Energypac Engineering Ltd.

Energy Center (1st & 2nd Fl.),

25 Tejgaon I/A, Dhaka-1208, Bangladesh.
Serial No.: EEL/EHS/Report-002

Energypac Engineering Ltd.

Energy Center, 25, Tejgaon I/A, Dhaka-1208, Bangladesh.

Accident/Incident/Near Miss Investigation Report

Section-1
Project Name Design, Supply, Installation, Testing & Contract No.:
Commissioning of 132/33kV Substation PGCB/KfW/2012.66.436/SS
Extensions, on Turnkey Basis.
Location Madaripur Mongla Bagerhat Type
Date & Time ..…/..…/…........ at …….:..….. am/pm Personal Injury Vehicle Damage
Reporting Date Property Damage Crime Lost Time
& Time ..…/..…/…........ at …….:..….. am/pm First Aid Others
Status
Investigation Accident Incident Workers Visitors Others
Report Type Near Miss

Section-2
Injured Persons Details
Name Designation Nature of Injury Contact No.

Section-3
Description

Section-4
Root Cause Analysis

Section-5

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Serial No.: EEL/EHS/Report-002
Contributing Factors
Hazardous method/Procedure used
Improper Position/Posture
Inadequate personal protective equipment
Incorrect/defective tools
Unsafe design or construction
Poor weather conditions
Hazardous housekeeping or arrangement
Energypac Engineering Ltd.
Energy Center (1st & 2nd Fl.),
25 Tejgaon I/A, Dhaka-1208, Bangladesh.
Inexperience of person in the task
Training/job instruction inadequate
Inadequate guarding of material & equipment
Inadequate lighting/ventilation
Other:
Detail Factors:

Section-6
Witness Statement
Name of Witness:
Contact Information:
Date & Time:
Location:
Account of the Accident/Incident/Near Miss:

Signature of Witness: Date:

Section-7
Actions and Follow up to prevent Recurrence Action Plan (Include what, why & how
recommendations are made)
Contact Occupational Health & Safety for assistance
Contact Physical Plant Department for assistance
Actions to improve design/procedures
Correct congested area
Repair or replace tool/equipment
Improve personal protective equipment
Install guard or safety device
Reinstruct person involved & provide support/coaching
Request Ergonomic Assessment
Update training
Refer to Rehabilitation Services

Section-8
Photograph

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 Energypac Engineering Ltd.
Energy Center (1st & 2nd Fl.),
25 Tejgaon I/A, Dhaka-1208, Bangladesh.
Serial No.: EEL/EHS/Report-002

Section-9
Additional Information

Section-10
Investigated By:
Name: Designation:

Signature: Date:

Reviewed By:
Name: Designation:
Signature: Date:

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