Incident / Accident Closeout Form

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Following any incident resulting in injury, property damage or loss of assets, the Project Manager with the responsibilities for
completing the investigation, will complete the following information so that the status of the completed recommendations and
actions identified to prevent a recurrence of a similar incident can reviewed and closed out.
On completion of the site actions the form shall be sent to the HSE Manager, for action by the Incident Review
Committee.

Date of Incident Time Site Location Inc Ref No.

09/01/2021 9.30AM PPT_CSA. Compounding Building Suroj/

Brief Description of Incident.

On 9th January 2021at around 9.30AM PEB Pennar Labours were lifting sag angle materials
by using boom lift platform for the erection of compounding building sheeting work. Due
to inappropriate stacking of materials without adequate tie up in platform lead to slip and
fall from 5 mtr.height. Sag angle hit to the hand of labour those who shifting materials
under ground level and got injury. Immediately first aid treatment administrated and taken
to SN Hospital, Sadasivpet for further medical assistance. X-Ray has been taken to ensure
born cracks if any and found normal. Wound stitched and dressing done. He is physically
and mentally fit as per Doctor’s diagnosis.

Causation Factors
Immediate Cause: Sag angle fall from 5Mtr. Height
Contributory Cause: Unsafe act of Labours and unsafe working condition.
Root Cause: Misuse of machineries’ and Inappropriate stacking of materials on Boom lift platform.
Recommendations: Status = Closed out (completed)
List Recommendations By Who When Status

 Do not use Boom lift platform for material shifting. PEB immediate Done
 Work area shall be cordoned off to ensure unauthorized
entry.
 Ensure PTW for work at height is strictly followed for
minimize the risk.
 Competent supervisor shall be appointed for regular
monitoring.
 TBT shall be conducted to workers prior to start
activities.
 Ensure smooth and safe environment at work place to
execute the task safely.

Incident Review Committee Action

Actions recommended by IRC Committee: √ or X
Comments
Closed Out √ Closed out.
Issue Safety Alert ×
Further Investigation ×
 Incident / Accident Closeout Form
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Additional Actions √
Signature of IRC Chairman Date:14/01/2021