PRELIMINARY ACCIDENT / INCIDENT REPORT FORM

1. Project Qatar Navigation Tower

2. Report by (Company) Al Misnad Trading WLL
3. Time of Accident 4. Date of Accident 5. Report Ref.No

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

Sathiyaseelan Carpenter Al Misnad Trading

11. Names of Witnesses 12. Tob Title 13. Company
A.Sritharan T.Thanatheeswaran Gang Leader Carpenter
Al Misnad Trading
14. Part/s of the body affected 15. Nature of Injury
Right side leg above knee Fracture mid shaft FEMUR ( Thigh Bone)

16. Medical action taken - Attach other sheet if required

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

19. Corrective action taken

Workers are informed regarding the danger zone and warning tapes are provided in front of the
doors. Shafts are secured now with its door locked.

20. Report prepared by 21. Job title 22. Company

Vipin Murthy Engineer Al Misnad Trading

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 / INCIDENT REFERENCE

Date: 08-01-2009 Project: QNT Organization: Al Misnad Trading
Time: 10.15 Am Venue: Car Park GF Remarks:

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.)

Was appropriate PPE in use? 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.

Assessment of Actual and Potential Consequences ( from table below)

Injury to People Actual : one Potential : Three
Property Damage Actual : Nil Potential : Nil
Environmental Damage Actual : Nil Potential : Nil

Severity Like hood of Exposure Rating

Injury to Asset Envn. V.Low Low Mediu High V.High
People Damage Impact m
< 5,000
Slight Slight 1
5,000 to
Minor 50,000 Minor 2
50,000 to
Major 250,000 Localized 3
250,000 to

PPD 500,000 Major 4

PTD or Over
Fatality 500,000 Massive 5
A B C D E
s, please specify.)

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:

Preparer's Signature Signature of Approval & Close-out

Prepared by : Project Manager :

Signature : Signature :
Date : Date :