INCIDENT REPORT FORM A
INSTRUCTIONS
1. Follow the Incident Management Guideline SRLGUI002
2. Contacts: Daniel Kpovowai 076919277
3. Manager / Supervisor must complete sections 1 to 7 and return form to the EHS Department.
4. You may contact SRL Clinic/Ambulance directly in case of any injury (076539504)
1. Incident details: Fire in Pre-Heater Control Panel 2. Details of person(s) involved:
Date: 02-01-18 Time: 02:30 Hrs Name/s & Occupation: Christopher Rogers- Electrical
Location: Power House Main Engine Hall Supervisor
Person reporting: Moses P Sawyerr Section: Power House 2
Position: Electrical Engineer
3. Type of Report (Where more than 1 - indicate as 4. Names of others involved
such)
Near Property Enviro
Injury MVA Other
Hit Damage Incident
5. Incident description
At 07:30Hrs, whilst doing the usual morning rounds, we observed that there was an alarm indicating Pre- Heater unit failure on
Engine 2. Upon inspecting the Pre- Heater Unit Panel, we noticed the connections points for the main incomer to the Bus Bar
had caught fire and melted the insulation and burnt the power cable. During the event of the fire, a short circuit had tripped the
Breaker feeding the panel, there by cutting off power which prevented the fire from spreading. It burned itself out after the
breaker Tripped.
6. Immediate Action(s) taken after the incident (Supervisor’s comments)
Main Breaker was isolated and locked out.
Operations Supervisor and Electrical manager were informed.
7. Incident Photos
EHS Forms/Incident Report Form A/Rev 2/July 2008
8. Head of Department Comments 9. Doctor Comments (where injury is sustained)
Injury Negligible Minor First Aid
Name Name
Signature Date Signature Date
CHECK ALL DIRECT CAUSES THAT APPLY
What CONDITION of tools, equipment, or work area contributed to incident? Not Applicable
Close Clearance/Congestion Floors/Work Surfaces Poor Housekeeping
Hazardous Placement Inadequate Ventilation Equipment Failure
Inadequate Warning System Inadequate Illumination Hazardous Materials
Improper Material Storage Inadequate Guards/Barrier Defective Tools/Equipment/Vehicle
Inadequate/Improper PPE Equipment/Workstation Design Other
What ACTION or INACTION contributed to the incident? Not Applicable
Failure to Make Secure Used Defective Equipment Failure to Use PPE
Improper Lifting Improper Technique Improper Loading
Used Equipment Improperly Unauthorized Actions Operating At Improper Speed
Operating Procedure Deviation Improper Position Used Wrong Tool/Equipment
Horseplay/Distractive Active Unsafe Act of Another Staff Under Influence Drugs/Alcohol
Nullified Safety/Control Devices Running/Rushing/Acting In Haste Failure to Warn/Signal
Servicing Equipment In Motion Other
CHECK ALL UNDERLYING OR ROOT CAUSES THAT APPLY
What caused or influenced the substandard conditions or behaviors?
Lack of Proper Procedures Inadequate Job Instructions Inadequate Tools
Inadequate Job Training Methods Inadequate Supervision Improper Layout or Design
Inadequate Maintenance Standards Unsafe Design or Construction Poor Work Practice
Poor Work Design Inadequate Purchasing Standards Lack of Skill
Lack of Communication Between Staff Improper Extension of Service Life Improper Planning
Inadequate Cleaning Inadequate Environmental Controls Inadequate Capacity
Inadequate Preventive Maintenance Inadequate Enforcement or Work Standards
Other Loose Connection/Contact, Over Heating _
CHECK ALL ACTIONS NECESSARY TO CORRECT THE DIRECT AND ROOT CAUSES
What corrective actions have been taken or are needed to prevent a recurrence?
JHA/Procedure Revision Improve Clean-Up Procedures Repair/Replace Equipment
Reinstruction of Employees Improve Storage/Arrangement Rotation of Employee
Eliminate Congestion Improve/Change Work Method Identify/Improve PPE
Task Analysis to Be Completed Install/Revise Guards/Devices Improve Enforcement
Improve Design/Construction Job Reassignment of Employees Use Other Materials/Supplies
Improve Illumination Mandatory Pre-Job Instructions Improve Ventilation
Other
Recommended corrective actions or preventive measures to be taken
Action Item Person Responsible Target Date Date Complete
EHS Forms/Incident Report Form A/Rev 2/July 2008
Investigation Review (Initial after reviewing the findings of the investigation):
Initials Review Comments
Date
Supervisor
Department Manager
EHS Manager
EHS Forms/Incident Report Form A/Rev 2/July 2008
