WORK PLACE INCIDENT

DETAIL INVESTIGATION REPORT (DIR)

To be submitted by project in-charge /HSE in-charge to Corporate office HR & HSEMS F-010 Rev-00
Admin /HOD-HSE within 3 days of the incidence occurrence.

Name of the Project Construction of Eight lane access controlled Expressway from Km 217.500 to Km
254.430 of Vadodara Mumbai Expressway( Ena to Kim Section) in the state of
Gujarat on Hybrid Annuity Mode under Bharatmala Pariyojna(Phase I-Package VI)
Project Code ENKI
Name of Project In-Charge Mr. ANUJ KUMAR SINGH
Name of HSE In-Charge Mr. BHRAMARBAR PADHIARY

INCIDENT DETAILS-
Occurrence Location: CH 237 (Tapi River) Date: 06/04/2022 Time: 04:30Pm

Nature of Incident: Physical Environmental Fire Vehicle Property Near

Injury Damage Miss
Mark (√) as appropriate √ ** ** ** ** **

DETAILS OF THE INJURED PERSON-

Name Employee Code Designation Department Age
(if any)
Mr. Akhilesh Shah 1006112 Mechanic P&E 37
Employee Category Company Contractor Name of Contractor
Mark (√) as appropriate (Mention if contractor employee involved)
√ ** **

INJURY DETAILS (Physical Injury Cases)

Severity Category FIRST MEDICAL RESTRICTED LOST TIME FATALITY MEDICAL
Mark (√) as AID TREATMENT WORK (LTI) REPORT
appropriate (FAC) (MTC) (RWC) AWAITED.
** √ ** ** ** **
TOTAL MANDAYS LOST 03 TOTAL MANADAYS TO BE SUFFERED
(As per Medical Report)

BRIEF DESCRIPTION OF THE INCIDENT

(Enclose Photographs/Sketches/Medical Report as annexure to this wherever necessary)
Mr. Akhilesh Shah was Engaged to assembling of Sany Crane Counter Weight along with his sub ordinate,
when he was cleaning the dust or soil in between suspended load or assembled crane counter weight gap
suddenly the suspended material (Counter weight) which one was hang by the hydra crane, suddenly
bubbling the material due to lose the break by the hydra operator and un even surface and hit him his head.

DETAILS OF PROPERTY DAMAGE (Material, Equipment)

N/A

This document is property of GR Infraprojects Ltd and is developed for internal use only. Copying or reproducing of this document is liable to be punishable as per law.

HSEMS F-010 Rev-00 1

 WORK PLACE INCIDENT
DETAIL INVESTIGATION REPORT (DIR)
To be submitted by project in-charge /HSE in-charge to Corporate office HR & HSEMS F-010 Rev-00
Admin /HOD-HSE within 3 days of the incidence occurrence.

DETAILS OF INJURED BODY PARTS Mark (√) as appropriate

Head √ Wrist

Eye Hand

Ear Finger

Neck Hip

Shoulder Upper leg

Chest Lower leg

Back Ankle

Abdomen Foot

Upper Arm Toe

Other parts
Lower Arm (if any)

Referred Hospital Transported By Case Registered with Police

Ambulance Any other √ Yes No

Vehicle

EQIPMENT /VEHICLE INVOLVED IN THE INCIDENT (IF ANY) Mark (√) as appropriate

Name of the operator Mr. Jaspreet Singh

Operator with valid licence. Licence No.PB 0220120109908

Driving /operating as per issued licence. Yes _√________No__________

Vehicle / Equipment Ownership Own √______Hired_______ Subcontractor_____

Vehicle/equipment Registration Number

Safety features/ PUC/ Insurance/Fitness available Yes _√_____ No

Valid Third-Party load lifting Certificate (Applicable to
all Lifting equipment & hardware Yes _______No__√_____

INVESTIGATION TEAM

Role Name Designation Department Signature

Chief Investigator
Mr. Bhramarbar Padhiary Deputy Manager H.S.E
Investigator
Mr. Mohd Imran Ali Officer Safety
Department
/Section In-charge Mr. Kamal Singh Sr. Manager P&E

This document is property of GR Infraprojects Ltd and is developed for internal use only. Copying or reproducing of this document is liable to be punishable as per law.

