ACCIDENT/INCIDENT/NEAR MISS REPORT FORM

Accident/Incident/Near Miss Investigation Form

Department HSE
1. Personal Information
Name of injured person NO INJURED PERSON
Address: RA International Base Camp, Johwar, Somalia

Phone Number: 0612811563

Occupation/Department
TEAM LEADER/SUPERVISOR PEM
Nature of injury (or damage/near
miss) ELECRTICAL FIRE IN THE DFAC DISTRIBUTION BOARD
Names of witnesses
GEOFFREY ASUGA
Statements taken Yes No

2. Accident, Incident or Near Miss details

Date: 13TH.09.2020

Time: 8:00pm
Location of accident, incident or
JOHWAR DINNING FACILITY
near miss
Work being
NO WORK PERFORMED (ELECTRICAL DISTRIBUTION PANEL)
Performed

Working conditions

Description of incident (state possible causes)

At about 8pm myself (Geoffrey Asuga and 3 other staffs) were in the DFAC watching television , all of a
sudden we heard a short circuit spark with loud blast flame from the electrical distribution board in the
DFAC, I shouted fire , get out and bring the fire extinguisher as the rest of the staffs exited the DFAC
through the rear door, the staff closer to the fire extinguisher brought it and aimed at the flame and we
managed to contain the fire from spreading,

3. Assessment of risks associated with accident, incident or near miss

Could have been worst and led to injuries if it
What was the likely severity of injury? H
was not managed
What is the likelihood of the incident If No inspection/maintenance is carried out often
H
recurring? on electrical equipments
How many people could have been affected? 1-4 Risk of reoccurrence rating H M L
Risk assessment ref no (if
N/A Risk assessment amended? N/A
applicable)

4. Conclusions
CAUSES OF ACCIDENT, INCIDENT OR NEAR MISS
Direct
It was suspected the wall lizard might have caused the spark because there is an open space between the
kitchen container and the plywood insulation for DFAC wall, The electrical board is located at that same
space, which is only open from the ceiling, unfortunately the wall lizard might have entered the Power
board using it as hideout

Contributory
1, The open top of the Distribution Board were the cables pass into the board might not be having cable
gland to protect the panel from external foreign object like lizard coming entering through the hole,

2, No inspection has been carried out on that distribution panel which can also be the cause of the fire
CORRECTIVE ACTION NEEDED
Type of action Date completed Signature

Remove and install new Distribution Panel 16th.09.2020

Inspection/Maintenance should be carried out regularly

on all electrical equipment
1, Visual inspection daily
2, Monthly Maintenance 16.09.2020

5. Review
Review of correction action required Yes No
Name of person carrying out review GEDFREY ASUGA
Signature
6. Investigator

Name Okenna Obi

Signature/Date