Incident Investigation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Incident Reporting

• Lease Or Roadway Sign If Available

  Media

• Date And Time Of Incident?

  Date

• Date And Time Reported To Rhyason?

  Date

• Type Of Location The Incident Happened On?

  Lease

  Lease Roadway

  Paved Roadway

  Compressor Site

  Gas Plant

• What Type Of Incident Was It?

  Personal Injury

  Property Damage

  Near Miss

• This Involved Which Branch Of Rhyason Contracting?

  Pipeline

  Facility

• Is There Any Other Details That Need To Be Brought Up In This Section? (enter details in provided area)

People involved

• Name Of Persons Involved. (use persons directly involved first, then witnesses)

• The Person Listed Above Was? (choose one)

  Directly Involved

  A Witness

• The Person Works For? (choose one)

  Rhyason Contracting

  A Subcontractor of Rhyason

  Third Party

  The Client

• Name Of Persons Involved. (use persons directly involved first, then witnesses)

• The Person Listed Above Was? (choose one)

  Directly Involved

  A Witness

• The Person Works For? (choose one)

  Rhyason Contracting

  A Subcontractor of Rhyason

  Third Party

  The Client

• Name Of Persons Involved. (use persons directly involved first, then witnesses)

• The Person Listed Above Was? (choose one)

  Directly Involved

  A Witness

• The Person Works For? (choose one)

  Rhyason Contracting

  A Subcontractor of Rhyason

  Third Party

  The Client

• Name Of Persons Involved. (use persons directly involved first, then witnesses)

• The Person Listed Above Was? (choose one)

  Directly Involved

  A Witness

• The Person Works For? (choose one)

  Rhyason Contracting

  A Subcontractor of Rhyason

  Third Party

  The Client

• Name Of Persons Involved. (use persons directly involved first, then witnesses)

• The Person Listed Above Was? (choose one)

  Directly Involved

  A Witness

• The Person Works For? (choose one)

  Rhyason Contracting

  A Subcontractor of Rhyason

  Third Party

  The Client

• Name Of Persons Involved. (use persons directly involved first, then witnesses)

• The Person Listed Above Was? (choose one)

  Directly Involved

  A Witness

• The Person Works For? (choose one)

  Rhyason Contracting

  A Subcontractor of Rhyason

  Third Party

  The Client

• Is There Any Other Details That Need To Be Brought Up In This Section? (enter details in provided area)

On Site Investigation

• The Weather Was? (choose one)

  Dark

• The Temperature Was? (degrees celcius)

  Select -35 to -40 -30 to -35 -25 to -30 -20 to -25 -15 to -20 -10 to -15 -5 to -10 0 to -5 0 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 30 30 to 35

  • -35 to -40
  • -30 to -35
  • -25 to -30
  • -20 to -25
  • -15 to -20
  • -10 to -15
  • -5 to -10
  • 0 to -5
  • 0 to 5
  • 5 to 10
  • 10 to 15
  • 15 to 20
  • 20 to 25
  • 25 to 30
  • 30 to 35

• Was A Morning Tailgate Held That Addressed The Incident Issue?

  Yes

  No

  Not That Day but Previously On This Job.

• Please Add Pictures Of Incident Here.

  Media

• Provide An Overview Of What Happened.

• Witness Statement #1

• Signature Of Witness Statement

  Sign

• Witness Statement #2

• Signature Of Witness Statement

  Sign

• Witness Statement #3

• Signature Of Witness Statement

  Sign

• Witness Statement #4

• Signature Of Witness Statement

  Sign

Factors

• List All Factors Of The Incident Here.

Corrective Measures To Be Implemented

• List Corrective Measures To Ensure This Doesn't Happen Again.

• Signature Of Investigator

  Sign