BOS Near Miss and Incident Report

Initial Phase: To Be Completed by the Injured/Involved Person

• Which are you reporting, Loss Event or Near Miss?

  Loss Event

  Near Miss

• Did this Near Miss have high potential and require follow up?

  Yes

  No

  N/A

• Time and Date Incident Occurred

  Date

• Has the Client/Company Man and BOS Supervisor Been Notified?

  Yes

  No

  N/A

• Time and Date Incident Reported to BOS Supervisor and Client

  Date

• District

  Select

• Prepared by

• Injured Person/Report Preparer’s Phone Number

• BOS Supervisor

• Location
  Address

Loss information

• Description of Loss and Sequence of events before and after the loss.

• Add associated pictures with descriptions

  Media

• If you are the Field Tech or Shop Tech, Stop here and inform your supervisor that your section is complete. If you are the Supervisor or QHSE, please continue with the document.

Investigation Phase: To be completed by Supervisor and QHSE

• Type of Loss:

  Injury

  Vehicle Loss Damage

  Environmental

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

  • First Aid
  • Near Miss
  • Restricted Modified Work
  • Medical Treatment (OSHA Recordable)
  • 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 Enviro Loss:

  Air

  Water

  Ground

  Waste

• Fluid Type:

• Amount:

• Owned, leased, rented:

  Yes

  No

  N/A

• Date of operator training:

  Date

• Daily pre use inspection:

  Yes

  No

  N/A

• Asset Number:

Loss Event Data Collection Checklist

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

Rig/Job Conditions

• Weather

• 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

• Contracting agency:

• BOS Contractor Orientation:

  Yes

  No

  N/A

Final Phase: Root 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 Root Causal Factors, Responsible Party and Date Due)

• 1. <>

• a. Task: <

  >

• b. Due Date: <>

  Date

• c. Accountability: <>

• 2. <>

• a. Task: <

  >

• b. Due Date: <>

  Date

• c. Accountability: <>

• 3. <>

• a. Task: <

  >

• b. Due Date: <>

  Date

• c. Accountability: <>

Associated Action Items

• 1. <>

• 2. <>

• 3. <>

HSE Review & Approval

• Name

• Signature

  Sign

• Date and Time for HSE Sign off

  Date

Management Review & Approval

• Name

• Signature

  Sign

• Date and Time of Management Sign off

  Date