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.