An incident report was filed for a vehicle accident that occurred on October 1, 2013 at 6:52 am on Mussafah Road. According to the report, an employee of Royal Catering Services named Abid Noor Khan was driving a company van that collided with 8 other vehicles. There were no reported injuries. The direct cost of the incident was estimated to be below 3000 AED. The cause of the accident was determined to be insufficient distance between vehicles.

1. Incident Report
1. Sl. No. : (HSE Use)
2. Date and Time of
October 1, 2013 06:52 am pm
Occurrence:
3. Project/ Location : Mussafah Road
4. Report Prepared By
:
Roxanmei Barrette
5. Company : Royal Catering Services L.L.C.
6. Notification
General Manager Yes No am pm
Operations Yes No am pm
HSE Department Yes No am pm
Civil defense (if required) Yes No am pm
Police (if required) Yes No am pm
Ambulance (if required)) Yes No am pm
Client (if required) Yes No am pm
Other (Please specified) Yes No am pm
Revision No.: 00 Issue Date: January 2013 Issue No.: 01
7. Type of Incident
Near Miss
Serious Near
Miss
Reportable Dangerous
Occurrence
Lost/ Damage
Lost Time
Injury
Restricted Work Day
Case
Vehicle
accident
Fallen
materials
Collisions
Other (Explain below)
8. Direct cost Below 3000 AED
Above
3000 AED
Not
Applicable
Figure to be calculated.
9. What happened? (Incident description)

2. Incident Report
Location: Mussafah Road
Incident Type: Vehicle Accident
Involved: Abid Noor Khan
This was to inform you that Mr. Abid drove the van 97029 going back to CPU,
while on the road 8 vehicle were collide. Unfortunately, RC Van 97029 hit the
other vehicle.
There was no injury reported.
10. Why did this happen? (Unsafe acts/ conditions contributing to this incident)
There is no proper distance of the vehicle.
11. Why did Incident and Conditions/ Acts exist? (Underlying or root cause/s)
12. What actions need to be taken to prevent recurrence & date to finish action?
(Corrective Action and Completion Date)
13. What lesson learnt form the incident:
Name & Job Date Signatu
PREPARED BY: re
Action
(INSPECTOR)
Comments/
Revision No.: 00 Issue Date: January 2013 Issue No.: 01

3. Incident Report
Revision No.: 00 Issue Date: January 2013 Issue No.: 01
REVIEWED BY:
FOLLOW UP BY:
(INSPECTOR)
CLOSED OUT BY :
(INSPECTOR/ EHSQ
MANAGER)

4. Incident Report
14. Attach if Applicable/Available: Sketch of damage, Photograph, and/or
Additional explanation as required
Revision No.: 00 Issue Date: January 2013 Issue No.: 01