Incident/Accident Investigation Report

1. General information:

Port Name Report No.

Incident Date Time of Incident

Incident Location Reporter Detail

Lead Investigator Incident type

2. Individual(s) involved in incident:

Name Job title:

Contact no.

Are the individual(s) involved in incident received the safety induction

3. Activities undertaken at the time of incident:

4. Description of events when incident occurred Give full details in a chronological order including

location, sketch & equipment involved

5. Details of direct causes leading up to the incident: including weather , lighting , housekeeping ,

North Sector - El Arish Port : El Arish Port - North Sinai

Tel : +2 068 3320045 Fax : +2 068 3322431
Email : elaresh.port@sczone.eg

HSF – 02 Rev/1
 etc.

6. Method statement for the activity

7. Risk Assessment:

1. Is the hazard was properly identifed in risk assessment? Yes No

2. If yes to above, was the control measure stated in the risk assessment or the method statement?
Yes No

3. What other safety precautions were being used? Yes No

4. Is the activity was under direct supervision? Yes No

5. Employee’s experience (Skill ,knowledge ,ability ,training ,etc)details in that type of work

8. Investigator conclusion : this shall include at least but not limited to indirect cause , underlying cause, immediate

remedial action , precaution to be taken to prevent recurrence

North Sector - El Arish Port : El Arish Port - North Sinai

Tel : +2 068 3320045 Fax : +2 068 3322431
Email : elaresh.port@sczone.eg

HSF – 02 Rev/1
9. Attachments:

Attachment
Photo

Method Statement /Risk Assessment

Technical Information

Witness Statements

Others

10. Action Tracking Table:

Responsible
Action Date Close out Date
party

11. Investigation Team Details:

Name:
Title:
Investigation Conducted By:
Date:
Signature:

Name:

Title:
Investigation Approved By:
Date:

Signature:

12. Report Status / Comments

North Sector - El Arish Port : El Arish Port - North Sinai

Tel : +2 068 3320045 Fax : +2 068 3322431
Email : elaresh.port@sczone.eg

HSF – 02 Rev/1
 EDECS Consultant
Comments

Status open Closed

North Sector - El Arish Port : El Arish Port - North Sinai

Tel : +2 068 3320045 Fax : +2 068 3322431
Email : elaresh.port@sczone.eg

HSF – 02 Rev/1