Accident Report
Content
PRELIMINARY ACCIDENT / INCIDENT REPORT FORM
1. Project
Qatar Navigation Tower
2. Report by (Company)
Al Misnad Trading WLL
3. Time of Accident
4. Date of Accident
5. Report Ref.No
10.15 Am
6. Type of Accident
Fall during Work
8. Name/s of injured
8/1/2009
7. Location of Accident
Ground floor Car Park, North, Right side shaft size of
3.8m * 2.5m
9. Job Title
10. Company
Sathiyaseelan
11. Names of Witnesses
Carpenter
12. Tob Title
A.Sritharan T.Thanatheeswaran
Gang Leader
Carpenter
Al Misnad Trading
15. Nature of Injury
14. Part/s of the body affected
Right side leg above knee
Al Misnad Trading
13. Company
Fracture mid shaft FEMUR ( Thigh Bone)
16. Medical action taken - Attach other sheet if required
Attached
17. Description of Accident - Attach other sheet if required
Attached
18. Cause of Accident - Attach other sheet if required
No warning sign / Information regarding this danger zone was present at the time of accident
19. Corrective action taken
Workers are informed regarding the danger zone and warning tapes are provided in front of the
doors. Shafts are secured now with its door locked.
20. Report prepared by
Vipin Murthy
23. List all enclosures ( Photos etc.)
Item 16 - Photograph 1
Item 17 - Photograph 2
21. Job title
Engineer
22. Company
Al Misnad Trading
24. Signature and date
REPORT DATE
ACCIDENT / INCIDENT ANALYSIS REPORTRPT. NO.:
SECTION 1: ACCIDENT / INCIDENT REFERENCE
Date: 08-01-2009
Project: QNT
Organization: Al Misnad Trading
Time: 10.15 Am
Venue: Car Park GF
Remarks:
SECTION 1: ACCIDENT IMPACT ( record actual impact of accident here, please check all that apply)
Injuries (indicate no..)
Property / Equipment Damage ( Qatari Riyal) Environmental Damage
FAC
PPD
< 5,000
250,000-500,000
Slight
Major
> 500,000
Minor
Massive
MTC
1
PTD
5,000-50,000
LTC
6hr
FTL
50,000-250,000
Any injuries / damages to 3rd parties ?
Localized
Yes
No (if yes, please specify.)
SECTIN3: PERSONNEL DATA (Indicate below all personnel involved in accident / incident.)
Time
Time in
Hours Worked
Indicate
Company or
Immediate Supervisor
Assigned
current
whether
Other
to
Position
(Specify)
Name
Last 3 Days Injured and/or
Facility
Al Misnad
Sathiyaseelan 6.30 am
10:00 AM
Anton De Silva
Nil
Injured
Trading
SECTION 4: ANALYSIS OF CAUSES & CONSEQUENCES
Are any safety violations involved in the accident / incident? Yes
No (if yes, please specify.)
Was appropriate PPE in use?
No (if yes, please specify.)
Yes
Describe below causes of the accident / incident and its consequences. Include direct causes as
well as underlying / root causes, which may have contributed to the event and / or its
consequences.( Attach additional pages and witness statement sheets as required)
* Person victim unaware of hazard
* No warning sign displayed ( Regarding the hazard)
* Danger area was not secured and was easily accessible
* workers had to attend job on top of the door frame with the shaft door open which resulted in
accident by his fall in the shaft ( Approx 3 m height), due to both personal & environmental
Personal factor: Attention and concentration was on the job and not the danger beside,
Environmental factor: Poor lighting ( no Visibility inside shaft), a plastered rail which added to
the cause of tripping and fall into the shaft.
Assessment of Actual and Potential Consequences ( from table below)
Injury to People
Actual : one
Potential : Three
Property Damage
Actual : Nil
Potential : Nil
Environmental Damage
Actual : Nil
Potential : Nil
Injury to
People
Severity
Asset
Damage
Slight
< 5,000
Minor
Major
PPD
PTD or
Fatality
Envn.
Impact
V.Low
Like hood of Exposure
Mediu
Low
High
m
V.High
Slight
5,000 to
Minor
50,000
50,000 to
250,000 Localized
250,000 to
500,000
Over
500,000
Rating
1
2
3
Major
4
Massive
5
A
B
C
D
E
(if yes, please specify.)
(if yes, please specify.)
SECTION 5: CORRECTIVE ACTION
Describe below the suggested corrective actions to be taken to prevent recurrence and/ or minimize consequences
* To secure and lock doors of all such danger areas.
* To prominently display warning signs with the information of hazard present.
* Informing workers regarding the hazard area.
* provide adequate Lighting inside shaft so that workers in the vicinity can early recognize that ,
there is no floor level inside the door and will avoid entering the shaft without fall protection. safety Harness
Corrective action approval for implementation? ( Y or N) ( if yes, attach a copy of the CA issued implementation.)
Comments:
Preparer's Signature
Signature of Approval & Close-out
Prepared by :
Project Manager :
Signature :
Signature :
Date :
Date :
1. Project
Qatar Navigation Tower
2. Report by (Company)
Al Misnad Trading WLL
3. Time of Accident
4. Date of Accident
5. Report Ref.No
10.15 Am
6. Type of Accident
Fall during Work
8. Name/s of injured
8/1/2009
7. Location of Accident
Ground floor Car Park, North, Right side shaft size of
3.8m * 2.5m
9. Job Title
10. Company
Sathiyaseelan
11. Names of Witnesses
Carpenter
12. Tob Title
A.Sritharan T.Thanatheeswaran
Gang Leader
Carpenter
Al Misnad Trading
15. Nature of Injury
14. Part/s of the body affected
Right side leg above knee
Al Misnad Trading
13. Company
Fracture mid shaft FEMUR ( Thigh Bone)
16. Medical action taken - Attach other sheet if required
Attached
17. Description of Accident - Attach other sheet if required
Attached
18. Cause of Accident - Attach other sheet if required
No warning sign / Information regarding this danger zone was present at the time of accident
19. Corrective action taken
Workers are informed regarding the danger zone and warning tapes are provided in front of the
doors. Shafts are secured now with its door locked.
20. Report prepared by
Vipin Murthy
23. List all enclosures ( Photos etc.)
Item 16 - Photograph 1
Item 17 - Photograph 2
21. Job title
Engineer
22. Company
Al Misnad Trading
24. Signature and date
REPORT DATE
ACCIDENT / INCIDENT ANALYSIS REPORTRPT. NO.:
SECTION 1: ACCIDENT / INCIDENT REFERENCE
Date: 08-01-2009
Project: QNT
Organization: Al Misnad Trading
Time: 10.15 Am
Venue: Car Park GF
Remarks:
SECTION 1: ACCIDENT IMPACT ( record actual impact of accident here, please check all that apply)
Injuries (indicate no..)
Property / Equipment Damage ( Qatari Riyal) Environmental Damage
FAC
PPD
< 5,000
250,000-500,000
Slight
Major
> 500,000
Minor
Massive
MTC
1
PTD
5,000-50,000
LTC
6hr
FTL
50,000-250,000
Any injuries / damages to 3rd parties ?
Localized
Yes
No (if yes, please specify.)
SECTIN3: PERSONNEL DATA (Indicate below all personnel involved in accident / incident.)
Time
Time in
Hours Worked
Indicate
Company or
Immediate Supervisor
Assigned
current
whether
Other
to
Position
(Specify)
Name
Last 3 Days Injured and/or
Facility
Al Misnad
Sathiyaseelan 6.30 am
10:00 AM
Anton De Silva
Nil
Injured
Trading
SECTION 4: ANALYSIS OF CAUSES & CONSEQUENCES
Are any safety violations involved in the accident / incident? Yes
No (if yes, please specify.)
Was appropriate PPE in use?
No (if yes, please specify.)
Yes
Describe below causes of the accident / incident and its consequences. Include direct causes as
well as underlying / root causes, which may have contributed to the event and / or its
consequences.( Attach additional pages and witness statement sheets as required)
* Person victim unaware of hazard
* No warning sign displayed ( Regarding the hazard)
* Danger area was not secured and was easily accessible
* workers had to attend job on top of the door frame with the shaft door open which resulted in
accident by his fall in the shaft ( Approx 3 m height), due to both personal & environmental
Personal factor: Attention and concentration was on the job and not the danger beside,
Environmental factor: Poor lighting ( no Visibility inside shaft), a plastered rail which added to
the cause of tripping and fall into the shaft.
Assessment of Actual and Potential Consequences ( from table below)
Injury to People
Actual : one
Potential : Three
Property Damage
Actual : Nil
Potential : Nil
Environmental Damage
Actual : Nil
Potential : Nil
Injury to
People
Severity
Asset
Damage
Slight
< 5,000
Minor
Major
PPD
PTD or
Fatality
Envn.
Impact
V.Low
Like hood of Exposure
Mediu
Low
High
m
V.High
Slight
5,000 to
Minor
50,000
50,000 to
250,000 Localized
250,000 to
500,000
Over
500,000
Rating
1
2
3
Major
4
Massive
5
A
B
C
D
E
(if yes, please specify.)
(if yes, please specify.)
SECTION 5: CORRECTIVE ACTION
Describe below the suggested corrective actions to be taken to prevent recurrence and/ or minimize consequences
* To secure and lock doors of all such danger areas.
* To prominently display warning signs with the information of hazard present.
* Informing workers regarding the hazard area.
* provide adequate Lighting inside shaft so that workers in the vicinity can early recognize that ,
there is no floor level inside the door and will avoid entering the shaft without fall protection. safety Harness
Corrective action approval for implementation? ( Y or N) ( if yes, attach a copy of the CA issued implementation.)
Comments:
Preparer's Signature
Signature of Approval & Close-out
Prepared by :
Project Manager :
Signature :
Signature :
Date :
Date :
