Académique Documents
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10.15 Am 8/1/2009
6. Type of Accident 7. Location of Accident
Ground floor Car Park, North, Right side shaft size of 3.8m
Fall during Work * 2.5m
8. Name/s of injured 9. Job Title 10. Company
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
23. List all enclosures ( Photos etc.) 24. Signature and date
Item 16 - Photograph 1
Item 17 - Photograph 2
REPORT DATE ACCIDENT / INCIDENT ANALYSIS REPORT RPT. NO.:
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
MTC 1 PTD 5,000-50,000 > 500,000 Minor Massive
LTC 6hr FTL 50,000-250,000 Localized
Any injuries / damages to 3rd parties ? Yes No (if yes, please specify.)
SECTIN3: PERSONNEL DATA (Indicate below all personnel involved in accident / incident.)
Time Time in Immediate Supervisor Hours Worked Indicate Company or
Assigned current whether Other
Name to Facility Position Last 3 Days Injured and/or (Specify)
involved in
Al Misnad
cause
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 / inciden Yes No (if yes, please specify.)
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 factor.
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.
s, 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: