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HSE PROCEDURE .Doc. No NUS-HSE-IIP/01

Rev 02
INCIDENT INVISTIGATION PROCEDURE Date 26/07/2016

Incident Investigation Report IIR

1. Report No.:

2. Created By: Administration information

3. Created On: under utilities
4. Updated By:
5. Updated on:

6. Work Related: Yes: No:

7. Contractor involvement: Yes: No:

:If yes, Contractor Name
8. Third party involvement: Yes: No:
:If yes, identify the third party

9. Event Location: Spare part Store

10. Event Date / Time:
11. HSE Severity:

12. Loss Category: ( Please tick the appropriate type of incident)

Health Safety Environment

Personnel Occupational illness Personnel Injury Environment Hazardous material Spill
Non- occupational illness Vehicles Light Environment physical Damage
Heavy Environment regulation breach
Property Equipments Inappropriate Disposal
Products
3rd Party
(Values will come from Root cause tree)

13. Event Description:

Incident / Event Type 13.1
Type of Incident or Potential Incident

:Detailed Description of Event (S) Leading to the Incident 13.2

Statement of person involved

14. Details of the Injured:

1 Name Age
Company Position
Injury Body Part injured
(First Aid / LWD/ Medical Treatment/RTW Days) Absence start Return
Outcome Lost Days
(Characteristics value) to work
Edit Restrictions (Work
Return to work day Restricted days
Days)
Local / International (Characteristic Value)
MedEvac
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HSE PROCEDURE .Doc. No NUS-HSE-IIP/01
Rev 02
INCIDENT INVISTIGATION PROCEDURE Date 26/07/2016

15. Details of the witness:

SN Name Position Sign
1
2
3

16. Property Damage Details:

SN Company Property Nature of Damage $ Damage Cost
From Plant or Dept Characteristic with Text Characteristic with Text .Characteristic with No
information

Grand Total $

17. Investigation Team

SN Name Position Company
1

18. Investigation Duration

Investigation Start Date Investigation Start Time

Investigation End Date Investigation End Time

19. Investigation Data Analysis

19.1 Immediate Causes:
19.1.1 Substandard Acts: (e.g. Improper Loading, Improper Lifting, ..etc.)
19.1.2 Substandard Condition: ( e.g. Noise Exposure, Inadequate Lighting, ..etc.)
19.2 Root Causes:
19.2.1 Personal Factors ( e.g. Lack of skill/ Practice,Improper Motivation/ Lack of Incentives, ..etc)

19.2.2 Job Factors (e.g. Inadequate contracting/ Client/Inadequate bid, Inadequate Communication/
Inadequate message length, ..etc).

19.3 Lack of Management System Control: (e.g. Organization and Recourses/ Organization Structure,
Planning/ Process, Audit and Reviews/ Audit, ...etc.)

20. Corrective / Preventive Action(s):

Action Item 1
Description Characters 2000
Protection Goal
Created on Created By Updated By
Planned Start Date Plan End Date Actual Completion Date
Person Responsible for Implementation
Status Not Started/ In progress/ Completed
Person Responsible for Check
Effectiveness .Successful/ Prtially Successful/ Not Successful