Sequitur Energy Incident Report - duplicate

• Incident Title

• Document Number

• Activity

• Site conducted

  Select

• Occured on company premises?

  Yes

  No

• Date and Time of Occurrence

  Date

• Prepared by

• Location
  Address

• Incident type

  Select Injury Environmental Release Motor Vehicle Accident Fire Property Damage Regulatory Occupational Illness Explosion Equipment Failure Community Affairs Security

  • Injury
  • Environmental Release
  • Motor Vehicle Accident
  • Fire
  • Property Damage
  • Regulatory
  • Occupational Illness
  • Explosion
  • Equipment Failure
  • Community Affairs
  • Security

Event Details

• Task or Activity at time of Incident

• Physical or immediate causes of incident

• Immediate Actions Taken

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

  Employee

  Contractor

  Member of the Public

  Other

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

  Employee

  Contractor

  Member of the Public

  Other

Internal Reporting

• Reported by

• Date Reported

  Date

External Reporting Environmental Release

• Reportable Environmental Release

  Yes

  No
Environmental Release

• Chemical Name

• Release Source

  Select Flowline/Piping HHS Unit Fire Tibe Sight Glass Transfer Pump Pop Off Valve Gasket Failure Stuffing Box Packing Equipment Failure Corrosion/Erosion Electrical/SCADA Weather Plugged Line Frac Impact Employee Error Contractor Error Other

  • Flowline/Piping
  • HHS Unit
  • Fire Tibe
  • Sight Glass
  • Transfer Pump
  • Pop Off Valve
  • Gasket Failure
  • Stuffing Box Packing
  • Equipment Failure
  • Corrosion/Erosion
  • Electrical/SCADA
  • Weather
  • Plugged Line
  • Frac Impact
  • Employee Error
  • Contractor Error
  • Other

• Released To

  Select Air Pasture Caliche Pad Lined Secondary Containment Earthen Secondary Containment Water Other

  • Air
  • Pasture
  • Caliche Pad
  • Lined Secondary Containment
  • Earthen Secondary Containment
  • Water
  • Other

• Quantity Released

• Onsite Area Affected

• Chemical Class

• Quantity Recovered

• Offsite area Affected

Weather Conditions

• Weather Conditions

  Select Clear Rain Wind Fog Sleet Hail Smog Haze Snow

  • Clear
  • Rain
  • Wind
  • Fog
  • Sleet
  • Hail
  • Smog
  • Haze
  • Snow

• Wind Speed

• Wind Direction

  Select East North Northeast Northwest South Southeast Southwest West

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

Remediation

• Remediation Required

  Yes

  No

• DESCRIBE REMEDIATION

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow Up Responsibilities

• Responsible For Incident Investigation

Follow up Responsibilities

• Responsible for Incident Closure

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

  Employee

  Contractor

  Member of the Public

  Other

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

  Employee

  Contractor

  Member of the Public

  Other

Event Details

• Task or Activity at time of Incident

• Object or Substance that directly injured or made person ill

• Physical or immediate causes of incident

• Immediate Actions Taken

External Reporting injury/illness

• Reportable Injury/Illness?

  Yes

  No

  Undetermined
Agency

• Agency

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Agency Contact Info

  Yes

  No

  N/A

• External Report Number

• Reported Date

  Date

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date

Treatment Provided

• First Aid or Medical Aid?

  Select First Aid Medical Aid

  • First Aid
  • Medical Aid

• First Aid Responder

• Description of Treatment Provided

Safe Work Practices

• ALCOHOL TEST PERFORMED?

  Yes

  No

  Undetermined

• Date and Time of Test

  Date

• DRUG TEST PERFORMED?

  Yes

  No

  Undetermined

• Date and Time of Test

  Date

Classification

• Injury Classification

  Select Restricted Work Lost Work Fatality

  • Restricted Work
  • Lost Work
  • Fatality

• Estimated Restricted Days

• Description of restrictions

• First Restricted Day

  Date

• Date Returned

  Date

• Number of restricted days

• Estimated Lost Days

  Yes

  No

  N/A

• First Lost Day

  Date

• Date Returned

  Date

• Number of Lost work days

• Date of fatality

  Date

Injury/Illness Details

• Type of Injury/Illness

  Select Abrasion Amputation Bruise Chemical Burn Chipped Tooth Contusion Electrical Burn Electrocution Fracture Hearing loss Laceration Poisoning Puncture Radiation Burn Respiratory Condition Skin Disorder Sprain Thermal Burn Other

  • Abrasion
  • Amputation
  • Bruise
  • Chemical Burn
  • Chipped Tooth
  • Contusion
  • Electrical Burn
  • Electrocution
  • Fracture
  • Hearing loss
  • Laceration
  • Poisoning
  • Puncture
  • Radiation Burn
  • Respiratory Condition
  • Skin Disorder
  • Sprain
  • Thermal Burn
  • Other

• Body Part

  Select Abdomen Ankle Arm Back Buttocks Cardio System Chest/Ribs Ear Elbow Eye Face Fingers Foot/Ankle Groin Hand Hand/Wrist Head Hip Internal Body Jaw Knee Leg Leg/Knee/Hip Mouth Neck Nervous System Nose Pelvis Respiratory System Shoulder Teeth Toe Trunk Wrist Other

  • Abdomen
  • Ankle
  • Arm
  • Back
  • Buttocks
  • Cardio System
  • Chest/Ribs
  • Ear
  • Elbow
  • Eye
  • Face
  • Fingers
  • Foot/Ankle
  • Groin
  • Hand
  • Hand/Wrist
  • Head
  • Hip
  • Internal Body
  • Jaw
  • Knee
  • Leg
  • Leg/Knee/Hip
  • Mouth
  • Neck
  • Nervous System
  • Nose
  • Pelvis
  • Respiratory System
  • Shoulder
  • Teeth
  • Toe
  • Trunk
  • Wrist
  • Other

• Left or right

  Select Left Right

  • Left
  • Right

• Accident Type

  Select Contact with electricity or an electric discharge Contact with moving machinery or material being machined Drowned or asphyxiated Exposed to fire/explosion Exposed to, or in contact with, a harmful substance Fell from a height Hit by a moving vehicle Hit by a moving, flying, or falling object Hit by something fixed or stationary Injured by an animal injured while handling, lifting, or carrying Injured while working at a computer Physically assaulted by a person Slipped, tripped, or fell on the same level Trapped by something collapsing Other

  • Contact with electricity or an electric discharge
  • Contact with moving machinery or material being machined
  • Drowned or asphyxiated
  • Exposed to fire/explosion
  • Exposed to, or in contact with, a harmful substance
  • Fell from a height
  • Hit by a moving vehicle
  • Hit by a moving, flying, or falling object
  • Hit by something fixed or stationary
  • Injured by an animal
  • injured while handling, lifting, or carrying
  • Injured while working at a computer
  • Physically assaulted by a person
  • Slipped, tripped, or fell on the same level
  • Trapped by something collapsing
  • Other

• Accident Agent

  Select Animal/inspect Building/Structures Chair/Desk (office furniture) Chemical Compressed Gas Container Container (box, barrel, bag) Conveyor (belt/screw) Conveyor/Elec. / Hoist Drum Dust/Fume/Particles Electrical Apparatus Equipment/Apparatus (Fork Truck) Flammables Floor Fuel (gas, diesel) Glass Ground/Roadway Hand Tool Hot Surface Ice, Snow, Wind Knife Ladder/Scaffold Machine Noise Power Tool Stairway/Stairs/Ramp Tote Trash Vehicle Water/Stream Working Surface Other

  • Animal/inspect
  • Building/Structures
  • Chair/Desk (office furniture)
  • Chemical
  • Compressed Gas Container
  • Container (box, barrel, bag)
  • Conveyor (belt/screw)
  • Conveyor/Elec. / Hoist
  • Drum
  • Dust/Fume/Particles
  • Electrical Apparatus
  • Equipment/Apparatus (Fork Truck)
  • Flammables
  • Floor
  • Fuel (gas, diesel)
  • Glass
  • Ground/Roadway
  • Hand Tool
  • Hot Surface
  • Ice, Snow, Wind
  • Knife
  • Ladder/Scaffold
  • Machine
  • Noise
  • Power Tool
  • Stairway/Stairs/Ramp
  • Tote
  • Trash
  • Vehicle
  • Water/Stream
  • Working Surface
  • Other

Safe Work Practices

• Was PPE Worn?

