First Aid Case (FAC) Environmental Incident / Spills
Medical Treatment Case (MTC) Reputation Impact
Restricted Workday Case (RWC) Non-Accidental Death
Lost Time Injury Case (LTI Case) Fires and Explosions
Permanent Total Disability (PTD) Occupational Illness
Fatality Case Asset Rules / Security Violations
Third Party Fatalities Life Saving Rules Violations
High Risk Incident (HRI) Others:__________
Full description of the incident:
Form No: PGCC-HSSE-AIR-001 Page 1 of 3
Root cause of Accident/Incident
Lack of job training/knowledge/experience
Using defective equipment/tools Inaccessible or poorly maintained PPE Others(Specify)________ Lack of Supervision Poor working conditions Congested work environment Safety rules not clear or understood Missing guard Ignoring instructions Inadequate communication Horse play Inadequate/no inspection system Known hazards not corrected Deliberate unsafe act Inadequate design of engineering Inappropriate method of work Lack of attention/ focused on the job No access/platform/scaffold
Enter any Immediate corrective actions(Correction) taken:
Corrective action/ Preventive action proposed to prevent recurrence:
Actual Severity Rating (as per RAM matrix) Potential Risk Rating
Fountain reported by: Fountain ID No: Date/Time:
Investigation Team Members
Prepared by: Designation: Signature: Date:
Reviewed by (HSSE): Designation: Signature: Date:
Reviewed by (Concern Dept.): Designation: Signature: Date:
Follow-up Review (to be completed by HSSE Department) Report closed: Yes No
Form No: PGCC-HSSE-AIR-001 Page 2 of 3
Follow up reviewed by: Designation: Signature: Date: