BOS Investigation Report

• SECURE THE SCENE: Before completing this report, and immediately following reporting the incident to your BOS Supervisor and the Site Supervisor / Company Man, secure the site of the incident, the equipment involved, and any evidence against tampering, movement, alteration, or removal from the scene.

INITIAL NOTIFICATION: To be completed by the Injured/Involved Person (if possible)

• NOTE: The Initial Notification phase of this Report must be completed within three (3) hours of the incident occurrence.

• Date and time the incident occurred

  Date

• Select the type of incident that occurred

  Select Injury / Illness Environmental Vehicle Loss Damage Asset

  • Injury / Illness
  • Environmental
  • Vehicle Loss Damage
  • Asset

• Briefly describe the incident as soon as possible following the incident. Give your best recollection of the events as they occurred without speculation. Give only the facts.

• Date and time the incident was reported to the BOS Supervisor

  Date

• Was the Site Supervisor / Company Man notified of the incident immediately?

  Yes

  No

  N/A

• Date and time the incident was reported to the Site Supervisor / Company Man

  Date

• Explain the reason(s) the Site Supervisor / Company Man was not notified immediately.

• When was the Site Supervisor / Company Man notified?

  Date

• Who notified the Site Supervisor / Company Man?

• Initial Notification prepared by

• Reporter's phone number

• BOS Supervisor's name

• Location
  Address

• Check the box to confirm the BOS Supervisor has been assigned an Action Item (paperclip to the right) stating this Initial Notification is complete and the LER investigation needs to be conducted, then sign below.

• STOP HERE if you are the Injured/Involved Person (IP) and sign this Initial Notification below. If you are a Supervisor, continue with the Loss Event Report (LER) AFTER assigning yourself the above required Action Item and signing this Initial Notification below.

• Report initiator's signature

  Sign

Initial Notification of Loss Event: To be completed by Supervisor

• Description of the situation before and leading to the loss event.

• Add associated pictures with descriptions

  Media

• Description of work and events as they transpired and resulted in the loss event.

• Add associated pictures with descriptions

  Media

• Description of the situation immediately following the loss event, e.g., site control, preservation, and security.

• Add associated pictures with descriptions

  Media

• At this point, the Initial Notification Phase is complete. The Supervisor now assigns an Action Item to their Manager (paperclip to the right) stating the Initial Notification is complete and ready for distribution as needed.

• Notify your Manager and QHSE representative of the incident, sign below, and continue with the Initial Investigation Phase in collaboration with your QHSE representative.

• Investigating Supervisor's signature

  Sign

Initial Loss Event Investigation Phase: To be completed by Supervisor

• Type of Loss:

  Injury / Illness

  Environmental

  Vehicle Loss Damage

  Asset

Injury Info

• Body Part Affected:

  Select Head, neck, face Shoulder Arm Hands, Fingers Chest Abdomen Lower Back Pelvis Leg Knee Ankle, Foot, Toe Respiratory System Central Nervous System Digestive System Circulatory System

  • Head, neck, face
  • Shoulder
  • Arm
  • Hands, Fingers
  • Chest
  • Abdomen
  • Lower Back
  • Pelvis
  • Leg
  • Knee
  • Ankle, Foot, Toe
  • Respiratory System
  • Central Nervous System
  • Digestive System
  • Circulatory System

• Activity that led to Injury:

  Select Stepping (Walking) Manual Lifting Chemical Handling Driving Handling (Using Hands) Mechanical Lifting Noise Pressure Working at Heights Temperature Extreme Fire/Explosives

  • Stepping (Walking)
  • Manual Lifting
  • Chemical Handling
  • Driving
  • Handling (Using Hands)
  • Mechanical Lifting
  • Noise
  • Pressure
  • Working at Heights
  • Temperature Extreme
  • Fire/Explosives

• Loss Severity:

  Near Miss

  Minor

  Serious

  Major

  Catastrophic

Outcome:

• Injury Outcome

  Select Near Miss First Aid Medical Treatment (OSHA Recordable) Restricted Modified Work Lost Time Fatality

  • Near Miss
  • First Aid
  • Medical Treatment (OSHA Recordable)
  • Restricted Modified Work
  • Lost Time
  • Fatality

• Truck Unit Number:

• Type of Travel:

  Work

  Personnel

• Activity that led to Loss

  At Fault

  No Fault

• Type of VLD:

  Select Hit vehicle in front Hit from behind Backed into Hit stationary object Hit pedestrian Sideswiped Hit and Run Hit an animal Ran off the road Head on collision

  • Hit vehicle in front
  • Hit from behind
  • Backed into
  • Hit stationary object
  • Hit pedestrian
  • Sideswiped
  • Hit and Run
  • Hit an animal
  • Ran off the road
  • Head on collision

• Direct Cause of VLC:

  Select Aggressive Driving Fatigue Backing Drug/alcohol use Distracted Driving Driving to fast for conditions Following too close Nature/ Natural conditions Improperly securing items Pre Use inspection Improper planning 3rd party Inexperience with driving conditions

  • Aggressive Driving
  • Fatigue
  • Backing
  • Drug/alcohol use
  • Distracted Driving
  • Driving to fast for conditions
  • Following too close
  • Nature/ Natural conditions
  • Improperly securing items
  • Pre Use inspection
  • Improper planning
  • 3rd party
  • Inexperience with driving conditions

• Repair Cost Estimate

• Type of Environmental Loss:

  Air

  Water

  Ground

  Waste

• Fluid Type:

• Amount:

• Is the asset owned, leased, or rented:

  Owned

  Leased

  Rented

• Date of operator training:

  Date

• Daily pre use inspection:

  Yes

  No

  N/A

• Asset Number:

  Select

Loss Event Data Collection Checklist: To be completed by Supervisor and QHSE

• Please attach the following documents (to an email to the appropriate QHSE representative)and answer the questions as applicable. If the answer is No or N/A, explain why.

• Ensure the injured person(s) are taken care of and the scene is secured and undisturbed until investigation is complete.

  Yes

  No

  N/A

• Post incident Drug and Alcohol test

  Yes

  No

  N/A

• Injured or involved person(s) detailed written statement of events

  Yes

  No

  N/A

• Witnesses written statement of events

  Yes

  No

  N/A

• A Police report

  Yes

  No

  N/A

• Pictures of the employee, equipment involved, and include up-close, detailed pictures and overall site pictures (taken from a distance)

  Yes

  No

  N/A

• Top-view site schematic of injury/incident scene which includes where injury occurred, equipment was, and personnel were located

  Yes

  No

  N/A

• Pictures of position of employee at time of injury

  Yes

  No

  N/A

• Evidence of any PPE worn and condition of PPE (pictures if possible)

  Yes

  No

  N/A

• Evidence of any information/warning sign

  Yes

  No

  N/A

• Copy of Pre-Job Risk Assessment

  Yes

  No

  N/A

• Copy of all associated work permits

  Yes

  No

  N/A

• Copy of Geotab report (required for all BOS truck loss events)

  Yes

  No

  N/A

• Copy of injured or involved person`s training record and associated training for work being performed

  Yes

  No

  N/A

• Copy of equipment inspection and time last checked

  Yes

  No

  N/A

• Copy of any communications related to the injury event

  Yes

  No

  N/A

Jobsite Conditions

• Weather

  Select Day Night Sunny/Clear Overcast Raining Snowing

  • Day
  • Night
  • Sunny/Clear
  • Overcast
  • Raining
  • Snowing

• Temperature

Contractor or Employee info

• Was a PJRA and equipment inspection (If applicable) completed prior to the incident?

  Yes

  No

  N/A

• Hours on shift in prior 24 hours prior to incident

• Hours SINCE last sleep prior to current shift

• Hours the employee slept prior to the current shift

• Days worked in a row

• Number of days employed at time of loss

• Is the involved employee a contractor?

  Yes

  No

• Contractor Company:

• Did the Contractor employee complete the BOS Contractor Orientation?

  Yes

  No

• Date of Orientation completion:

  Date

• Investigating Supervisor's signature

  Sign

• QHSE representative's signature

  Sign

Final Phase: Causal Factors to be completed by QHSE

• Causal Factor 1

• Description of why this cause was selected

• Causal Factor 2

• Description of why this cause was selected

• Causal Factor 3

• Description of why this cause was selected

Corrective Action Items.

• (Please add your descriptive action items to include creating a "Action" to address Causal Factors, Responsible Party and Date Due)

• 1. <>

• a. Task: <

  >

• Checking this box certifies the Action Item (paperclip to the right) has been assigned.

• b. Due Date: <>

  Date

• c. Accountability: <>

• 2. <>

• a. Task: <

  >

• Checking this box certifies the Action Item (paperclip to the right) has been assigned.

• b. Due Date: <>

  Date

• c. Accountability: <>

• 3. <>

• a. Task: <

  >

• Checking this box certifies the Action Item (paperclip to the right) has been assigned.

• b. Due Date: <>

  Date

• c. Accountability: <>

• Investigating QHSE representative's signature

  Sign

Corporate QHSE Management Review & Approval

• Name, Title

• Signature

  Sign

• Date and Time of QHSE Sign-off:

  Date

Executive Management Review & Approval

• Name, Title

• Signature

  Sign

• Date and Time of Executive Management Sign-off:

  Date