  Yes

  No

  Undetermined

• PPE Worn

  Select Chemical Apron Chemical Gloves Chemical Goggles/Face Shield FR Gloves Cotton Gloves Fall Protection FRC 2112 and CAT 2 Certified Fire Retardant Clothing Hard Hat Hearing Protection Impact Goggles/Face Shield Leather Gloves Neoprene Boots Personal Monitor Reflective or High Visibility Clothing Respirator Safety Glasses Non FR Raingear Raingear meeting ASTM F2733 Certification Face Shield Safety Shoes Steel Toed Boots Welding Helmet/Shield Other

  • Chemical Apron
  • Chemical Gloves
  • Chemical Goggles/Face Shield
  • FR Gloves
  • Cotton Gloves
  • Fall Protection
  • FRC 2112 and CAT 2 Certified
  • Fire Retardant Clothing
  • Hard Hat
  • Hearing Protection
  • Impact Goggles/Face Shield
  • Leather Gloves
  • Neoprene Boots
  • Personal Monitor
  • Reflective or High Visibility Clothing
  • Respirator
  • Safety Glasses
  • Non FR Raingear
  • Raingear meeting ASTM F2733 Certification
  • Face Shield
  • Safety Shoes
  • Steel Toed Boots
  • Welding Helmet/Shield
  • Other

• Describe PPE Worn

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow up Responsibilities

• RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

• Responsible for Incident Closure

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

Event Details

• Task or Activity at time of Incident

• Physical or immediate causes of incident

• Immediate Actions Taken

External Reporting MVA

• Reportable MVA?

  Yes

  No

  Undetermined
Agency

• Agency

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Agency Contact Info

  Yes

  No

  N/A

• External Report Number

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Reported Date

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

Safe Work Practices

• ALCOHOL TEST PERFORMED?

  Yes

  No

  Undetermined

• Date and Time of Test

  Date

• DRUG TEST PERFORMED?

  Yes

  No

  Undetermined

• Date and Time of Test

  Date

Weather Conditions

• Weather Conditions

  Select Clear Rain Wind Fog Sleet Hail Smog Haze Snow

  • Clear
  • Rain
  • Wind
  • Fog
  • Sleet
  • Hail
  • Smog
  • Haze
  • Snow

• Wind Speed

• Wind Direction

  Select East North Northeast Northwest South Southeast Southwest West

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

MVA Information

• Physical Cause

  Select Struck animal Struck building Struck moving vehcile Struck non-moving vehcile Struck object Struck Person

  • Struck animal
  • Struck building
  • Struck moving vehcile
  • Struck non-moving vehcile
  • Struck object
  • Struck Person

• Posted Speed Limit

• Road Conditions

  Select Black ice Clear Compact snow Flooded Icy Snow covered Wet

  • Black ice
  • Clear
  • Compact snow
  • Flooded
  • Icy
  • Snow covered
  • Wet

• Road Type

  Public Road

  Lease Road

  Gravel Road

  Highway

  Parking Lot

• Visability

  Fair

  Good

  Poor

• Police Report Filed

  Yes

  No

  Undetermined

Vehicle Information

• Driving Activity

  Select Backing Up Parallel parking Parking Parked Pulling forward Stalled during shifting Turning left Turning right

  • Backing Up
  • Parallel parking
  • Parking
  • Parked
  • Pulling forward
  • Stalled during shifting
  • Turning left
  • Turning right

• Driving Speed

• Vehicle Ownership

  Employee

  Employer

  Lease company

  Rental company

  Third party

• Vehicle ID Number

• Drivers Liscense Number

• Duty Status

  Off Duty

  On Duty

• Condition of Driver

  Normal

  Distracted

• Driver wearing their seatbelt?

  Yes

  No

  Undetermined

• Citation Issued?

  Yes

  No

  Undetermined

• Driver Information

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow up Responsibilities

• RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

• Responsible for Incident Closure

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

Event Details

• Task or Activity at time of Incident

• Physical or immediate causes of incident

• Immediate Actions Taken

External Reporting Fire/Explosion

• REPORTABLE FIRE/EXPLOSION

  Yes

  No

  Undetermined

External Reporting Fire/Explosion

• External Reporting Fire/Explosion ?

  Yes

  No

  Undetermined
Agency

• Agency

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Agency Contact Info

  Yes

  No

  N/A

• External Report Number

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Reported Date

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date

Fire Information

• Ignition Source

  Select Electrical Equipment Electrical Welding Arc Exposed Incandescent material Grass/Pasture/Vegetation Hot Flare Shroud Pieces Hot Surfaces Lightning strike Mechanical Equipment Mechanical Spark Naked Flame Oil or Fluids in Flare Line Other Static Electricity Spark

  • Electrical Equipment
  • Electrical Welding Arc
  • Exposed Incandescent material
  • Grass/Pasture/Vegetation
  • Hot Flare Shroud Pieces
  • Hot Surfaces
  • Lightning strike
  • Mechanical Equipment
  • Mechanical Spark
  • Naked Flame
  • Oil or Fluids in Flare Line
  • Other
  • Static Electricity Spark

• Extinguishing Method

  Select Fire Hose Fire Sprinkler System Portable Fire Extinguisher

  • Fire Hose
  • Fire Sprinkler System
  • Portable Fire Extinguisher

• Time to Extinguish Fire

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow up Responsibilities

• RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

• Responsible for Incident Closure

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

  Employee

  Contractor

  Member of the Public

  Other

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

  Employee

  Contractor

  Member of the Public

  Other

Event Details

• Task or Activity at time of Incident

• Physical or immediate causes of incident

• Immediate Actions Taken

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow up Responsibilities

• RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

• Responsible for Incident Closure

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

Event Details

• Task or Activity at time of Incident

• Physical or immediate causes of incident

• Immediate Actions Taken

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date

Regulatory Information

• Regulatory Agency

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Agency Contact Information

• Citation Number

• Regulatory Reference

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow up Responsibilities

• RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

• Responsible for Incident Closure

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

  Employee

  Contractor

  Member of the Public

  Other

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

  Select Employee Contractor Member of the Public Other

  • Employee
  • Contractor
  • Member of the Public
  • Other

Event Details

• Task or Activity at time of Incident

• Object or Substance that directly injured or made person ill

• Physical or immediate causes of incident

• Immediate Actions Taken

External Reporting injury/illness

• Reportable Injury/Illness?

  Yes

  No

  Undetermined
Agency

• Agency

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Agency Contact Info

  Yes

  No

  N/A

• External Report Number

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Reported Date

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date

Treatment Provided

• First Aid or Medical Aid?

  Select First Aid Medical Aid

  • First Aid
  • Medical Aid

• First Aid Responder

• Description of Treatment Provided

Classification

• Injury Classification

  Select Restricted Work Lost Work Fatality

  • Restricted Work
  • Lost Work
  • Fatality

• Estimated Restricted Days

• Description of restrictions

• First Restricted Day

  Date

• Date Returned

  Date

• Number of restricted days

• Estimated Lost Days

  Yes

  No

  N/A

• First Lost Day

  Date

• Date Returned

  Date

• Number of Lost work days

• Date of fatality

  Date

Injury/Illness Details

• Type of Injury/Illness

  Select Abrasion Amputation Bruise Chemical Burn Chipped Tooth Contusion Electrical Burn Electrocution Fracture Hearing loss Laceration Poisoning Puncture Radiation Burn Respiratory Condition Skin Disorder Sprain Thermal Burn Other

  • Abrasion
  • Amputation
  • Bruise
  • Chemical Burn
  • Chipped Tooth
  • Contusion
  • Electrical Burn
  • Electrocution
  • Fracture
  • Hearing loss
  • Laceration
  • Poisoning
  • Puncture
  • Radiation Burn
  • Respiratory Condition
  • Skin Disorder
  • Sprain
  • Thermal Burn
  • Other

• Body Part

  Select Abdomen Ankle Arm Back Buttocks Cardio System Chest/Ribs Ear Elbow Eye Face Fingers Foot/Ankle Groin Hand Hand/Wrist Head Hip Internal Body Jaw Knee Leg Leg/Knee/Hip Mouth Neck Nervous System Nose Pelvis Respiratory System Shoulder Teeth Toe Trunk Wrist Other

  • Abdomen
  • Ankle
  • Arm
  • Back
  • Buttocks
  • Cardio System
  • Chest/Ribs
  • Ear
  • Elbow
  • Eye
  • Face
  • Fingers
  • Foot/Ankle
  • Groin
  • Hand
  • Hand/Wrist
  • Head
  • Hip
  • Internal Body
  • Jaw
  • Knee
  • Leg
  • Leg/Knee/Hip
  • Mouth
  • Neck
  • Nervous System
  • Nose
  • Pelvis
  • Respiratory System
  • Shoulder
  • Teeth
  • Toe
  • Trunk
  • Wrist
  • Other

