FORM ③ ⑤ ④⑥

INCIDENT REPORT FORM

NOTE:
1. This Incident Report Form must be completed before the completion of shift duty.
2. Fields with asterisk (*) are mandatory.
3. Part 1 to Part 3 to be filled up by the Reporting Person.
4. Part 4 to be filled up by the Initial Investigator.
5. 24-hr time format and DD/MM/YYYY date format must be used in stating time and date.
Part 1: Initial Reporting Details
OCC Log Reference TCDC1_21032024 CMMS Number* N/A
Number*
Date Reported to OCC* 21 March 2024 Time Reported to OCC* 07:00
Name of Person Reporting* Khairil Naim Job Title* Traffic Controller
Staff Number* 1000628 Contact Number* 0507864068
Signature* Khairil Naim

Part 2: Incident Details

Date of Incident* 21 March 2024 Time of Incident* 07:50hrs

Incident Categorization* CAT 5 (Negligible) ✘ CAT 4 (Low) CAT 3 (Medium)

CAT 2 (Major) CAT 1 (High)

Type of Accident Lost Time Injury (LTI) Medical Treatment Injury (MTI) First Aid Injury (FAI)
Near Miss/Close Call Property Damage/Loss Environmental Accident

TGA Reportable Incident Category A Category B Category C

Date Reported to TGA: Time Reported to TGA:
Who Reported to TGA:
Job Title:

Riyadh Metro Line* ✘ Line 3 Line 4 Line 5 Line 6 Line 4/6

Depot ✘ Line 3 West Line 3 East Line 4/6 Line 5
If along the tracks which
bound/area
Building (including Stations, Car Area/Room N/A
Parks, Depots, etc.) N/A (Concourse, platform, etc.)

Train Train Set Number: Estimated No. of Passengers on Board:

(tick as appropriate) Origin: Destination:
In service Out of Service

Rail - Road Vehicle/On- Type: Plate Number: Vehicle Number, if any:

Track-Plant
Motor Vehicle Accident Staff Bus/Coach Service Vehicle Personal
(tick as appropriate) Plate Number: Vehicle Number, if any:
Name of Official Attending (Police/Najm):

Brief Description*

FO Owner: Rail Safety Manager Document No.: HSE-FO-001-01

FO Sponsor: HSQE Director UNCONTROLLED COPY WHEN PRINTED Revision No.: D
Review Date: 25 April 2021 Page 1 of 8
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INCIDENT REPORT FORM

Type of Incident* Operational Incidents:
(tick as appropriate) Safety Critical Error, specify: Brake Failures
Power/Electrical Failure
Derailment Communication System Failure
Collision Wrong Side Failure
‘Runaway’ Train/RRV Train Division
✘ Signaling Failures Plant/machineries foul threat to
Signal Passed at Danger (SPAD) running line
Broken/Buckled Rail

Safety Incidents/Dangerous Occurrences:

Slips, Trips, and fall Failure of Lifting Equipment
Contact with Electricity Structural Collapse
Fire Collapse of a Scaffold
Fall from Height Explosion
Confined Space Incident Release of Hazardous Substance

Security Incidents:
Physical Assault Missing Person
Verbal Assault Bomb threat
Overcrowding Civil Disturbance
Persons Trapped Suicide/Suicide Attempt
Trespassing Theft
Anonymous Security Alert/Threat Vandalism (including Graffiti)

Environmental / Extreme Weather Incidents:

Minor Spill (<25 Liters) Flooding
Major Spill (>25 Liters) Sandstorm

Medical Incidents:
Illness
Injury

Near Miss/Close Call:

Other Incident (specify):

Did the Incident Cause Time the Delay Started: Time the Delay Finished:
Service Delay? Extent of the Delay:
(tick as appropriate) Sections Affected From: To:
Bus Replacement Requested Yes No

Any Infrastructure / Asset Approximate Amount of Damage:

Damage? (specify the name, type
and location)
Person Affected Passenger Staff Contractor Member of Public Visitor Third Party

Did the Incident Required an Yes ✘ No

Evacuation?
FO Owner: Rail Safety Manager Document No.: HSE-FO-001-01
FO Sponsor: HSQE Director UNCONTROLLED COPY WHEN PRINTED Revision No.: D
Review Date: 25 April 2021 Page 2 of 8
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INCIDENT REPORT FORM

Did the Incident Required a Police Civil Defense SRC SEC Saudi Water Authority
Response from Third GACA TGA Others specify
Parties? Team Leader Name: Job Title:
Team Leader Name: Job Title:

Incident/Event Timeline *(Please provide details of the sequence of events and names, job titles, organizations involved here)

07:50HRS:
TC FLOW asked permission from TCO Hariz to perform points functional test at West Depot, East Depot and Mainline. TCO
Hariz has authorized to perform all points functional test at West Depot & East Depot automatic area and Mainline. TC FLOW
has performed all points at West Depot & East Depot automatic area and Mainline for all unblocked points.

07:58HRS-
All points functional test for Mainline, West Depot and East Depot automatic area has completed. However, SA08 at West
Depot was out of correspondence. TC FLOW has informed TCO regarding SA08 out of correspondence.

09:45HRS-
Point SA08 at West Depot back to normal affer rectidfied by maintainence as per TCO Nahid

Did anyone witness the Name Hamad Alsalman Tel. No. 12345678 Name Tel. No.
incident? (give names/ Name Tel. No. Name Tel. No.
contact details)
Name Tel. No. Name Tel. No.
Evidence Gathered (please attached):
Witness Statements CCTV Recordings Audio recording Photos
Permit to Work Risk Assessment Method Statement
Evidences stored at:

FO Owner: Rail Safety Manager Document No.: HSE-FO-001-01

FO Sponsor: HSQE Director UNCONTROLLED COPY WHEN PRINTED Revision No.: D
Review Date: 25 April 2021 Page 3 of 8
 FORM ③ ⑤ ④⑥

INCIDENT REPORT FORM

Photo 1 Photo 2

Photo 3 Photo 4

Photo 5 Photo 6

Part 3: Injury / Illness Details

Total Number of Injured NOTE: Fill up separate incident report form for each
Persons injured person
Name of Injured Person Contact Age
Number
Address Gender

Job Title (if Staff/Contractor) Contractor

Name
Type of Injury Strains/sprains Contusion(Hematoma) Dislocation Fracture Burns
(tick as appropriate) Laceration Bruising Concussion (Brain injury) Amputation
Electric Shock Psychological Shock Multiple Injuries Fatality
Illness (Specify):

Body Part Affected Ankle Back Ear Eye Fingers Face (Other parts)
(tick all body parts affected) Foot Hand Head Neck Torso Lower limb
Toe Wrist Several locations General locations Unknown

If First Aid is administered, please fill in the following:

Name of First Aider

FO Owner: Rail Safety Manager Document No.: HSE-FO-001-01

FO Sponsor: HSQE Director UNCONTROLLED COPY WHEN PRINTED Revision No.: D
Review Date: 25 April 2021 Page 4 of 8
 FORM ③ ⑤ ④⑥

INCIDENT REPORT FORM

Designation of First Aider
Details of First Aid
Provided
Treated by Ambulance Yes ✘ No Taken to Hospital Yes ✘ No
If yes, name of the hospital:
For Occupational IQAMA 12345678
Injury incurred by Number
staff Report to Yes ✘ No
GOSI
Staff sent home? Yes ✘ No If yes, (date & time): Line Manager informed? ✘ Yes No

Part 4: Initial Investigation (Level 4 Investigation)

Factor/s involved in the Slips/trips/falls Manual handling Electrocution Crushing injury
incident* Physical assault Using equipment Stairs, lifts Entrapment
(tick as appropriate) Exposure to/contact with harmful substance Fall from train Fall onto the line
Fall from height < 2m Fall from height > 2m Struck by falling/flying object
Struck against fixed or stationary Struck by train Struck by RRV
Struck by vehicle During Shunting Coupling/uncoupling
Lapse of memory Slips of action Mistake Violation
Competency Supervision Horseplay PPE
Heat Fatigue Overcrowding Hazard Management
Use/consumption of illegal substance (drug, alcohol and other)
Bypass of Safety Components
Others (Please specify)

Environmental Details* Floor Surface Condition:

(tick as appropriate) Even Uneven Level ✘ Dry Wet Greasy Polished
Sandy Other
Floor Surface Type:
Floor Tile Concrete Carpet Painted ✘ Other Line side track
Lighting Condition:
Working Not Working Part Working ✘ Adequate Inadequate
Lighting Type:
✘ Daylight Darkness Fluorescent Floodlight Bulb Torch/Flashlight
Other
Temperature:
Indoor Temperature: N/A Outdoor Temperature: 35
Weather, if outdoors:
✘ Sunny Raining Foggy Windy Sandstorm Other
Visibility at the Time of the Incident:
less than 50m 51m – 200m 201m – 500m more than 500m
Immediate Cause/s *
(The unsafe act or unsafe
condition that immediately
preceded the event)

Underlying Cause/s *
(Factors relating to the job or
environment that contributed to
the accident)

FO Owner: Rail Safety Manager Document No.: HSE-FO-001-01

FO Sponsor: HSQE Director UNCONTROLLED COPY WHEN PRINTED Revision No.: D
Review Date: 25 April 2021 Page 5 of 8
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INCIDENT REPORT FORM

Root Cause/s *
(if possible, at the time of
reporting)
(e.g., failure of policies or
procedures that contributed to the
accident)
Declaration
Investigator Name*: Signature*:

Title*: Date*:

Part 5: To be Filled up by HSQE Team only

Report Received*: Job Tile*:

Investigation Level*: Further Investigation Yes No

Needed*
Remarks / Comments:

Some Helpful Information

FLOW Incident Category

Category 5 Category 4 Category 3 Category2 Category 1

Incident Category
(Negligible) (Low) (Medium) (Major) (High)
Single fatality,
Worst Credible No injury or Minor injuries Major injury and/or multiple major Multiple fatalities,
Outcome damage and/or damage damage injuries, multiple significant damage
damages

FLOW Category of Accident

First Aid Injury (FAI) Any injury that requires first aid treatment (including paramedic treatment) without
visitation to a medical facility.
Medical Treatment Injury (MTI) Any injury that requires medical treatment within a medical facility.
Lost Time Injury (LTI) Any injury that prevents FLOW or subcontractor employees from performing their regular
duties for a rostered shift or more.

TGA Reportable Categories

Category A
Subject Guidance
A.1 Deaths to passengers, members of the public, or staff, caused in Include on trains, in stations, yards, terminals, depots,
accidents or incidents on the railway system. workshops, offices, car parks, ports etc.
A.2 Serious injuries to five or more passengers, members of the Also include A1 and A2 for members of staff on duty but away
public, or staff, caused in accidents or incidents on the railway from the railway estate e.g. travelling in road vehicle.
system.
A.3 Level crossing accidents involving death or serious injury to a Include staff, vehicle users, pedestrians etc.
person or persons.
A.4 Derailments on running lines open to traffic, or which block Do not include derailments or collisions in yards, depots and
running lines open to traffic.

FO Owner: Rail Safety Manager Document No.: HSE-FO-001-01

FO Sponsor: HSQE Director UNCONTROLLED COPY WHEN PRINTED Revision No.: D
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INCIDENT REPORT FORM

Subject Guidance
A.5 Collisions between trains on running lines open to traffic which terminals; or on running lines if already under engineering
causes damage to some or all of the vehicles involved. possession arrangements unless it affects open lines.
A.6 Collision of rolling stock in revenue earning service with buffer Running line only
stops or other automatic stop devices on running lines open to
traffic that cause damage to the rolling stock.
A.7 Release of dangerous goods (including radioactive material), or All lines
fires involving dangerous goods (including radioactive material) or
its residue, that require an area to be evacuated.
A.8 Accidents or incidents, including fires, causing in excess of 10 Use initial judgement when reporting
million Saudi Riyals damage to trains, infrastructure or the
environment. This includes significant pollution incidents.
A.9 Accidents or incidents which, under slightly different Include near miss events that almost resulted in a category A1 to
circumstances, could have led to deaths or multiple serious A8 accident. Also, collisions between trains and vehicles at level
injuries. crossings

