Initial Incident Report Form

• Conducted on

  Date

• Prepared by

• TechnipFMC Location
  Address

Client Info

• Client Name

  Select C & J Specialty Inc - 53615 Halliburton SA - 57689 Halliburton KILGORE - 53109 BJ Services - 66115 Schlumberger - 52784 Misc - 52268 TechnipFMC FTP - CEPEU TechnipFMC SWH - CEWHP Pioneer - 53481 Sanjel - 64546 S & S - 53399 Calfrac - 56452 Holt at - 65589 Performance Tech - 56682 STEP - 64403 Seismos - 52268 TechnipFMC PPS - 488390

  • C & J Specialty Inc - 53615
  • Halliburton SA - 57689
  • Halliburton KILGORE - 53109
  • BJ Services - 66115
  • Schlumberger - 52784
  • Misc - 52268
  • TechnipFMC FTP - CEPEU
  • TechnipFMC SWH - CEWHP
  • Pioneer - 53481
  • Sanjel - 64546
  • S & S - 53399
  • Calfrac - 56452
  • Holt at - 65589
  • Performance Tech - 56682
  • STEP - 64403
  • Seismos - 52268
  • TechnipFMC PPS - 488390

• Client Representative

• Client Location

• Client Phone Number / Contact info

Equipment

• Equipment Description

• Equipment Number

• Part# / Serial# / EQ# / WO#

• Pressure When Failure Occurred

• Activity Being Performed When Failure Occurred

• Total NPT (Hours and Minutes)

Incident Classification

• NPT

  Very High: Greater than 24 hours

  High: Greater than 10 hours and less than 24 hours

  Medium: Greater than 1 hour and less than 10 hours

  Low: Less than 1 hour

• Service Impact PONC

  Very High: Greater than $100k

  High: Greater than $25k and less than $100K

  Medium: Less than $25k

  Low: Minimal Impact

• Product Impact PONC

  Very High: Greater than $100k

  High: Client Complaint

  Medium: Less than $25k

  Low: Minimal Impact

• Detailed Description Of Failure

• Initial Containment Actions

• Customer Reaction

Service Notification Creation (For Management)

• SN Number