Incident Field Report (Beta)

• Document No.

• Incident Name:

• Prepared by:

  Select Chad Sicari Sidney Crosby Mario Lemieux Evgeni Malkin

  • Chad Sicari
  • Sidney Crosby
  • Mario Lemieux
  • Evgeni Malkin

• Conducted on

  Date

• Personnel present during completion of report:

General Information

• Event Type:

  Incident

  Near Miss

• Event ID (Filled in by IMPACT reporting party):

• Rig:

• Local BP HES Representative:

• DSM/WSM CAI:

• Responsible Department

  Select Kern River Drilling Kern River Workover TTA Drilling TTA Workover WCC Drilling WCC Workover

  • Kern River Drilling
  • Kern River Workover
  • TTA Drilling
  • TTA Workover
  • WCC Drilling
  • WCC Workover

• On which field did this occur?

  Select Kern River Cymric Midway Sunset Lost Hills Coalinga San Ardo

  • Kern River
  • Cymric
  • Midway Sunset
  • Lost Hills
  • Coalinga
  • San Ardo

• Specific Field Location

• Add location
  Address

• Supervisor:

• Did you notify your supervisor?

• Date and Time Occurred:

  Date

• Date and Time reported to your supervisor:

  Date

• Short Description ( The short description should be concise, describe what happened, and be based on only fact. It should not include any opinions or personal data (names or CAIs)

• Please provide additional event details (included the what, how, where and when it happened):

• Immediate Actions Taken:

• Temperature (degrees F):

• Weather:

  Select Clear Cloudy Rain Windy Snow Hail

  • Clear
  • Cloudy
  • Rain
  • Windy
  • Snow
  • Hail

• Lighting

  Select None Dawn Day Dusk Indoor Night

  • None
  • Dawn
  • Day
  • Dusk
  • Indoor
  • Night

• Is this a process related event?

• Type of operation when incident occurred:

• Consequence Types:

  Select Aviation Fire/Explosion Injury/Illness MVC Property Damage or Loss Marine Process Upset Reliability Environmental Impact Permit Non-Compliance Spill/Release

  • Aviation
  • Fire/Explosion
  • Injury/Illness
  • MVC
  • Property Damage or Loss
  • Marine
  • Process Upset
  • Reliability
  • Environmental Impact
  • Permit Non-Compliance
  • Spill/Release

Spill/Release Details

• Where did spill/release occur

  Yes

  No

  N/A

• Operating temperature (F):

• Environmental Type:

  Environmental Impact

  Spill/Release

• Description of Spill or Release:

• Material Released:

• Receiving Medium:

  Air

  Land

  2nd Containment

  Water

• Unit:

  Select BBL GAL KG M SCF MM SCF SCF (F3)

  • BBL
  • GAL
  • KG
  • M SCF
  • MM SCF
  • SCF (F3)

• Release Rate (unit/hr):

• Quantity Released:

• Quantity Recovered:

• Release Classification:

  Combustible

  Flammable

  Toxic

  None of the above

• Notes/Comments

• Insert photos relating to spill/release

  Media

Injury Details

• Company IP works for:

• Work Related-Recordable

• Non Industrial/Non Recordable

• Industrial Non/Recordable

• Work Related-First Aid

• IP Name (if BP write Contractor)

• Hospitalized?

  Yes

  No

• Restricted Duty?

  Yes

  No

• Estimated number of days lost/restricted:

• Describe injury: (Nature of injury, body part, location)

• What was the injured person doing just before the incident occurred? How did the injury occur?:

• Length of time with Chevron:

• Years:

• Months:

• Years of experience in this type of work:

• Years:

• Months:

• How long at present work location:

• Years:

• Months:

• Number of hours person worked this week before injury occurred:

• Work Schedule:

  Select 7/7 12/11 14/14 28/28 7/2

  • 7/7
  • 12/11
  • 14/14
  • 28/28
  • 7/2

• Insert photos relating to injury here.

