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NATIONAL CONTRACTING CO. LTD.

(CONSTRUCTION DIVISION )
INCIDENT REPORT

1) Name & Address of the Company:

National Contracting Company Limited, Post Box No.90, Al Khobar, Kingdom of Saudi Arabia

2) NAME OF WORKMAN: N/A SR. NO.

PAY ROLL BADGE NO.: N/A DATE: 03.10.15

JOB TITLE: N/A DATE OF JOINING COMPANY:

SITE / LOCATION: Qassim ID/PASSPORT NO.:

TYPE OF INCIDENT / NO INJURY NEAR MISS FIRST AID ONLY

MINOR MAJOR CRTICAL TRAFFIC

HOSPITALLISATIO N GOSI

While a group of scaffolder was erecting scaffolding, two workers

3) Brief Description of
Incident/Accident
was sending couplers/beam clamps using scaffold bag as they
pulling the rope to raise the materials suddenly the scaffold bag
broken causing the materials in the bag to fell down (4 pcs of
beam clamps fall from the height of 5 to 6 mts). Fortunately the
two workers were away from the dropped zone, and not get any
injured.

4) Date and time of

accident 03/10/2015 08:25 AM

5) Place/process
HRSG 20
6) Part of the body injured
None

7) Type of the injury N/A

8) Root cause of incident Failure of the scaffold bag

/accident
9) Immediate Corrective The scaffold bag was removed and replace new one
actions taken
1.TBT was conducted to scaffolding group together with their
supervisor and foreman and discuss the potential consequences of
the near miss
10) Preventive action 2. Prior to use scaffolding bag must be inspected for any damages,
taken/suggested if found damages it should be removed immediately
3. Safe Distance of the workers pulling the rope from dropped
zone area.

12) Disruption in work (Hrs)

Rev.0 Issue 6 Date: 01.07.2015 Document No. OHSE- FM -29 Page 1 of 2
 NATIONAL CONTRACTING CO. LTD.
(CONSTRUCTION DIVISION )
INCIDENT REPORT

N/A
13) Reported back to duty N/A

14) Signatures of
responsible Superiors Supervisor Safety Officer Project Manager

Rev.0 Issue 6 Date: 01.07.2015 Document No. OHSE- FM -29 Page 2 of 2