HSEMS F-010 Rev-00 2

 WORK PLACE INCIDENT
DETAIL INVESTIGATION REPORT (DIR)
To be submitted by project in-charge /HSE in-charge to Corporate office HR & HSEMS F-010 Rev-00
Admin /HOD-HSE within 3 days of the incidence occurrence.

Witness
Mr. Harish Kr. Tayler Asst. Manager P&E

INVESTIGATION DETAILS (REMEMBER-WHAT, WHEN, WHERE, WHY & HOW)

What task or type of job being performed? Sany Crane Assembling (CSR-198).

At what time the injured started the work on the 12:10Pm

incident day?
Was the person involved in these activities trained Mr. Ravi Kumar
and if so when?
Was the person authorised to carry out that type of Mr. Harish Kumar Tailor
work/use machinery /

What instruction had been given? by Whom? Crane assembling with proper and safe manner &
care about material lifting & shifting instruction given
by Job Manager Mr. Harish Kumar Tailor

Was there any work supervisor at the time of Yes Mr. Ravi Kumar (Engineer-P&E) was present at
accident at that spot? If not where was the the time of accident .
supervisor of that job at the time of incident
Was there any risk assessment made by the Yes
section for the activity and necessary control
measures put in place?
Was there any tool box talks conducted for the Briefing by job engineer
performed task? If so when?
Were correct safe procedures being observed? Even surface should be ensure , proper
communication be maintained in between operator
and rigger
Are the procedures available with the working Yes, Job Engineer explained about the job
crew? Any one explained about those to them?
What safety equipment /arrangements/PPE and Yes, Safety reflective jacket, safety shoes & hand
protection available? gloves was worn.

WITNESS DETAILS

Name Address Contact Number

Mr. Harish Kumar Tailor ENKI-228 Camp (Segva) 7073475875
Mr. Ravi Kumar ENKI-248 Camp (Tadkeshwar) 6358980596

WITNESS STATEMENT
He was engaged to do the assembling of counter weight activity due to lose the break by the hydra operator
and un even surface hit to him his head.

This document is property of GR Infraprojects Ltd and is developed for internal use only. Copying or reproducing of this document is liable to be punishable as per law.

HSEMS F-010 Rev-00 3

 WORK PLACE INCIDENT
DETAIL INVESTIGATION REPORT (DIR)
To be submitted by project in-charge /HSE in-charge to Corporate office HR & HSEMS F-010 Rev-00
Admin /HOD-HSE within 3 days of the incidence occurrence.

ROOT CAUSE ANALYSIS (Direct Causes: what acts, failure to act and what condition may have contributed
most directly to this incident/accident)
Due to uneven surface and missed communication in between hydra operator or working person, & unsafe
act.

ANALYSIS (Indirect Causes: What are the other contributing factors to the direct causes?)

CORRECTIVE & PREVENTIVE ACTIONS

(What actions are made to correct the cause/avoid reoccurrence of the incident/accident)
Ground preparation should be done before start of assembling/erection work.
Proper communication should be maintained n between operators and rigger.

REPORTED BY

Position Name Signature Date

Project HSE In-Charge

Project In-Charge

(Attach photographs & additional sheets wherever required)

This document is property of GR Infraprojects Ltd and is developed for internal use only. Copying or reproducing of this document is liable to be punishable as per law.

HSEMS F-010 Rev-00 4

 WORK PLACE INCIDENT
DETAIL INVESTIGATION REPORT (DIR)
To be submitted by project in-charge /HSE in-charge to Corporate office HR & HSEMS F-010 Rev-00
Admin /HOD-HSE within 3 days of the incidence occurrence.

This document is property of GR Infraprojects Ltd and is developed for internal use only. Copying or reproducing of this document is liable to be punishable as per law.

HSEMS F-010 Rev-00 5