• Left or right

  Select Left Right

  • Left
  • Right

• Accident Type

  Select Contact with electricity or an electric discharge Contact with moving machinery or material being machined Drowned or asphyxiated Exposed to fire/explosion Exposed to, or in contact with, a harmful substance Fell from a height Hit by a moving vehicle Hit by a moving, flying, or falling object Hit by something fixed or stationary Injured by an animal injured while handling, lifting, or carrying Injured while working at a computer Physically assaulted by a person Slipped, tripped, or fell on the same level Trapped by something collapsing Other

  • Contact with electricity or an electric discharge
  • Contact with moving machinery or material being machined
  • Drowned or asphyxiated
  • Exposed to fire/explosion
  • Exposed to, or in contact with, a harmful substance
  • Fell from a height
  • Hit by a moving vehicle
  • Hit by a moving, flying, or falling object
  • Hit by something fixed or stationary
  • Injured by an animal
  • injured while handling, lifting, or carrying
  • Injured while working at a computer
  • Physically assaulted by a person
  • Slipped, tripped, or fell on the same level
  • Trapped by something collapsing
  • Other

• Accident Agent

  Select Animal/inspect Building/Structures Chair/Desk (office furniture) Chemical Compressed Gas Container Container (box, barrel, bag) Conveyor (belt/screw) Conveyor/Elec. / Hoist Drum Dust/Fume/Particles Electrical Apparatus Equipment/Apparatus (Fork Truck) Flammables Floor Fuel (gas, diesel) Glass Ground/Roadway Hand Tool Hot Surface Ice, Snow, Wind Knife Ladder/Scaffold Machine Noise Power Tool Stairway/Stairs/Ramp Tote Trash Vehicle Water/Stream Working Surface Other

  • Animal/inspect
  • Building/Structures
  • Chair/Desk (office furniture)
  • Chemical
  • Compressed Gas Container
  • Container (box, barrel, bag)
  • Conveyor (belt/screw)
  • Conveyor/Elec. / Hoist
  • Drum
  • Dust/Fume/Particles
  • Electrical Apparatus
  • Equipment/Apparatus (Fork Truck)
  • Flammables
  • Floor
  • Fuel (gas, diesel)
  • Glass
  • Ground/Roadway
  • Hand Tool
  • Hot Surface
  • Ice, Snow, Wind
  • Knife
  • Ladder/Scaffold
  • Machine
  • Noise
  • Power Tool
  • Stairway/Stairs/Ramp
  • Tote
  • Trash
  • Vehicle
  • Water/Stream
  • Working Surface
  • Other

Safe Work Practices

• Was PPE Worn?

  Yes

  No

  Undetermined

• PPE Worn

  Select Chemical Apron Chemical Gloves Chemical Goggles/Face Shield FR Gloves Cotton Gloves Fall Protection FRC 2112 and CAT 2 Certified Fire Retardant Clothing Hard Hat Hearing Protection Impact Goggles/Face Shield Leather Gloves Neoprene Boots Personal Monitor Reflective or High Visibility Clothing Respirator Safety Glasses Non FR Raingear Raingear meeting ASTM F2733 Certification Face Shield Safety Shoes Steel Toed Boots Welding Helmet/Shield Other

  • Chemical Apron
  • Chemical Gloves
  • Chemical Goggles/Face Shield
  • FR Gloves
  • Cotton Gloves
  • Fall Protection
  • FRC 2112 and CAT 2 Certified
  • Fire Retardant Clothing
  • Hard Hat
  • Hearing Protection
  • Impact Goggles/Face Shield
  • Leather Gloves
  • Neoprene Boots
  • Personal Monitor
  • Reflective or High Visibility Clothing
  • Respirator
  • Safety Glasses
  • Non FR Raingear
  • Raingear meeting ASTM F2733 Certification
  • Face Shield
  • Safety Shoes
  • Steel Toed Boots
  • Welding Helmet/Shield
  • Other

• Describe PPE Worn

Safe Work Practices

• ALCOHOL TEST PERFORMED?

  Yes

  No

  Undetermined

• Date and Time of Test

  Date

• DRUG TEST PERFORMED?

