CGC HSE Form No 021

PAGE No 1 of 3
Rev/Issue 0/1
DATE OF ISSUE Jan 01, 2018
HSE MANAGEMENT SYSTEM

ACCIDENT/INCIDENT INVESTIGATION REPORT

/PROJECT DETAILS
Construction and Rehabilitation of Roads and
Division / Project: Infrastructure Services for Infill Plots at Sila’a in Al Project No.: C-48C
Dhafra Region
Project Manager: Mahmoud Fareed Task Manager:

ACCIDENT / INCIDENT DETAILS

Date/Time of Occurrence: 2/10/2023 (11:15pm) Date/Time Reported: 3/10/2023

Location: Zone -1 Area -2 (Al Rizq Street) Weather Condition: Good

Injury occurred (PD)
(Complete Details of injured person No Injury occurred (NII) Reportable Dangerous Occurrence (DO)
below)
CLASS 1 CLASS 2 Reportable Serious Injury
CLASS 3 Property
Fatality LTI LTI MTI AWI Damage Only

DETAILS OF INJURED PERSON (COMPLETE A SEPARATE SHEET FOR EACH PERSON)

Note: if personal details have already been completed as required by a statutory authority or client, attach a copy of the
completed details to this investigation report.

Name: Position:
Date of Birth: Age: Female Male
Employer Name: Employed in the Project
Experience In Current Occupation: Since:

INJURY DETAILS
Body Part Injured

Head/Neck Arms Hands Back

Chest
Abdomen Feet Legs Skin Eyes
Others
Internal Organs
_________________________________________
Type of Injury

Abrasion Burn Crush Paralysis

Exposure
Cut/
Amputation Fracture Sprain
Concussion Laceration
Other
Bruises Bruise Dermatitis Fatality ___________
__
Mechanism of Injury
Flying/ Falling
Caught between Struck By
Objects
Chemicals Handling equipment Transport
Contact Electric Knocked Trip/Slip
Using Power tools/
Contact Hot Metal Manual Handling
Hand tools
Fall another level Moving Machinery Vehicles

Fall same level Struck Against Welding/ Hot work

Other:
_____________________________________________________________

PROTECTIVE CLOTHING & EQUIPMENT (What Protective Clothing and Equipment were being worn at the
time of incident?)
 CGC HSE Form No 021
PAGE No 2 of 3
Rev/Issue 0/1
DATE OF ISSUE Jan 01, 2018
HSE MANAGEMENT SYSTEM
ACCIDENT/INCIDENT INVESTIGATION REPORT
Safety Glasses Safety Shoes Splash Goggles Gloves Overalls

Respiratory Protection Hearing Protection Safety Helmet Fall Protection Other

DAMAGE CLASSIFICATIONS
Initial Initial Work consequences Work consequences Work consequences
Treatment Prognosis - immediate - after 24 hours (LTI CGC) - after 3 days (LTI CGC)
Return to pre-injury Return to pre-injury
Hospital Class 1 Return to pre-injury duties
duties duties
Medical Class 2 Restricted duties Restricted duties Restricted duties
First Aid Class 3 Off work Off work Off work
No. of Work
Date Ceased Work Resumed
Days
Work
Absent:
Return to Work Duties: Modified Normal

This damage is considered to be: Aggravation of previous personal damage The source of the personal
damage

DESCRIPTION OF THE INCIDENT / ACCIDENT

(Include detail of injuries / damage and assessment of apparent cause):
Incident Description
Zone -1 Area -2 (Al Rizq Street) Back Side of Site Office
 Where did the incident happen? Give
as precise location as possible
Excavation for Storm water in Progress, Fire Hydrant DI Pipe line was Crossing Between the
 What was the task? Describe the
Excavation which was Already Exposed, When the Operator Excavating there was Big Stone
work activity and exact task being Fire Hydrant DI Pipe line, when the Operator Try to Excavate the area with pressure suddenly
performed Small piece of cut and hit to the Fire Hydrant DI Pipe line,
Saqib Ali (Operator) Immediately Informed to Mamdouh (Site Engineer), He Reached the
 What was being done when the
Incident location in 10 mints Inform to Construction and Project Manager They Reported to
incident happened? E.g. transporting the Concern Authority ADDC. Construction Manager and Project Manager reached the location
materials to workplace; conducting The Damage Pipe was Repaired/Rectified by the ADDC team
housekeeping.
Wheel Excavator was Excavating.
 What equipment, tools and materials
were being used? Were they
appropriate?
Fire Hydrant DI Pipe line
 Include detail of injuries/damage.
Provide information on all injuries or
damage sustained with most serious
first.
Excavation Adjacent to Under ground Pipe line
 What was the apparent cause?
(General and specific comment as
required) Be as factual and clear as
possible.

 (Where possible, include distances,

weights, slopes, speeds, etc., plus
photos, sketches) List here

Witness Name Occupation Employer

 CGC HSE Form No 021
PAGE No 3 of 3
Rev/Issue 0/1
DATE OF ISSUE Jan 01, 2018
HSE MANAGEMENT SYSTEM
ACCIDENT/INCIDENT INVESTIGATION REPORT
Noman Pipe fitter
Saqib Ali Excavator Operator

ROOT CAUSES OF INCIDENT / HAZARD / NEAR MISS

Review the lists below and tick all those that are thought to have contributed to the cause of incident
Equipment/ Material Worker Environment Management
Excessive Noise Ambient conditions (wind, Hazardous work method
Fatigue/ Stress
dust, rain etc.) specified
Difficulty in Operating Physical/disability affecting Excessive Noise Lack of supervision / supervisor
(tools, equipment, etc.) performance competence

Hazardous machine, tool Poor Lighting Provision of correct safety

Culpable Act
or equipment equipment or clothing
Terrain

Malfunction or defective Misconduct Inadequate training provided

Temperatures
material/machine/ equipment

Unsuitable/ inappropriate Possible personal problem Poor Housekeeping Poor Housekeeping Standard
material/ safety clothing/
equipment
Inexperience in task being Building surface conditions
Difficult to maintain Poorly maintained equipment
performed (stairs, floors)
Inadequate guarding or Failure to use safety Storage/ stacking of Suitable plant/equipment
protection clothing material unavailable
Manual Handling Hazardous work method Exposure or contact Inadequate or no documented
used chemicals or other harmful procedures
material
Possible influence of Exposure to infectious Insufficient inadequate
alcohol or drugs sickness/ disease instruction or information
Act or omission of another Visibility Production pressure
person
Congested work area
State the Action to be taken to prevent it from happening again
Action (list in order from immediate to long-term) By Whom When

HSE Manager Name (Print) Signed

PROJECT MANAGER’S CLOSE OUT COMMENTS

Project Manager Name (Print) Signed Date

INVESTIGATION TEAM
No Investigation Team Members Position
1. Mohammed Liyaqath HSE Engineer
2.
3.

Distributio  Project Manager  Deputy Project Manager  General Manager  Deputy General
n Manager

 QA/QC Manager  Project Engineer  Site Eng.  Safety Engineer/

Officer

 Project file  Other

 CGC HSE Form No 021
PAGE No 4 of 3
Rev/Issue 0/1
DATE OF ISSUE Jan 01, 2018
HSE MANAGEMENT SYSTEM
ACCIDENT/INCIDENT INVESTIGATION REPORT