Lufkin Middle East

HSE department
Date
Incident report/ investigation form

Date of incident: 20/12/2020 Report date: 20/12/2020

Name of the location Inshas

Time of the incident am/pm 13.00 PM

Name of the employee Hany Hasan

Araby
Name of the foreman No foreman

Name of the supervisor No supervisor

1- Details of incident:
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while performing lifting of the counter weight in Inshas area, the loading chain has
been cut, and the counter weight fell down. No one was standing under the weight as
per Lufkin lifting instructions. So, no injury recorded. No damage for the
counterweight because the distance travelled by the chain has been so short which
reveal negligence in chain storing which lead to damage in addition to the absence of
inspection and this is a violation of safety rules and lifting plan.
Contributing factors:
What conditions contributed to the incident (match all contributing causes?)

1❏ operating without permission

2❏ failure to lock out
3❏ insufficient training
4● insufficient care
5❏ failure to use personal protective equipment
6❏ not guarded or improperly guarded
7❏ inadequate illumination
8❏ poor housekeeping
9● unsafe practice
0❏ others (explain) negligence of chain storing and periodic and pre-use inspection

Explanation of the contributing factors:

Negligence of chain storing. I have repeatedly recommended the people in free zone to carefully store
the chains. The last time was two weeks ago for
Araby.---------------------------------------------------------------------------------------------------------------------
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Detail of property damage ---------------------------------------------------------------------------------------------

Injury

❏ Eyes ❏ head ❏ arms ❏ chest ❏back

❏ hands ❏ legs ❏ feet ❏ internal

Incident classification:

1 ❏ first aid
2 ❏ Medical treatment
3 ❏ Restricted work
4 ❏ lost work day
5 ● Injury free event

Detail of injury and classification criteria:

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No injury (near-miss)
Corrective measures
Actions to prevent recurrence
Indicate which action taken to prevent recurrence

● Reinstruction of person involved 2 ❏ Reassignment of person

3 ● equipment repair 3 ● Order job safety analysis
5 ❏ improved personal protective equipment 6 ● Actions to improve work procedures
6 ●training

Describe actions taken to prevent recurrence:

The corrective actions to be taken to prevent recurrence:

1- Isolation and segregation of all damaged or long period used chains.

2- Inspection and measuring the elongation of all chains stored in the free zone.
3- Relevant storing.
4- Application of Lufkin lift plan.
5- Training all lifting involved people on lifting.

HSE Manager _______Talaat A.kader___________________ signature

Date received 20/12/10________