EXTENION OF SARAB COMMUNITY MARKET AT SARAB MALL
INCIDENT AND INVESTIGATION REPORT
This document must be used to report all HSE incidents, in accordance with the requirements specified in SOP ‘HSE Incident
Reporting’, and in ‘Key HSE requirements for contractors ‘and are required to meet the notification and reporting requirements
specified by their HSE Sector Regulatory Authority.
Incident details: THE HOARDING FELL DOWN DUE TO STRONG WINDS
Incident Date Incident Time Date / Time Reported
Reported By Employer Of Person
Reporting
Incident type
Fatality Journey Incident Harm to animal
Injury Property Damage Spill/Release/Discharge to Air
Occupational Injury Unsafe condition Spill/Release/Discharge to Land
Near Miss Harm to Vegetation Harm Spill/Release/Discharge to Water
Details of Injured Person(s)( if Applicable)
Name Age /sex
Position Nationality
Date of hire/ id Contact details
Name Age /sex
Position Nationality
Date of HIRE/ ID Contact details
Witness details:
Name Department
Contact details Manager
Name Department
Contact details Manager
Injury
Please indicate body part injured on chart below
Strain / sprain Cut /laceration
scratch bruising
fracture dislocation
burn foreign body
Sting / bite
other
Treatment Given
hospital (admitted) doctor
Consequences of Incident
__________________________________________________________________________________________________________________
GSC HSE Incident and Investigation Report Approved Page 1 of 4
GSC/SCM/F001
EXTENION OF SARAB COMMUNITY MARKET AT SARAB MALL
INCIDENT AND INVESTIGATION REPORT
Lost time injury (days)
Restricted work case (days)
Analysis – mark ‘X’ against the factors which are thought to have contributed to the cause of the incident
task environment organizational human factors equipment
Lifting Housekeeping Poor communication Lack of experience Faulty equipment
Carrying Slippery conditions No policy/ procedures Lack of competence Lack of equipment
Repetitive movement Excessive noise Poor job design Stress / fatigue Poorly maintained
Twisting Weather conditions Hazards not identified Procedures not followed Wrong for task
Driving Heat / cold Lack of staff / budget Improper technique Lack of signage
Lighting /visibility Lack of training Physical limitations
Surface conditions Lack of supervision Skylarking / horseplay
Pressure to complete task
other
Corrective Action – what action is required to prevent the incident from happening again?
By who? By when?
Outcome of review of Risk Assessment
Report Preparation Review and Approval
name signature designation date
Prepared by
Reviewed by
Approved by
__________________________________________________________________________________________________________________
GSC HSE Incident and Investigation Report Approved Page 2 of 4
GSC/SCM/F001
EXTENION OF SARAB COMMUNITY MARKET AT SARAB MALL
INCIDENT AND INVESTIGATION REPORT
BEFORE
PHOTO 01 PHOTO 02
AFTER
PHOTO 01 PHOTO 02
__________________________________________________________________________________________________________________
GSC HSE Incident and Investigation Report Approved Page 3 of 4
GSC/SCM/F001
EXTENION OF SARAB COMMUNITY MARKET AT SARAB MALL
INCIDENT AND INVESTIGATION REPORT
__________________________________________________________________________________________________________________
GSC HSE Incident and Investigation Report Approved Page 4 of 4
GSC/SCM/F001
