Perstorp Elephant Project Form No:

Incident Report Form

Preliminary information shall be submitted within 3 hrs of incident

Name of the Contractor:Trimurti Fabricators Pvt Ltd Report No: 1

Accident Near Miss First Aid injury Security Incident

Incident Type: Injury Fire Spill Gas leak Traffic (Man / Machine)
Property damage Dangerous Occurrence Others
Other (If any), then specify- (_____________________________________________________________)

Date of Incident: Time: Work Permit No:

Specific Location: Equipment involved:

Brief Description (Who, What, & How):

Consequences due to Incident:

Injury: Yes / No Name of Injured:
Fatal Employee. ID No:
Non-Fatal Sex : Male/Female Age:
If non-fatal, state precisely the nature of injuries: Fist-Aid Received: Yes / No
PPE Used:
Doctor / Medic comments:

Loss: Yes / No Damage: Yes / No

Immediate Corrective Actions Taken:

Signature
Name
Date & Time
Designation HSE Manager- Contractor RCM - Contractor
Reviewed by APG HSEM/HSE Engineer Signature:
Detail Analysis shall be submitted within 48 hrs of incident

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Perstorp Elephant Project Form No:

Incident Report Form

Root cause:

Preventive Measures/Actions:

Attachments
Work Permit Witness Statement
Vehicle / Equipment Documents Victim statement
Operator Documents TBT Record
Training Record Others
Case Identification
Psychosocial and Organizational Factors: Life Saving Rules:
Radiation Bypassing safety controls
Personal and workplace hazards Confined space
At risk behavior Driving
Dropped object Energy isolation
Failure in safety critical barriers/functions Hot work
Fire/explosion Line of fire (excl. dropped object)
Housekeeping Safe mechanical lifting
Personal protective equipment Work authorisation (Permit to Work)
Scaffolding and temporary platform Working at height
Slip, trip and fall Organizational factors:
Spill and leakage of flammable liquid/gas Competence and training
Tools and equipment Interaction and communication
Transport and logistics Risk assessment, planning and job
Health and Working Environment: External Environment:
Chemical, dust and smoke Spill and Leakage to the Environment
Ergonomic factors Waste Management
Facilties: External Factors:
Indoor Air Pollution
Outdoor Natural Disasters
Noise Weather
Unspecified - Other
Signature
Name
Date & Time
Designation HSE Manager- Contractor RCM - Contractor
Reviewed by APG HSEM/HSE Engineer Signature:

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