PPL - HSE / FM / IIR / 03 Rev : 01

INCIDENT INVESTIGATION REPORT (IR 03)

Dept. / Field / Location: __________________________ Area: _______________________

Type of incident investigated: (check below)Fatality Lost time

injury or illness

Occupational injury or illness without lost time

Restricted Work Case

Fire / explosion

Property damage

Near Miss

Environmental incident

Exact location of incident: (area, building, floor, department)

Person(s) involved:Full name: Employee Number: Shift:

Department: Occupation:

Witnesses: Name(s): Department: Occupation:

Incident date: Time:

Investigation Team: Name: Department: Occupation:

Date of Investigation:

Details of incident: (Who was involved, what happened and why, actions taken at the time etc. (attach additional information if necessary)

Number of work days lost (calendar days):

PPL - HSE / FM / IIR / 03 Rev : 01

Investigation Findings (Immediate and underlying causes and contributory factors)

Actions to prevent re-occurrence (Attach additional information if necessary)Primary or Underlying Cause: Action: Responsible: Completion Date:

Compiled by:(Sectional Head)Name:Designation:Date:

Reviewed by:(HSE Representative)

Approved by:(Dept. Head / Field / Location Incharge)

Report distribution:

Summary of Action Review:

Date of Review, Name and Signature:

All incidents must be reported to HSE at HO within 5 days on IR 03 with copy to all concerned. In case of unavailability of victim for investigation purpose report may be submitted on his arrival as soon as possible.