  Media

Property Damage/loss details

• Owner/classification:

  Select Company Damage Company Loss Contractor Damage Contractor Loss Third Party

  • Company Damage
  • Company Loss
  • Contractor Damage
  • Contractor Loss
  • Third Party

• Description:

• Insert photos relating to property damage

  Media

Fire

• Type:

  Select Direct Cost Indirect Cost

  • Direct Cost
  • Indirect Cost

• Cleanup Cost Amount:

• Equipment Damage Amount:

• Product Loss Amount:

• Ownership Percentage:

• Insert Photos relating to Fire/Explosion

  Media

Motor Vehicle Collision Detaila

• Ownership Type:

  Company Owned

  Company Leases

  Company Personal

  Contractor Owned

  Contractor Personal

• Driver Name (If BP write Contractor)

• Vehicle Owner (Name company if not personal vehicle):

• Accident Type:

• MVC Classification:

  Select Level 1 Actual Level 2 Actual Level 3a Actual Level 3b Actual Level 1 Probable Level 2 Probable Level 3a Probable Level 3b Probable

  • Level 1 Actual
  • Level 2 Actual
  • Level 3a Actual
  • Level 3b Actual
  • Level 1 Probable
  • Level 2 Probable
  • Level 3a Probable
  • Level 3b Probable

• Road Surface Type

  Select None Asphalt Asphaltic Concrete Brick Cement Concrete Dirt Gravel Metal Grating Oiled Open Field

  • None
  • Asphalt
  • Asphaltic Concrete
  • Brick
  • Cement Concrete
  • Dirt
  • Gravel
  • Metal Grating
  • Oiled
  • Open Field

• Road Conditions

  Select Dry Ice Below Freezing Ice Wet Packed Snow Dry Packed Snow Wet Pot Holes Rough Smooth Wet

  • Dry
  • Ice Below Freezing
  • Ice Wet
  • Packed Snow Dry
  • Packed Snow Wet
  • Pot Holes
  • Rough
  • Smooth
  • Wet

• Years Driving Motor Vehicles

• Years Driving with Chevron

• Movement of Vehicle

  Select North Northeast Northwest South Southeast Southwest East West

  • North
  • Northeast
  • Northwest
  • South
  • Southeast
  • Southwest
  • East
  • West

• Approximate Road Grade:

• Number of Passengers:

• Speed Prior to Breaking (MPH)

• Vehicle Year/Type/Make

• License Plate Number:

• Does the driver have a valid driver license?

• Has the driver attended company approved defensive driver training?

• Insert photos relating to MVC:

  Media

Timeline/Individuals Involved/5 Why

• Timeline (Be sure to enter dates/times with description and verification method [interview, investigation, etc.]):

• BP Supervisor Identification:

  Media

• Years in Position:

• Months in Position:

• Years in Industry

• Months in Industry

• Operator/crew chief:

  Media

• Years in Position:

• Months in Position:

• Years in Industry

• Months in Industry

• Safety Captain:

  Media

• Years in Position:

• Months in Position:

• Years in Industry

• Months in Industry

• Crew member 1

  Media

• Years in Position:

• Months in Position:

• Years in Industry

• Months in Industry

• Crew member 2

  Media

• Years in Position:

• Months in Position:

• Years in Industry

• Months in Industry

• Crew member 3

  Media

• Years in Position:

• Months in Position:

• Years in Industry

• Months in Industry

• Crew member 4

  Media

• Years in Position:

• Months in Position:

• Years in Industry

• Months in Industry

• Crew member 5

  Media

• Years in Position:

• Months in Position:

• Years in Industry

• Months in Industry

• 1. Why

• 2. Why

• 3. Why

• 4. Why

• 5. Why

• By signing, I acknowledge that all the information in this initial incident report is as factual as can be and was completed using only the data provided to me by those involved and my own investigative observations.

  Sign