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Construction Incident Reporting

Incident Number: Incident Statement: Creation Date: Last Revised On: GBU: Site where Incident occurred: Contractor: Sub Contractor: Originator:

20130320001 Fall from ladder 28/03/2013 3/28/2013 10:01:26 AM BEAUTY CARE Rio

BiancaCarneiroDeRezende Renha.B

Craft/Trade: Position: Experience on site:

Pipe Fitter Laborer New on Job

Incident Date: Incident Code: Near Miss: Nature of Injury: Body Part: Immediate Cause: Basic Cause(s): Mechanism of Incident: Mechanism Detail: Hours Worked Previous Week: Hours Worked Current Week: Consecutive Days Worked:

20/03/2013 12 PM Class III - Lost Workday Case Email to Network Fracture Ankle Not Following Safety Procedures Operating Procedures Slip Trip or Fall -- Ladder/Scaffold/Stairs

Attachments:

1. Relatorio de Reporte d e InvestigaC'C#o Incidentes Acidentes Everton ETEMA.doc


No

Is MCA Attachment:

Contributing Causes: Description of Incident:

Follow-Up Steps:

Not following safety procedures. The contractor had to place a pipe on it's support. He was using a ladder to do the activity but he didn't anchor it. The ladder fell and the contractor ended up falling from a 1,5 meter height. He fell on his feet and fractured his anckle Safety intervention with all contractors in the site to reinforce the obligation of following safety procedures.

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