  Yes

  No

  Undetermined

• Date and Time of Test

  Date

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow up Responsibilities

• RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

• Responsible for Incident Closure

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

Event Details

• Task or Activity at time of Incident

• Physical or immediate causes of incident

• Immediate Actions Taken

External Reporting Fire/Explosion

• Reportable Fire/Explosion

  Yes

  No

  Undetermined
Agency

• Agency

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Agency Contact Info

  Yes

  No

  N/A

• External Report Number

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

• Reported Date

  Select Coast Guard Emergency Response Federal Environmental Federal Health and Safety Federal Human Res/Dev Federal Industry Board Federal Police Local Police OSHA State/Prov Health and Safety State/Prov Health and Safety State/Prov Human Res/Dev State/Prov Industry Board State/Prov Police State/TCEQ/RRC Environmental Transportation Workers Compensation Board

  • Coast Guard
  • Emergency Response
  • Federal Environmental
  • Federal Health and Safety
  • Federal Human Res/Dev
  • Federal Industry Board
  • Federal Police
  • Local Police
  • OSHA
  • State/Prov Health and Safety
  • State/Prov Health and Safety
  • State/Prov Human Res/Dev
  • State/Prov Industry Board
  • State/Prov Police
  • State/TCEQ/RRC Environmental
  • Transportation
  • Workers Compensation Board

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date

Fire Information

• Ignition Source

  Select Electrical Equipment Electrical Welding Arc Exposed Incandescent material Grass/Pasture/Vegetation Hot Flare Shroud Pieces Hot Surfaces Lightning strike Mechanical Equipment Mechanical Spark Naked Flame Oil or Fluids in Flare Line Other Static Electricity Spark

  • Electrical Equipment
  • Electrical Welding Arc
  • Exposed Incandescent material
  • Grass/Pasture/Vegetation
  • Hot Flare Shroud Pieces
  • Hot Surfaces
  • Lightning strike
  • Mechanical Equipment
  • Mechanical Spark
  • Naked Flame
  • Oil or Fluids in Flare Line
  • Other
  • Static Electricity Spark

• Extinguishing Method

  Select Fire Hose Fire Sprinkler System Portable Fire Extinguisher

  • Fire Hose
  • Fire Sprinkler System
  • Portable Fire Extinguisher

• Time to Extinguish Fire

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow up Responsibilities

• RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

• Responsible for Incident Closure

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

Event Details

• Task or Activity at time of Incident

• Physical or immediate causes of incident

• Immediate Actions Taken

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date

Equipment Failure Information

• Type of Equipment Failure

  Select Electrical Pressure Static Elevator/Escalator Instrumentation Mechanical Failure Pipeline Pressure Equipment

  • Electrical
  • Pressure
  • Static
  • Elevator/Escalator
  • Instrumentation
  • Mechanical Failure
  • Pipeline
  • Pressure Equipment

• Equipment

• Equipment ID

• Model

• Serial Number

• Commisson Date

  Date

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow up Responsibilities

• RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

• Responsible for Incident Closure

• Description of Incident

Where

• Specific location of Occurrence

• Rig Number

Who

• Person Involved

• Relationship of Person Involved

• Supervisor of Person Involved

• Date and Time Shift Began

  Date

Witnesses

• Witness

• Relationship of Witness

Event Details

• Task or Activity at time of Incident

• Physical or immediate causes of incident

• Immediate Actions Taken

Insurance Reporting

• Insurance Group Notified

  Yes

  No

• CLAIMS HANDLER CONTACT INFORMATION

• INSURANCE CLAIM NUMBER

• Date Reported

  Date

Community Affairs

• Community Concern

  Select Dust Noise Odor Traffic/transportation Vapor Water Other

  • Dust
  • Noise
  • Odor
  • Traffic/transportation
  • Vapor
  • Water
  • Other

• Additional Community Affairs Information

Risk Assessment

• Open Risk Matrix

• Consequence

  Minor

  Moderate

  Major

  Serious

• Likelihood

  Remote

  Unlikely

  Likely

  Frequent

• Risk Level

  High

  Medium

  Low

Root Cause Analysis

• Root Cause

  Select Equipment and Tools Facilities Leadership and Supervision Nature of Task Personal Factors Process Controls Work Processes Working Conditions

  • Equipment and Tools
  • Facilities
  • Leadership and Supervision
  • Nature of Task
  • Personal Factors
  • Process Controls
  • Work Processes
  • Working Conditions

