Preliminary Incident Notification Form

• Preliminary Incident Notification

• TES-MS-1022

PRELIMINARY INCIDENT NOTIFICATION FORM

Document Number: TES-HS-1005

Revision Level: 3.0

Release Date: 4/25/13

INCIDENT DETAILS

• Date of Incident

  Date

• Time of Incident

  Date

• Incident Location

• Product Line

  Stimulation

  Wireline

  Coiled Tubing

  McAlester Yard

• Incident Type

  Select Injury/Illness Environmental Property Damage Vehicle Security Near Miss

  • Injury/Illness
  • Environmental
  • Property Damage
  • Vehicle
  • Security
  • Near Miss

• INJURED PERSON (IP) DETAILS (ONLY COMPLETE IF REPORTING AN INJURY OR ILLNESS)

INJURED PERSON

• Employee Name

• Job Title

• Supervisors Name

• INCIDENT DETAILS (Include information about activities being performed during incident)

• IMMEDIATE ACTIONS TAKEN (describe in detail)

• Add Pictures

  Media

• INCIDENT DETAILS (Include information about activities being performed during incident)

• What chemical(s) or substance(s) was/were involved?

• IMMEDIATE ACTIONS TAKEN (describe in detail)

• Add Pictures

  Media

• INCIDENT DETAILS (Include information about activities being performed during incident)

• IMMEDIATE ACTIONS TAKEN (describe in detail)

• Add Pictures

  Media

• ANALYSIS

• Immediate causes, failure to act, and conditions contributed directly to this accident?

• Basic causes, what are contributing factors? ( Job factors, personal factors)

• PREVENTION

• What action or recommendations are made to prevent recurrence? When? And action by?

• FREQUENCY POTENTIAL

  Frequent

  Probable

  Occasional

  Remote

  Improbable

• SEVERITY

  Catastropic

  Critical

  Moderate

  Minor

• SUMMARY - TO BE COMPLETED BY THE HSSE PERSONNEL

• Person Completing Report

• Job Title

• Incident Injury Classification

  DAFWC

  Restricted/Transfer Case

  Medical Treatment Case

  First Aid Case

  N/A

• Quantity Contained ( Gallons )

• Quantity Outside Containment ( Gallons )