Document: 10000602876-PDC-000

HSE accident / near miss report form Version: 01 - IFC

Issue date: 14.04.2014
India Procedure Page: 1 of 6

For accidents involving injury to personnel, this Report must be completed by either the injured party or
the First Aider, and must be checked by the supervisor/manager. It should be signed / dated and
delivered by hand to the HSE Department.

For other types of accident (property/equipment/structures) OR Near Miss Incidents OR Dangerous

Occurrences, this Report should be completed by the witness(s) to the incident and checked and
signed/dated by the supervisor or manager and delivered by hand to the HSE Department.

Location of Incident: Kakinada base, India Area/Department: Clean

room ,workshop

Details of Injured Party/Person performing the task: Date & Time of incident:
12/04/2014 16:00hrs
Job Title:
Staff / Contract:
Home Phone No: Project Name (if applicable):
Date of Birth :
Circumstances Surrounding the incident: (attach diagrams, photographs extra sheets, as appropriate)

There was an electric short circuit from the Aircon voltage stabilizer input socket at the clean
room in W/S. The socket was completely burnt and damaged the stabilizer input plug

In the investigation , it is observed that the copper wires in the socket are corroded due to
moisture built up in the room. The Aircon voltage stabilizer plug is connected to a general 16
amp socket which is not preferable for Aircons .Aircons are connected to MCB socket
which is made of ceramic.

The aircon runs 24/7 in the clean room . the switch board panels are not sealed properly .
Due to that, Dust and reptiles(lizards) are in the switch board panels.

No smoke/ fire was detected, No damage to the Aircon was Noticed

No damage to any other property

Full details of apparent injury or damage:

No person injured , No damage to the Aircon noticed
Voltage stabilizer and main power socket are damaged

Details of any First Aid administered locally and by whom: NA

Details of any professional medical treatment administered, by whom and where: NA

Was person able to continue working after treatment during same shift? Yes / No
Own Duties? - Yes / No Alternative Duties? - Yes / No
If alternative duties, give details:- NA
If not able to continue working same shift, give estimate of return date:-
At the time of the incident, was the person:
 Document: 10000602876-PDC-000
HSE accident / near miss report form Version: 01 - IFC
Issue date: 14.04.2014
India Procedure Page: 2 of 6

1 Following any Aker Solutions India specific Yes

procedures or instructions?
2 Using appropriate safety equipment or PPE? Yes
3 Following Aker Solutions India safety procedures Yes
/rules / guidelines?
Note: Add any other relevant information as an attachment and indicate by ticking here:
Area Supervisor (name) Signature Date 14/04/14 Job Title
P Ganesh Workshop lead technician
Completed by (name) Signature Date 14/04/14 Job Title
T.M.Phani Mohan HSE officer
Checked by (name) Signature Date Job Title
N.V.V.S. Prasad Yadav 14/04/14 HSE advisor
Witness (No 1) details: Witness (No 2) details:
Name: Y.V.Suresh Name: Ahmad.Farisan

Aker solutions ,KKD base ,INDIA Aker solutions ,KKD base ,INDIA
Signature: Date: Signature: Date: 14-04-2104
Job Title W/S technician Job Title : workshop Manager
Details of corrective measures taken:

MCB socket is proposed for Aircon with ceramic holders

Aircon is switched off at nights
Switch board panels are protected by sealing them perfectly
Details of preventive measures taken/proposed: (delete as appropriate)
To be completed by Area Supervisor/Manager. (continue on additional sheet if required and attach
supporting details)

RCCB are to be checked every month

PAT is done every month to all the electric appliances

Name:(Area Manager) Signature: Date:

Ahmad Farisan
Preventive measures accepted by:-
Name:(HSE) T.M.Phani Mohan Signature: Date:
Reviewed at Safety Committee meeting held on (date):-
Name:(HSE) Signature: Date

HSE USE ONLY:-

Date entered into HSE database (Synergi):
Type of HSE Accident/Incident Tick Box No. of days lost
1. Lost Time – DOSH Reportable
2. Lost Time – Not Reportable
3. Medical Treatment Cases
4. HI-Potential Near Miss
5. DOSH Dangerous Occurrence
6. Near Miss 
7. First Aid
8. Environmental Accident / Incident
9. Equipment/Property Damage
 Document: 10000602876-PDC-000
HSE accident / near miss report form Version: 01 - IFC
Issue date: 14.04.2014
India Procedure Page: 3 of 6

10. Non-Work Related Case Incident

Actual Risk Category Potential Risk Category
High
Direct Cause : Short circuit Root Cause
Corrosion of wires due to moisture

Follow-up action required? By (who):Maintenance person By (date):

Yes
Incident Report and preventive action closed out: (date):-
Name: Signature: Date:
 Document: 10000602876-PDC-000
HSE accident / near miss report form Version: 01 - IFC
Issue date: 14.04.2014
India Procedure Page: 4 of 6
 Document: 10000602876-PDC-000
HSE accident / near miss report form Version: 01 - IFC
Issue date: 14.04.2014
India Procedure Page: 5 of 6
 Document: 10000602876-PDC-000
HSE accident / near miss report form Version: 01 - IFC
Issue date: 14.04.2014
India Procedure Page: 6 of 6