be ln Rav beae poms PUP aan Dae “WF ad sng Land niet oern Ca Pa ohn ent Sasi hi aint A Des ot Wael ‘Cana resign frm obs sta Aav Ons Pars HSE wh 20 days inet a eal inden. poradbor ae) ‘oporesty AOMEINON-) Lan der Regen Frm & ADMLFAA(OF-} a Wbss Sslr ae nce No (obtain from HSE) 0 | First aia O_| Near miss 36.11.2020 Time of fncident a7 es Incident Report Reference No — Date of favestigation Report | 17.11.2020 Incident Location Guq [Oz [eee [Owus [Or | Cother, speciy: KiZaD A? Tneident Investigation of Contractor Incident Byes One Ene ‘Team Leader Designation Origination / Department Mohammad Inamul Quadir | Project Mana ‘Asia Prime George om ‘Asia Prime ‘Asa Prime Tavestigation Team Members | Designation Origination / Department ‘Sajjad Anamd HSE Engineer ‘Asia Prime Darius HSE Engineer ‘Asia Prime ee ‘Name ‘Organization / Department | Contact Details; Phone & Email Mr. Qamar Bashir operator. immediately called. \sia Prime Male Nurse Mr. to the Injured Person (IP). Mar ‘Asia Prime John was called to the site at 17:18 hrs for providing (0565418717 ‘On 16 of Nov 2020 at 17:11 hrs Asia Prime Safety team received a call from Mr. Qamar Basheer (Stee! Fixer) that we have an accident at the Concrete washout area near Security Gate number 02. On reaching the accident location at 17:15 hrs it was found that the concrete pumps#74268 AD driver Sandoop Mohammadi was lying on the ground with injury on his right leg and been helped by his pump Based on the injury the Kizad Security Control room, Ad Ports PM, Port Duty Manager and Ambulance were t Aid treatment ‘The ambulance and Ad Police arrived at 17:21 hrs to site and shifted the IP to NMC Royal Hospital Khalifa City Abu Dhabi for further treatment. Ambulance left the site at 17:33 hrs. Asia Prime passed all the relevant information to Kizad Control Room and Program Management at the same time, and secured the accident scene for further investigation. Pease specy the total number of Fatality, Injury, lnesses, Spll, Pollution and or Damages Incident Type & Consequences CD rataity [5 spitor ova Fue cargo Damage | BB inyury 1D Spill of Hazardous Material 1 Operation interruption Tiiness environmental Postion T : Tassets/ Property! Equipment Dorner: Fire explosion oe LE 1 plicable; specific Detais of | Tnjury/ Wines (lease to Land, Sea, Quantty, ee.) (Git rare, bun ete) pee _ _ r2(5) of Body Injured (ead Ar, Chest, ea.) “ms Environmental Impact wapubs lini Kovoiacivons LAND INCIDENT INVESTIGATION REPORT ‘irom xe antler meses and dentao:crnfn Da Po Nn unde kestrel ba a Pee Vala ‘Corsi maaan or ote srs Rov Dsl Fo HSE wihin 2 days of ned sonal (ncnarsno a). supported by ADM-FRNO7-1}1 Land ident Report Form 8 ADM-FRIM017- 4 rial Wines Sateen Land, eee eee i Legal Cost (Compensation claims, judicial prosecutions, et.) i Productivity Cost (Business Disruptions, Delays, Production Loss / Day, Material Salaries, et.) Ti Asset Com (Propery, Machinery, Eauipmen, Stuciure, Vehicle, ete. ~ Repair, Maintenance, Replacement) Ti enforcement Action (Penalty Issued By AURhorey) Di thaident Scene / Area Restoration Cost (arrangements to making safe, deenup, et..) TD Emergency Response Cost (Frefighting, Hazmat, Ol Spl, ete other Gost relevant to / associated with the Incident Tota Person Preparing the Investigation Report some eine ahmea oo Postion | HSE Engineer. Organization [asinine canaratcontracing company [E208 [asa aossaze ate 7 nov 3030 Tine od ‘Accountable | Accountable = Department | Person ‘Status ‘Re-training of the operators and drivers on safe operating = i ” ane! HSE AL Falah Immediately | oper ‘Regular maintenance as per manufactures recommendations ‘Maintenance