NON-SERIOUS OSH INCIDENT INVESTIGATION REPORT FORM G2

Appropriate Investigation to be completed as per NEOM-OSH-GF SOP 2.0 Incident Notification,

Investigation and Reporting
All non-serious Incidents not requiring notification to NEOM-LP&FS should be investigated, and results recorded
using this Form (G2)
Part A – Incident Information
1. Reporting Organisation Information
Name of Organisation: SAPAC
Sector: SAFETY DEPARTMENT Classification Code:
Registration Number:
Address of Organisation: Ath Thumamah Al Yasmin District,
Riyadh 13322
Authorized Contact Person: JAWATH SIDDIQUI Email Address: [email protected]
Telephone Number: 0561891746 Mobile Number: 0561891746

2. Incident involving a Non-Registered Contractor

(hired by or working for Organisation but not registered currently with NEOM-LP&FS): Yes ✘ No

Name of Contractor:
Type of Business:
Address:

3. Incident Information:
Date of Incident (DD/MM/YYYY) 14/05/2022 Time (24 hr): 02:30pm
Incident Type:
Restricted Work Case
Medical Treatment Case
First aid Injury
✘ Equipment / Property Damage
Near-miss

4. Incident Details:
Brief description of the main On Monday 17th May 2021, SAPAC were tasked to carry out Excavation Activity to Expose
circumstances leading to the Fibre Optic Line Near the Utility of NEOM Community 1 Station 12+600. Sapac started work at
Incident: (Attach additional approximately 01.00 Pm Site Supervisor then proceed the work by JCB since he came to know
pages if more space is there is no underground utilities at excavation point. Whilst carrying out the excavation
required) operator accidentally hit Water line (PVC Pipe 2") by teeth of the JCB bucket. Site Supervisor
immediately get in and Closely Inspect Damaged Pipe and noticed an Error warning tape Not
Found On the pipe where it has to be layed at least 30centi above, PVC Pipe Was Unprotected
Nd Layed Near Half Meter. This happened at approximately 02.30hrs.

Sapac Construction Team Repaired Damaged Water Pipe Immediately,

Incident Location on Site: Utility Area (Station 12+600)

Incident Workplace
Neom Base Camp Utility Area
Address:
Medical Report: (If
N/A
applicable)

5. Injured Person’s Personal Details (For Injuries):

In case of an incident with more than one injured person, complete the information for each person using separate forms

Name: N/A Occupation:

Relationship with
Organisation Employee Contractor Employee Other Person (e.g. Visitor,)
Organisation:
Nationality: Date of Birth:

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Passport Number: Length of Service: ____ Years __ Months
Contact Phone Number: Gender: Male Female

Part B – Incident Investigation Summary

1. Incident Causes Details:
To be supported with the incident investigation report
✘ Failure to secure Operating equipment without authority

Failure to warn Servicing equipment in operation

Removing / Defeating Safety Devices Using defective equipment / tools

Failure to use PPE properly ✘ Using equipment improperly

Immediate Cause
(Unsafe Act) Operating at improper speed Improper lifting/ loading/ placement
✘ Lack of awareness / knowledge Improper position for task
Lack of attention / concentration Horseplay (practical joke with harmful impacts)
Violation / taking shortcuts Others _______________________________

Inadequate guards or barriers Inadequate or improper protective equipment

✘ Inadequate warning system or notice Inadequate or excess illumination

Inadequate ventilation Congestion/ restricted action/ poor access

Immediate Cause Fire and explosion hazards Poor housekeeping, disorder

(Unsafe Conditions) High / Low temperature exposure Excessive noise exposure

Hazardous gases/dusts/vapours/fumes Radiation exposure

Defective tools, equipment or materials Equipment failure

Others

Physical Capability Physical Condition

(Any sensory deficiency, Inadequate size (previous injury/illness, Fatigue, blood sugar or strength
or physical disabilities) or Impairment due to drugs)

Mental State ✘ Skill Level

(poor judgment, memory failure, poor (Inadequate required skill, lack of coaching condition, fears
or emotional disturbance) on skill or infrequent performance of skill)
Root Causes
(Personal factor) Behaviour Mental Stress
(save time, avoids discomfort, improper (emotion Frustration, confusion/conflicting directions, al

overload, extreme meaningless supervisory, inadequate disciplinary activities or

concentration/judgment process or inappropriate aggression) demands)

Human Error Others _____________________________

✘ Inadequate Training / Knowledge transfer Inadequate Leadership Supervision

Root Causes
Inadequate / Missing Work Procedures (SOP)
(System Factor) Inadequate Incident Investigation / Analysis
Inadequate Purchasing/Material handling Inadequate Engineering / Design / Controls
Inadequate Tools/Equipment Inadequate Maintenance
✘ Inadequate Risk Assessment / Management Inadequate Communication

Inadequate Contractor Management Inadequate Planned Inspections

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 Inadequate Management of Change Inadequate Emergency Response Plan

Others____________________________

2. Injury Details:
To be supported with diagnosis by Licensed Health Care Professional and/or Medical Report

Abrasions / Bruising Amputation - Traumatic Bite / Sting

Burn Concussion Crush / Internal Injury
Cuts/ Laceration / Open
Hearing Loss / Deafness Dislocation
Wound
Electric Shock Foreign Body under Skin Fracture

Foreign Body in Eye Infectious Disease Hernia

Occupational Illness / Musculoskeletal Disorder
Nature of Injury / Illness: Heat Related Illness Disease Chronic / RSI
Nerve / Spinal Cord Poisoning / Toxic Effect -
Psychological (Stress)
Injury Ingestion
Poisoning / Toxic Effect –
Strain / Sprain Respiratory Disease
Inhalation
Skin Irritation / Disease Other _______________ Other _______________

Bite / Sting Biological Factors Cave-In or Collapse

Dust / Fumes / Gases
Chemicals / Substances /
Drowning / Submersion Equipment / Property
Radiation
Damage
Extreme Temperature / Fire Electricity Fall from Height
Mechanism of Injury / Hit by Moving Object / Crush / Manual Handling Mental Stress
Illness: Vehicle
Occupational Violence Penetrating Injury (needle stick, puncture wound)

Repetitive Motion Slip, Trip and Fall Sound / Pressure

Other Unspecified
Struck by Falling Object
Mechanism: _____________________

Animal / Human Confined Space Environmental Conditions

Materials or Chemical
Fixed Machinery / Plant Infectious Agent
Substances
Mobile Plant / Equipment Non-Powered Equipment /
Tools / Appliances
Agency / Source of Injury Powered Equipment / Tools /
Road Transport / Vehicles
/ Illness: Appliances Scaffolding or Ladders
Sharps / Scalpels / Needles / etc.
Trench or Excavations Other ______________

Cervical Spine Ear Eye

Head /
Face (excluding eye) Forehead Mouth
Neck
Neck Nose Scalp / Skull
Abdomen Back Genitals
Trunk
Pelvis Spine Thorax
Clavicle (Collar Bone) Elbow Fingers (other than Thumbs)
Upper
Forearm Hand Shoulder
Extremity
Bodily Thumb Upper Arm Wrist
Location:
Ankle Buttocks Foot
Lower
Hip / Groin Knee Lower Leg
Extremity
Thigh Toes
Arteries Brain Heart
Internal
Intestines Kidney Liver
Organs
Lungs Spleen Stomach
General Heat Related Occupational Illness Other: ______________

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3. Actions Taken Immediately after the Incident:
(Attach additional pages if more space is required)

Date
No. Actions: Responsibility Completed:
(DD/MM/YYYY)

1. SUSPENDED ACTIVITY & Informed Tamimi Establishment SAPAC 16-05-2022

2. Isolated Work Area SAPAC 16-05-2022

3. Informed PMC SAPAC 16-05-2022

4. Incident Root Cause(s):

(Refer to Section 1. Attach additional pages if more space is required)

1. Improper Methodology
2. Through Out Checking Of The Work Area Was Not Correctly Carried Out
3. Underground Utility Post Not Installed

5. Corrective Actions to Prevent Recurrence:

(Attach additional pages if more space is required)
Target
No. Actions: Person Responsible: Date
(DD/MM/YYYY)
1. Visual Inspection OF The Working Area To Be Yahiya Saleh 15/5/2022
Carried Out By The Site Management Team
2. Manual Excavation to Be Done For Trial Yahiya Saleh 15/5/2022

Pits

3. Pre-Inspection To Be Done By Site Yahiya Saleh/Jawath 15/5/2022

Siddiqui
Management Team In Coordination With
Relevant Authorities For Underground
Services Prior To Execute Excavation

4. Suspended Foreman Jawath SIddiqui 15/5/2022

6. Incident Cost:
(Approximate / Best Estimate)
No. Item / Area Amount (SAR.)
1. Injury Cost (Treatment, Hospital, Transport, Insurance, etc.)
2. Legal Cost (Compensation claims, judicial prosecutions, etc.)
Productivity Cost (Business disruptions, Delays, Production loss / day, Material, Salaries,
3.
etc.)
Asset Cost (Property, Machinery, Equipment, Structure, Vehicle, etc. – Repair &
4.
Maintenance)
Asset Cost (Property, Machinery, Equipment, Structure, Material, Vehicle, etc. –
5.
Replacement)
6. Enforcement Action (Penalty Issued by Authority etc.)
Incident Scene / Area Restoration Cost (arrangements to make safe, clean up,
7.
etc.)
8. ☐ Other Cost relevant to / associated with the Incident
9. Total Cost

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7. Risk Assessment
(considering / implementing the post incident corrective actions and controls) Refer to NEOM-OSH GF Technical Guideline
on Process of Risk Management
Probability: Rare Possible ✘ Likely Often Frequent
Severity of Catastrophic
Insignificant ✘ Minor Moderate Major
Consequence:
Level of Residual Risk: Low ✘ Moderate High Extreme

8. Declaration by Injured Person (If applicable)

I declare that all information provided in this document is true, correct and complete.
Name of Injured Signature of Injured
Person or Person or
Representative: Representative:
Date:
_____ / _____ / _____
(DD/MM/YYYY)

9. Reviews & Approvals:

✘ Complete investigation report attached – as per NEOM-OSH-GF SOP 2.0 Incident Notification, Investigation and Reporting
Relevant evidence included / attached to report (e.g. Copies of Relevant Procedures, Permits to Work, Photos, Drawings,
MSDS, Copy of Police Report, Copy of Medical Report, Interviews, etc.)
Corrective actions listed in this form and/or the attached investigation report will be fully implemented in a timely manner

Incident Investigation Status: ✘ Closed – Completed Report attached

Signature of Investigation Team Leader Signature of OSH Manager or Equivalent

Date (DD/MM/YYYY) _____ / _____ / _____ Date (DD/MM/YYYY) 02 / 01 / 2022

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