• Equipment and Tools

  Select Access to equipment limited Equipment arrangement or placement Equipment guarding / protective controls inadequate Equipment isolation difficult Equipment labels unclear or missing Equipment status unclear Proper tools unavailable or inadequate

  • Access to equipment limited
  • Equipment arrangement or placement
  • Equipment guarding / protective controls inadequate
  • Equipment isolation difficult
  • Equipment labels unclear or missing
  • Equipment status unclear
  • Proper tools unavailable or inadequate

• Facilities

  Select Facility Changes Facility design limits for application Facility equipment design specifications Facility equipment shipping and handling Preventative or predictive maintenance practices Procurement practices Quality control practices Repeat failure of facility equipment

  • Facility Changes
  • Facility design limits for application
  • Facility equipment design specifications
  • Facility equipment shipping and handling
  • Preventative or predictive maintenance practices
  • Procurement practices
  • Quality control practices
  • Repeat failure of facility equipment

• Leadership and Supervision

  Select Communications ineffective Expectations unclear/misunderstood Impact of concurrent activities not considered Inadequate participation in planning and preparation Inconsistent follow-through of expectations Roles and Responsibilities unclear Trends of past incidents not communicated Worker selection process need to be reviewed

  • Communications ineffective
  • Expectations unclear/misunderstood
  • Impact of concurrent activities not considered
  • Inadequate participation in planning and preparation
  • Inconsistent follow-through of expectations
  • Roles and Responsibilities unclear
  • Trends of past incidents not communicated
  • Worker selection process need to be reviewed

• Nature of Task

  Select Communication difficult during task Complex Task - many variables Heavy lifting required to perform Routine task - repetitive Special required equipment / tools unavailable Task changed after starting work Task hazards not considered

  • Communication difficult during task
  • Complex Task - many variables
  • Heavy lifting required to perform
  • Routine task - repetitive
  • Special required equipment / tools unavailable
  • Task changed after starting work
  • Task hazards not considered

• Personal Factors

  Select Changes to task situation not recognized Communication methods ineffective Knowledge of the task inadequate Many variable requiring attention at once Skills for the task not verified Task not analyzed for hazards Time to complete task led to shortcuts Worker fatigue/distraction

  • Changes to task situation not recognized
  • Communication methods ineffective
  • Knowledge of the task inadequate
  • Many variable requiring attention at once
  • Skills for the task not verified
  • Task not analyzed for hazards
  • Time to complete task led to shortcuts
  • Worker fatigue/distraction

• Process Controls

  Select Alarm messages unclear Alarm priorities unclear Arrangement of displays is confusing Controls operate opposite of normal convention Critical display information not obvious Display labels unclear or ambiguous Early warning indicators inadequate Repetitive alarms / messages System feedback to user delayed

  • Alarm messages unclear
  • Alarm priorities unclear
  • Arrangement of displays is confusing
  • Controls operate opposite of normal convention
  • Critical display information not obvious
  • Display labels unclear or ambiguous
  • Early warning indicators inadequate
  • Repetitive alarms / messages
  • System feedback to user delayed

• Work Processes

  Select Communication between groups inadequate Established procedure not used / not followed Planning process incomplete Policies, admin controls not applied Procedure not adequate for the situation Procedure not available or difficult to use Requirement for procedure unclear

  • Communication between groups inadequate
  • Established procedure not used / not followed
  • Planning process incomplete
  • Policies, admin controls not applied
  • Procedure not adequate for the situation
  • Procedure not available or difficult to use
  • Requirement for procedure unclear

• Working Conditions

  Select Confined working spaces Housekeeping conditions Lighting levels impacted visibility Noise levels impacted communication Required protective clothings constrained movement Signs or labels missing or improperly located Weather condition, temperature or air quality effects

  • Confined working spaces
  • Housekeeping conditions
  • Lighting levels impacted visibility
  • Noise levels impacted communication
  • Required protective clothings constrained movement
  • Signs or labels missing or improperly located
  • Weather condition, temperature or air quality effects
Cost

• Cost Type

  Select Contract Labor Equipment Loss Penalties/Fines Permit Fee Physical Damage Production Loss Remediation Training/Eduction Disposal Other

  • Contract Labor
  • Equipment Loss
  • Penalties/Fines
  • Permit Fee
  • Physical Damage
  • Production Loss
  • Remediation
  • Training/Eduction
  • Disposal
  • Other

• Amount

• Description

Follow up Responsibilities

• RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

• Responsible for Incident Closure