Immediately | open Installation/ Repair ofthe interlocking mechanism to prevent the 3. | agitator from rotating ifthe hopper grill Is opene Immediately | open nae Designation Department Date signature Mohammed nama Qvadv 7H aa rime | 37/43/2020 Genre om Tae Prime | a7raraeae Salad Anew HSE Engineer asa raime[s7raro | ea ease ar tr cen ror rer reer an Sat Pos tose Coreen Grater eh skeen CHnesim on Rake | ICES oa a Tomer bot sen | Cleat eset | Oiaacoves | tases | Sato amt pease Ty | Not Recorded as Neer First aig tneident Giear miss | Recor Tivinor ingry [Dl environmental pansion | El winor Dangerous Occurence | E] Niner Oecvpatona nese serous ryury Tr Serious Occupational tines | C1 Seraus Dangerous Occurrence a aan D1 Permanent Partial Disability C1 Permanent Total Disability CO Fatality Tncident Classification | Chcategory0 (Minar) Tiestesery 1 (Sevous) | El category 2 (Get) | EI cotegary 3 (Cases) Emergency Level Ciestesery 0 (050) Clestesery camry | Desteoorr 2 (GA) | Eh category 3 HD fooYonbgs lee ASU DHABIPORTS PUPP uur as ‘Gar esa arb sen A Dal Pts HBE itn 2 aye of nln ema Gnedeporieodbora) ‘opatea by ADMIT) Lane drt Rope Fam & ADL ON) bts Sse ar Reference No (obtain from HSE} ‘Assets/ Property/ Equipment | 7 ‘damage NA | ork, Generator & costo Damage) | cargo Damage NA wt Severity Injury Severity; Te acta! severty and consequences of inury based nos by profession = Spill / Release (Discharges to Land, Water, Including Groundwater) Ti tinor Injury require first aid treatment TD winor Sp 5 200 ser Tiree 51,000 ere TG Medical Teatment- Outpatient TD ederte Sa 201-5000 ere Gi Mecieal treatment tn-patient, How Many Days? Restricts Wark ~ Bh Lost Time case 1 aor Spt 50 50,000 ters o [Ti cateoshie Spi more ton 80,001 Utes Wa Berea ai 1D medical [ChPemicto work 1D tira party investigation Gaice Cl wiork instruction/ Procedure msos - Remote Ceuta Rete “The concrete pump driver opened the hopper grill and was trying to repair the blockage by standing Ti Proto/ Drawing Tlotrer ‘the hope! TD woderte Spit 3005- 10,000 Lies TD coeantropie Spl mare thon 500,008 Lars Ti invoiveas witness Statement rated and his right foot got stuck In the agitator bladk ‘Action status 1, | Immediately informed to PM, HSE department, Kizad Security Control | HSE 16.1,2020 | Closed Room, Duty Manager regarding the incident 2. | Shifted IP to NMC Royal hospital Khalifa City HSE 16.44.3020 | Closed 3. | Work stopped at concer washout area and barricaded the area HSE 16.44.2020 | Closed a Groups Contributions Incident Root Causes (Uneate Ae Uneoe Conion, Tada, aminstratve, Direct | incirect roe) 1 | Fail to follow agreed rules, and use of shortcuts. Unsafe act Direct 2, | Fale Lack of the interlocking system (opening the hopper gril should have | Waste conaition = prevented the agitator from rotating). Incident Inv Tnterlocking system to be in place and working to prevent the agitator from rotating ifthe hopper grill is opent ‘Operators/ drivers of concrete pump to be re-trained on the safe operating procedure, sms to be done and records to be maintained by the contractor. 1 2 '3, | Regular maintenance as per manufactures recommends GgPM UO au ‘Th Fom ob st ong Land nnd awn A OP er Ne ese neat Fis id yng Au Daan Woke. ‘ont avergalon rv ob ene Abu Dhab Fors HSE win 20 dys fino! ve ena neietsrisaba a Serie Gan ‘ppoted by ADMLFRIOT-1 Land Wert Rape For &ADMAFRAC?-Tha tl Wines Somer Land, Reference Ho (obtain Som HGR! Ts Investigation Required | By Who (Organization / Department) Tavestigators Team leader (Name and Designation) Des a (Esco neae nd ‘Authorized Contact Person ‘Contact Number Email Address Date & Time HSE Stamp