Terra Oilfield Solutions Incident Report

• Incident Number

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Personal Information

• Name

• Address

• Title

• Length of Employment

• What time and date did the incident occur?

Type of Incident

• What type of incident is it?

  Injury

  Near Miss

  Environmental Concern

  Property Damage

  For Information Only

• Complete form and turn in to HSE.

• Complete form and turn in to HSE so a Safety Alert can be created.

• Is the damage to Third Party Equipment or Terra Equipment?

  3rd Party

  EDS

• Is the Property Damage Minor,Significant, or Major?

  Minor

  Significant

  Major

• Limit possible harm to people and fill out report within 6 hours with Superintendent.

• Limit possible harm to people and fill out report within 2 hours with Superintendent.

• Limit possible harm to people and Superintendent must report to site within 2 hours

• Was the spill Minor,Significant, or Major?

  Select Minor Significant Major

  • Minor
  • Significant
  • Major

• What material was spilled?

• Clean spill,call Regional HSE Coordinator, forward Incident Report to HSE Manager.

• What material was spilled?

• Clean spill,call Regional HSE Coordinator, forward Incident Report to HSE Manager. Notify Rig Manager

• What material was spilled?

• Contain and Notify Rig Manager
  Superintendent must report to location within 2 hours

• Was the injury a Minor, Significant, or Major as defined in the Incident Response flow Diagram?

  Minor

  Significant

  Major

• What part of the Body was injured?

• Administer First-Aid, call Regional HSE Coordinator, forward Incident Report to HSE Manager.

• What part of the Body was injured?

• Name of Doctor and Treating Facility with address.

• Contact Superintendent Immediately.
  Fill out Report with in 2 hours.
  Contact HSE within 8 hours

• What part of the Body was injured?

• Name of Doctor and Treating Facility with address.

• Contact EMS, Notify Rig Manager Immediately.
  Contact HSE and Superintendent with Immediately.
  HSE will contact HSE manager Immediately.
  Fill out report within 2 hours

Incident Specifics

• What is the specific location of the incident?

• Who was the incident reported to, what time was it reported and what date was it reported?

• What Phase of the Employee's Work day did the incident occur?

  Select During Rest Period During Meal time Working Overtime Entering or Leaving Location Performing Normal work duties Other

  • During Rest Period
  • During Meal time
  • Working Overtime
  • Entering or Leaving Location
  • Performing Normal work duties
  • Other

• Describe how the Incident occurred.

Incident Sequence.

• Injury event

• Incident Event

• Preceding event # 1

• Preceding event #2 and #3 ect.

Task and Activity at time of Incident

• General type of Task

• Specific Activity

• Who was the employee working with?

  Alone

  With Fellow Worker

  With Crew

  Other

• What is the Attitude of the Employee?

• Is the employee directly or indirectly supervised

  Direct

  Indirect

• Was the Supervisor on site at the time of incident?

  Yes

  No

  N/A

• Casual factors

• Corrective actions that have or will be taken

• Signature

  Sign