Doc. No.

: VICPL/EHS/F/19
Venus Industrial Corporation Pvt. Ltd Org. Date: 15.12.2024
[Link]. 00
Incident Investigation Report Rev. Date:

FOR RECORDKEEPERS USE ONLY  Near Miss  Restricted Duty

Classification:  First Aid  Lost Workday
(Check all that apply)  Medical Treatment (Beyond first aid)  Property Damage

PRINT OR TYPE ALL ENTRIES

1. Name of Person Involved 2. Site Name & address

[Link]'s Department 5. Operation 6. Activity

4. Job Title

7. Incident Date: 8. Time: 9. Shift: 10. Date of Incident 11. Date Investigation
 AM Reported to : began:
 PM
12. Age of person: 13. 14. Length of Employment 15. Exact Location of the Incident:
Male  At Site:
Female  At Same Job:

16. Name of machine or tool 17. PPE required for the task: 18. PPE being used:
involved:

19. PART OF BODY INJURED: (Check all that apply :) INJURED SIDE:  Right Left  Both

 Multiple parts  Neck  Arm  Back  Foot

 Head  Nervous Systems  Elbow  Spine  Toes
 Ears  Throat  Wrist  Groin  Circulatory System
 Eyes  Shoulders  Hand  Hip  Internal Organs
 Nose  Chest  Fingers  Leg
 Mouth  Respiratory Systems  Knee  Reproductive Systems
 Teeth  Abdomen  Ankle  Digestive System

20. TYPE OF INJURY: (Check one) Other

 Abrasion  Contusion  Inflammation  Pulmonary edema  Systemic shock

 Allergic Reaction  Electric shock  internal injury  Puncture  Thermal burn
 Amputation  Eye (foreign body)  Laceration  Repetitive motion  Throat irritation
 Asphyxiation  Eye (irritation)  Mental / emotional disorder  None
 Avulsion  Fracture stress  Scratch  Other
 Cardiac condition  Hearing loss  Multiple  Skin irritation
 Chemical burn  Heat / cold stress  Muscle spasm  Sprain
 Concussion  Hernia  Poisoning  Strain

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 Doc. No.: VICPL/EHS/F/19
Venus Industrial Corporation Pvt. Ltd Org. Date: 15.12.2024
[Link]. 00
Incident Investigation Report Rev. Date:

21. TYPE OF INCIDENT: (Check one)

 Absorption  Exposure to hot temperature  Pinching

 Caught In / Between  Exposure to low oxygen  Pulling
/ Under  Exposure to noise  Pushing
 Collapsing object  Exposure to radiation  Repetitive motion
 Contact with electricity  Exposure to sun  Slip (indoors)
 Contact with hot liquid  Fall (from elevation)  Slip (outdoors)
 Contact with sharp object  Fall (other)  Splash
 Drowning  Fall (slip)  Struck against
 Exposure to chemical  Fall (trip)  Struck by
 Exposure to cold objects  Ingestion  Vehicle accident
 Exposure to cold  Inhalation  Trip
temperature  Lifting
 Exposure to gases  Near miss
 Exposure to hot object  Not work related

22. Describe the incident. Be as detailed as possible. Give Specific times, exact locations, etc.
Continue on separate sheet if necessary. Attach drawings/diagrams that will aid in description of the incident:-

23. NAMES OF EYEWITNESSES:

24. WAS THERE ANY PROPERTY DAMAGE?  YES  NO Estimated cost (if yes): ____________________

25. CONTRIBUTING BEHAVIORS AND CONDITIONS (Check all that apply

BEHAVIORS CONDITIONS

1.  Abuse or misuse of equipment 13.  Unsafe operation of vehicle 1.  Poor layout, arrangement, or
14.  Unsafe placing, mixing, or
2.  Bypassing safety devices construction
loading
3.  Cleaning, clearing, adjusting, or 2.  Defective equip, tools or items
15.  Unsafe position or use of body
repairing moving equipment 3.  Environnent (chemical, dust, vapors,
16.  Unsafe pushing or pulling
4.  Failure to use proper personal Heat , etc.)
17.  Unsafe speed
protective equipment 4.  Housekeeping
18.  Unsafe use of caustics, acids,
5.  Failure to warn before startup 5.  Illumination
toxics, flammables, etc.
6.  Horseplay, distraction or teasing 6.  Improper or inadequate
19.  Using defective equipment or
7.  Improper use of equipment, storage
tools
tools, etc. 7.  Inadequate equipment guards or
20.  Violations of instructions,
8.  Improper use of hands, feet, etc. barriers
policies, or procedures
9.  Inattention to surroundings or 8.  Noise exposures
21.  Wearing unsafe clothing
conditions 9.  Ventilation
22.  Other___________________
10.  Operating without authority 10.  Inadequate protective equip.
11.  Failure to secure 11.  Inadequate warning systems
12.  Unsafe lifting or carrying 12.  Fire and explosion hazards
13.  Other _____________________

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 Doc. No.: VICPL/EHS/F/19
Venus Industrial Corporation Pvt. Ltd Org. Date: 15.12.2024
[Link]. 00
Incident Investigation Report Rev. Date:

26. WHY-WHY Analysis:

WHY-1

WHY-2

WHY-3

WHY-4

WHY-5

WHY-6

27. ROOT CAUSES: Keep these factors in mind when formulating recommended corrective actions.
(Check all that apply):
PERSONAL FACTORS JOB FACTORS

1.  Inadequate knowledge or skill 6.  Inadequate HSE management systems, 11.  Inadequate enforcement
2.  Inadequate physical capability standards, or procedures 12.  Inadequate reliability or
3.  Physical or mental stress
4.  Personal problems 7.  Inadequate job-related management maintenance program
5.  Improper motivation 13.  Inadequate supervision
systems, standards, or procedures
8.  Inadequate design process 14.  Inadequate
9.  Inadequate purchasing 10.  communications
Inadequate tools or equipment provided
15.  Lack of accountability

28. Correction action:

[Link]. CORRECTION ACTION RES. PERSON TGT DATE STATUS

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 Doc. No.: VICPL/EHS/F/19
Venus Industrial Corporation Pvt. Ltd Org. Date: 15.12.2024
[Link]. 00
Incident Investigation Report Rev. Date:

29. RECOMMENDED CORRECTIVE ACTIONS: Continue on separate sheet if necessary.

Item # Action Item Person Target Completion

Responsible Date Date
1

30. Effectiveness.

Item # Action Effectiveness observation 1st Month 2ndst Month 3rd Month
1

31. Horizontal Deployment to Other Process:-

32. Review Signature:

Dept. In-charge: Dept. Head: Safety Officer Factory Manager

Date: Date: Date: Date: