).

Sunny Day
6. How did people influence the incident/accident? (Actions, emergency response, etc.)
After the incident our safety officer called the Ambulance and we took him to nearest hospital
7. How does the witness think the incident/accident could have been prevented?
Un safe work system
8. Additional comments/observations:
No

NAME: ________________________________
SIGNATURE: __________________________
DATE: _______________________________