INITIAL INCIDENT RE

NOTE: ALL INCIDENT REPORTS MUST BE REPORTED WITHIN 24 HOURS TO INS

Project Name:

Al- k

Report No.
Incident Date :
Incident Time :
Date & time reported:

28-

Incident location:
Has the incident been notified to Police / Kahramaa ?

TYPE OF INCIDENT
Fatality
Near Miss
Environmental Damage
Property Damager

INJURY INFORMATION (IF

Name of the Injured Person
Nationality
Date of Birth
ID Number (If Any)
Name of the Company:
Job Title:
Name of the Supervisor
Name of the Witness:

DESCRIPTION OF INCIDE

HSE Form No. 4.5.3-01-02

Issue : 2
Rev : 0
Rev Date : 01.Dec.2014

On 28/02/2015 Saturday around 10.30 A.M. at Road D-20 a tanker (Plate number:1722
aggregates, an excavator(plate number : 50667) operator didnt notice that tanker lor
break windshield , cabin and side glass partially.

Immediate action taken

If yes, specify:

Yes
Foreman Inform HSE Department & call traffic

ATTACHMENTS
Special Remarks (IF ANY)
Witness statement (IF ANY)
Photographs (IF ANY)
Shop Drawings (IF ANY)
Work Permit (IF ANY)
RO / SIS (IF ANY)
Others

SIGNATURES

Prepared By :
Signature :

HSE Form No. 4.5.3-01-02

Issue : 2
Rev : 0
Rev Date : 01.Dec.2014

Loveson Glariyans

IAL INCIDENT REPORT

E REPORTED WITHIN 24 HOURS TO INSURANCE DEPARTMENT & HSE DEPARTMENT

Al- kheesa Project

AK/IR/23
28-02-2015
10:30 AM
28-02-2015, 12:30 AM
D-20 Road
Yes

TYPE OF INCIDENT
Motor Vehicular Accident
Physical Injury
Others (please specify):

URY INFORMATION (IF ANY)

Mobile no.:

Mobile no.:
Mobile no.:

ESCRIPTION OF INCIDENT:

HSE Form No. 4.5.3-01-02

Issue : 2
Rev : 0
Rev Date : 01.Dec.2014

a tanker (Plate number:172214 ) was going outside the area after finishing watering the
didnt notice that tanker lorry while making turn and hit front side of tanker lorry and

No

SE Department & call traffic department.

yans

REPORT DISTRIBUTION
Original Copy : Risk & Insurance Manager
Copy to : Project Manager
Copy to : Department HSE Manager
Copt to : HSE Operation Manager

SIGNATURES
Site HSE Manger :
Signature :

HSE Form No. 4.5.3-01-02

Issue : 2
Rev : 0
Rev Date : 01.Dec.2014

Eng.Enrique Fjardo

HSE Form No. 4.5.3-01-02

Issue : 2
Rev : 0
Rev Date : 01.Dec.2014

nishing watering the

of tanker lorry and

ON

ique Fjardo

HSE Form No. 4.5.3-01-02

Issue : 2
Rev : 0
Rev Date : 01.Dec.2014