Safety Violation Investigation Form

Pacific refractories Date / Violation 05.06.2024/PRL-01

Company
limited number
Name & Designation of reporting Mr.B K. kunwar GM -Projects
person
Name & Designation of person Mr.Bichitra ku behera - HSE officer
filling the form
Area CCM One man is working at height without full body harness
produc
tion
Violation
Type of Height
Identified
Violation work
violatio
n
Persons Involved (workers/Supervisor/Engineer)
Name Pass Number Designation Previous Violations?

Mr. Ashard Sr Rabindra No

1 What barriers / precautionary measures do you currently employ to prevent this type
of incident occurring?
Proper use access & egress, use safety harness work at height.

2 Why did these barriers fail?

Didn’t take ladder and went up to work.

3 Actions to prevent this type of violation in the future (Actions should fix failed barriers
or add additional barriers)
Action Responsible Target Status
Date

PRL If one has to work above 1.8 m , one Mr. Rabindra

has to wear safety belt and have proper 05.06.2 Open
access. .Also will keep some spares to 024
combat anticipated damages in future

Mr.Ashrad responsible supervisor for the Mr. Rabindra 05.06.2

job is being suspended from work for three 024 Closed
days for the violation

Confined space safety training will be

conducted for all workers and staff in Mr. Rabindra
association with Coromandel international 05.06.2 Close
safety department 024
Project No:
Date:
WARNING LETTER

Name of Company Pacific refractories ltd.

Name of Violator
Location
Name of Supervisor

Description of the violation:

TYPE OF VIOLATION
Personnel protective equipment’s Confined Space Excavation

Safety Equipment’s Lock out Tag out Working at height

Permit to work Electricity Fighting

Scaffolding Environmental Horse play

Machine/Equipment use Barricading Vehicle use/Speed limit

House keeping Lifting Others

Comments/Recommendations:

I hereby accept that I have violated the HSE rule I hereby note that necessary actions regarding the violation will be
mentioned above taken under my supervision

Name and sign of Supervisor

Name and sign of Violator

I have been observed violating the HSE rule Original copy is received and attached to the file of violator
mentioned above

Human resource Dpt.

HSE Officer