L&T-STEC JV MUMBAI

MUMBAI METRO LINE 3

Package No : UGC 01

ref: IM-23-C Rev 01

MINOR INCIDENT REPORT

PART A – TO BE FILLED BY SITE ENGINEER

1. Details of the Project
Name of the Project & Job Number: Business Unit:

Mumbai Metro UGC-01, MM160004 Metro & Defence

2. Category of Incident (Tick as applicable)
Category 6 First Aid Case
Part 2
Category 7  Near Miss Case
Minor Incidents
Category 8 Minor Environment
3. Details of the Incident (Write N.A if not applicable)
Date of EHS
Name of the Injured Age Sex Designation Date of Joining
induction

Date & Time of Incident: 02/09/17, 3:45 pm

3.2) Exact Location where the Incident occurred: Church gate station in front of National insurance
building

3.3) Injury details : NIL

3.4) Name / Identity of the P&M / Equipment :

Asset Code: RIG SANY-SR200C Registration No: _____N/A___ Owned by: L&T Subcontractor

3.5) Describe briefly how the incident occurred: After removing the pile casing length of 6mtrs by rig
machine casing misbalanced, when touched the ground for other piling point and start drifting slowly
towards left side and hit the RCC canopy of national insurance building.

Name of the Section Incharge Signature:

/ Site Engineer:
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 L&T-STEC JV MUMBAI
MUMBAI METRO LINE 3
Package No : UGC 01

PART B – TO BE FILLED BY INVESTIGATION TEAM

Body Part Injured :- N/A Type of Injury :- N/A
Tick the injured body part Tick the type of injury

Sprain/strain Poisoning

Laceration / Cut Abrasion

Burn Internal organ

damage

Stab / Penetration Others (specify)

4. Causes of the Incident

4.1) Direct Causes: Tag line not provided.

4.2) Root Causes: (Tick the root cause)

1. Human factors  2. Physical condition  3. Management System 

1.1 Inexperienced/
Unauthorised/ untrained worker
1.2 Medically or physically
unfit
1.3 Poor task behaviour/
shortcuts
2.1 Wrong selection of
equipment / tools.
2.2 Faulty equipment / tools
(not safety inspected)
2.3Unsafe operation /
Safety devices not working
3.1 Hazard & controls not
identified previously
3.2 Unsafe work method /
Generic
 3.3 Design safety issues

3.4 Risk control measures not 

1.4 PPE not used / worn 2.4 Poor housekeeping implemented

1.5 Unsafe behaviour of 2.5 Poor storage of 3.5 Not enough training or
worker (horseplay/ mobile materials instruction
phone usage etc.) 2.6 Unsuitable work area 3.6 Poor compliance to safety
(inadequate space) inspection
1.6 Golden Safety rules 2.7 Unsafe Work 3.7 Lack / incompetent
 
violated environment (light / noise / supervision
1.7 Standing & operating in dust / smoke/ weather condition)
unsafe position 2.8 Hazards originated due 3.8 Poor selection/quality/ no
to external factors issue of PPE
1.8 Others 2.9 Others: 3.9 Inadequate emergency
response
5. Remedial Measures Action Plan

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 L&T-STEC JV MUMBAI
MUMBAI METRO LINE 3
Package No : UGC 01

4. What are the precautions taken / being taken to prevent similar occurrence?
1) Incident briefed to all workmen in pre job briefing.
2) Implementation of tag line during casing removing and inserting operation.

Names of the Minor Incident Investigation Team: Mr.Nitin kumar, Mr.Hitendra Solanki, Mr.Divakar
Signature:
EHS In-charge:

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