Category B
Subject Guidance
B.1 Train derailments on the railway system (including in yards, depots Include running line derailments within engineering possession
and terminals) that are not covered under category A. arrangements.
Exclude derailments in yards if the vehicle is stationary and it
was lifted off the rails by loading or unloading devices.
B.2 Collisions between trains or rolling stock on the railway system All lines
(including in yards, depots and terminals) that cause damage and
are not covered under category A.
B.3 Collisions of trains with objects (including animals and items placed Running lines only.
by trespassers on railway tracks or guideways) which would not
otherwise have required reporting under Category A.
B.4 Serious injuries to four or fewer persons on trains, stations or Exclude: serious injuries to those attempting suicide or from
other railway property if the event leading to the injury was assault or any serious injury as a consequence of an accident not
connected with the movement or operation of trains involving operation of trains.
B.5 Incidents where road vehicles or heavy plant and other mobile If a near-miss with a train occurs, treat as category A.9.
machinery foul treat running lines or damage track.
B.6 Unintended divisions of any trains while in service or being All lines.
prepared for service.
B.7 Train fires, severe electrical arcing, fusing as a result of severe All lines.
electrical arcing.
B.8 Accidents and incidents to a train containing at least one vehicle This applies even if the vehicle(s) containing dangerous goods
carrying dangerous goods (including radioactive material). These are not affected by the event.
accidents and incidents must be reported as "trains carrying
dangerous or hazardous goods".
B.9 Any event necessitating the evacuation of a complete passenger Do not need to notify if passengers are moved internally to other
train not at a station, such as prolonged total power loss and vehicle(s) where they are accommodated safely.
attendant temperature rise.
B.10 Any event necessitating the unplanned evacuation or closure to All lines.
passengers of any railway station or other facility or significant
part-thereof, for 2 hours or more.
B.11 Any runaway train or runaway rail-mounted vehicle that is on, Consider circumstances and report as a category A.9 if a serious
leaves, or enters a running line. near miss occurs.
B.12 Accidents or incidents which, under slightly different All lines.
circumstances, could have led to 10 million or more SAR of damage
to trains, infrastructure or environment.

Category C
Subject Guidance
C.1 Four or fewer serious injuries to persons during one event Includes injuries incurred in construction, testing &
anywhere on the railway system and associated property (unless commissioning, maintenance, operation of the whole railway
the incident is already notified under category A or B). system. Includes injuries to staff away from the railway tines,
passengers on escalators etc.
C.2 Failures of equipment at Level Crossings which affect the level of For example: Automatic level crossing emergency telephone or
railway safety at the crossing, that are not in category A or B. GSMR failure. Include road vehicles (etc.) striking LC equipment.

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FO Sponsor: HSQE Director UNCONTROLLED COPY WHEN PRINTED Revision No.: D
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INCIDENT REPORT FORM

Subject Guidance
C.3 Broken rails, or rails where pieces have broken off relating to a Includes events when emergency repairs such as rail clamps have
running line which necessitates an immediate closure or speed to be made to allow traffic to operate.
restriction.
C.4 Buckled rails or track where the route has to be closed or a speed Running lines only. Includes gauge spread.
restriction put in place.
C.5 Sand drifts large enough to cause an operating train to come to a Running lines only.
stand to report its inability to proceed further without some form
of assistance.
C.6 Any failure of a structure on the railway such as cuttings, bridges, All lines.
embankments, tunnels, and stations where under slightly different
conditions there may have been a death, five or more serious
injuries or 10 million Riyals of damage to rolling stock,
infrastructure or the environment.
C.7 A failure in the signaling system which reduces the level of railway Includes wrong-side signaling failures.
safety by affecting the ability of the system to detect or protect
trains (including a railway signal or signaling system displaying or
giving a less restrictive indication than that required for the
intended movement authority of rolling stock) and which are not in
category A or B.
C.8 Signals passed at danger by trains without due authorization or Includes yard, depot, terminal and shunting movements.
trains exceeding their movement authority unless the incident is Includes incidents of trains travelling over permitted speeds
notified under category A or B. where management action is required.
C.9 Occurrences of the unprotected overlap of operating authorities. Include facing point lock failures.
C.10 Switches on running lines not locked, not secured, or left Include facing point lock failures.
unprotected in an abnormal position.
C.11 Runaway rail vehicles not covered by other reports in category A or Includes yard, depot, terminal and shunting movements.
B.
C.12 Any person whose duties are directly related to the safe operation All safety critical staff and contractors.
of the railway who is unable to perform his or her duties as a result
of a physical incapacitation or fatigue and which poses a threat to
any person, property or the environment.
C.13 Broken wheels or axles on rolling stock not reported for other Includes yard, depot, terminal and shunting movements
reasons covered in categories A or B.

FO Owner: Rail Safety Manager Document No.: HSE-FO-001-01

FO Sponsor: HSQE Director UNCONTROLLED COPY WHEN PRINTED Revision No.: D
Review Date: 25 April 2021 Page 8 of 8