AGFAB Engineering INCIDENT NOTIFICATION & DESCRIPTION OF INCIDENT

• Incident Title

• Client / Site

SECTION 1. NOTIFICATION & DESCRIPTION OF INCIDENT within 24 hours to General Manager

• Date and Time of the Incident:

  Date

• Date and Time of the Notification:

  Date

• Project:

• Incident Number:

• Reported by:

• Supervisor:

ACTUAL OUTCOME & INCIDENT CLASSIFICATION

• Near Miss:

  N/A

  Report required

• Not Work Related/ Report Only:

  N/A

  Report required

• FAI:

  Class 3A

• MTI:

  Class 3A

• AWI:

  Class 1A

  Class 2A

• LTI:

  Class 1A

  Class 2A

• PROPERTY DAMAGE:

  Class 1A

  Class 2A

  Class 3A

• ENVIRONMENTAL DAMAGE:

  Class 1A

  Class 2A

  Class 3A

• NWR = Non Work Related RO = Report Only FAI = First Aid Injury MTI = Medical Treatment Injury AWI = Alternate Work Injury LTI = Lost Time Injury

• When Damage has occurred, estimated $ cost of the damage must be provided:

• INCIDENT POTENTIAL RATING :

• Overall Incident Potential Rating Class:

  Class 1P

  Class 2P

  Class 3P

• Note* The incident including Near Miss must be rated by the maximum credible potential, not the absolute worst case

• Nature of Incident: (Nature Code and Description)

  Select 010 Fracture 030 Dislocation 040 Sprains/strain of muscles 060 Internal injury 070 Amputation 080 Open wound 090 Superficial injury 100 Contusion 110 Foreign body 120 Burns 140 Poisoning toxic 150 Environmental 160 Multiple Injuries 311 Electric Shock 709 Hernia 802 Heart disease including heart attack 741 Contact Dermatitis 771 Noise induced hearing loss N1 Welding flash N2 Parasitic disease

  • 010 Fracture
  • 030 Dislocation
  • 040 Sprains/strain of muscles
  • 060 Internal injury
  • 070 Amputation
  • 080 Open wound
  • 090 Superficial injury
  • 100 Contusion
  • 110 Foreign body
  • 120 Burns
  • 140 Poisoning toxic
  • 150 Environmental
  • 160 Multiple Injuries
  • 311 Electric Shock
  • 709 Hernia
  • 802 Heart disease including heart attack
  • 741 Contact Dermatitis
  • 771 Noise induced hearing loss
  • N1 Welding flash
  • N2 Parasitic disease

• Body Location: (Body Code and Description)

  Select 129 Eye 130 Ear 160 Face 190 Head 219 Neck 329 Back 390 Trunk 410 Shoulder 450 Wrist 490 Upper limb - unspecified locations 469 Hands - fingers and thumb - unspecified 510 Hip 520 Upper leg 530 Knee 540 Lower leg 550 Ankle 569 Foot and toes - unspecified

  • 129 Eye
  • 130 Ear
  • 160 Face
  • 190 Head
  • 219 Neck
  • 329 Back
  • 390 Trunk
  • 410 Shoulder
  • 450 Wrist
  • 490 Upper limb - unspecified locations
  • 469 Hands - fingers and thumb - unspecified
  • 510 Hip
  • 520 Upper leg
  • 530 Knee
  • 540 Lower leg
  • 550 Ankle
  • 569 Foot and toes - unspecified

• Mechanism of Incident (Mechanism Code and Description)

  Select WORKING AT HEIGHT 01 Working at height 02 Fall from same level 03 Stepping - kneeling or sitting on objects WORKING OVER WATER M1 Working over water NOISE 32 Long term exposure to sounds 39 Other variations to pressure 31 Exposure to a single sudden sound MANUAL HANDLING 41 Muscular stress while lifting carrying or putting down objects 42 Muscular stress while handling other than lifting carrying or putting down objects 43 Muscular stress with no objects being handled 44 Repetitive movement - low muscle movement MENTAL STRESS 81 Exposure to a traumatic event 86 Other mental stress factors OTHER MECHANISIMS 11 Hitting stationary objects 12 Hitting moving objects 21 Being hit by falling objects 24 Being hit by a person accidentially 27 Exposure to mechanical vibration 28 Being hit by moving objects 52 Contact with hot objects 52 Contact with cold objects 53 Exposure to environmental heat 57 Contact with electricity 54 Exposure to environmental cold 61 Single contact with chemical or substance 63 Insect and spider bites and stings 92 Vehicle accident 93 Rollover M2 Single contact with dust/particles

  • WORKING AT HEIGHT
  • 01 Working at height
  • 02 Fall from same level
  • 03 Stepping - kneeling or sitting on objects
  • WORKING OVER WATER
  • M1 Working over water
  • NOISE
  • 32 Long term exposure to sounds
  • 39 Other variations to pressure
  • 31 Exposure to a single sudden sound
  • MANUAL HANDLING
  • 41 Muscular stress while lifting carrying or putting down objects
  • 42 Muscular stress while handling other than lifting carrying or putting down objects
  • 43 Muscular stress with no objects being handled
  • 44 Repetitive movement - low muscle movement
  • MENTAL STRESS
  • 81 Exposure to a traumatic event
  • 86 Other mental stress factors
  • OTHER MECHANISIMS
  • 11 Hitting stationary objects
  • 12 Hitting moving objects
  • 21 Being hit by falling objects
  • 24 Being hit by a person accidentially
  • 27 Exposure to mechanical vibration
  • 28 Being hit by moving objects
  • 52 Contact with hot objects
  • 52 Contact with cold objects
  • 53 Exposure to environmental heat
  • 57 Contact with electricity
  • 54 Exposure to environmental cold
  • 61 Single contact with chemical or substance
  • 63 Insect and spider bites and stings
  • 92 Vehicle accident
  • 93 Rollover
  • M2 Single contact with dust/particles

INCIDENT DESCRIPTION

• Injured/ Involved Person Details:

  Agfab Engineering Employee/s

  Subcontractor Employee/s

• Name - Classification - Company Name if Subcontractor:

• Additional injured Employees(s):

• Witness Names(s):

• Exact Location of Incident:

• Incident Description (Describe what happened - facts only):

• Immediate Actions Taken (Describe what immediate actions were taken - Include medical treatment):

• External Medical Treatment Provided (Such as GP visit - specialist - X-Ray - scan- ECG - physio, etc):

  Yes

  No

  N/A

• External Notification Required ?

  Yes

  No

  N/A

• Relevant Authority Notified ?

  Yes

  No

  N/A

• Client Notified ?

  Yes

  No

  N/A

• Other ? Please note:

THIS IS AN IAUDITOR VERSION OF THE INCIDENT NOTIFICATION SECTION 1 Doc No. HSE-F-006