United Pipeline Systems Incident Investigation

• Audit Title (name and or incident title).

• Location Incident Occurred.

• Date and Time of Incident.

  Date

• Responded By.

  Date

• Prepared By

• Location
  Address

• Incident Description:

• Add media

  Media

• After entering the incident description slide left to access the next step.

• Does the Incident Involve an Illness or Injury?

  Yes

  No
Tap to enter information

• Was WorkCare notified @ 1-888-449-7787

  Yes

  No

  N/A
Add Each Injured Employee (Click the add button to the right).

• What is the Employees Name (Last, First, M.I.)?

• Date of Birth:

  Date

• Employee ID:

• Date of Hire

  Date

• Length of service in industry:

• Length of service in current position:

• Job Title

• Short service employee (SSE)?

  Yes

  No

• Employment status:

  Regular full-time.

  Regular part-time

  Temp

• Did the incident result in a fatality?

  Yes

  No

• Was the incident work related?

  Yes

  No

• Would you describe the condition as an injury or illness?

  Injury

  Illness

• Has/will the employee be unable to attend work for more than 24-hours as a result of this incident or told by a doctor not to return to work?

  Yes

  No

• Has/will the employee need to have his normal duties altered as a result of this incident?

  Yes

  No

• Has the employee received medical treatment beyond first aid?

  Yes

  No

• Body parts injured:

  Select Hand Arm Head Eyes Legs Feet Back Shoulder Abdomen Chest Groin Lungs

  • Hand
  • Arm
  • Head
  • Eyes
  • Legs
  • Feet
  • Back
  • Shoulder
  • Abdomen
  • Chest
  • Groin
  • Lungs

• Nature of accident:

  Select Struck by Struck against Fall-same level Fall-lower level Caught in Caught by Caught between Contact with thermal Contact with chemical Contact with heat Contact with electricity Overstressed Poison Skin disorder Respiratory condition Hearing loss Environmental Release Equipment failure

  • Struck by
  • Struck against
  • Fall-same level
  • Fall-lower level
  • Caught in
  • Caught by
  • Caught between
  • Contact with thermal
  • Contact with chemical
  • Contact with heat
  • Contact with electricity
  • Overstressed
  • Poison
  • Skin disorder
  • Respiratory condition
  • Hearing loss
  • Environmental Release
  • Equipment failure

• Add pictures of injury if appropriate:

  Media

• Was employee doing his regular job?

  Yes

  No

• Date employer learned of injury:

  Date

• Able to work at least (1) full day after date of injury?

  Yes

  No

• Date lost time began:

  Date

• Date restricted time began:

  Date

• Return to work date (or expected):

  Date

• Restricted time end (or expected):

  Date

• If you need to add more than one person on the injury / illness page scroll up and click add for each additional employee. Once you are done with this section slide left to access the next step.

• Would you like to enter an Auto Incident?

  Yes

  No
Tap to enter information Add all drivers (click the add button to the right for each driver):

• Is this a UPSL (Aegion) employee or other driver?

  UPSL (Aegion) driver

  Other driver

• Name (Last, First M.):

• Employee ID (UPSL drivers):

• Date of Birth

  Date

• Name of company:

• Driver contact #:

• Address:

• Operator's license #:

• License class:

  A

  B

  C

• License expiration:

  Date

• Length of service with UPSL (Aegion):

• Length of service in current position in UPSL (Aegion):

• Position:

• Employment status (UPSL drivers):

  Regular full-time.

  Regular part-time

  Temp

• Insurance company (other driver):

• Insurance agent name (other driver):

• Insurance telephone # (other driver):

• Insurance policy # (other driver):

Add all vehicles involved (click the add button to the right for each vehicle):

• Who does the vehicle belong to?

  UPSL (Aegion)

  Other party

• Vehicle type:

  Select 18-wheeler Auto with trailer Automobile Delivery van Heavy truck Light truck Other SUV Truck with trailer

  • 18-wheeler
  • Auto with trailer
  • Automobile
  • Delivery van
  • Heavy truck
  • Light truck
  • Other
  • SUV
  • Truck with trailer

• Year/make/model of vehicle:

• Vehicle license plate #:

• Vehicle identification # (VIN):

• Names of all passengers involved:

• Was driver wearing a seatbelt?

  Yes

  No

• Were passengers wearing seatbelts?

  Yes

  No

• Where may the vehicle be seen?

• Describe damage to vehicle:

• If able take pictures of all vehicle damage. (click the button to the right):

  Media

• Speed before incident:

• Speed at impact:

• Damage to property of others?

  Yes

  No

• Describe damage to property of others:

• If able take pictures of all property damage (click the button to the right):

  Media
Add all equipment involved (click the add button to the right for equipment involved):

• Equipment description:

• Part #:

• Part description:

• Model #:

• Serial #:

• If able take pictures of all equipment damage (click the button to the right):

  Media
Tap to enter information

General auto incident questions:

• Was fault admitted or discussed at the scene?

  Yes

  No

• Alcohol/drugs involved?

  Yes

  No

• Were police summoned to the scene?

  Yes

  No

• Who was charged or ticketed by police?

  Select Both drivers Neither drivers N/A Other driver Our driver Police were not summoned

  • Both drivers
  • Neither drivers
  • N/A
  • Other driver
  • Our driver
  • Police were not summoned

• Was our vehicle parked off road at the time of the incident?

  Yes

  No

• Was our vehicle parked legally on a public roadway?

  Yes

  No

• Was our vehicle damaged as part of a theft, road chips, environmental damage, or vandalism?

  Yes

  No

• Was our vehicle tied directly to a work specific function?

  Yes

  No

• Could mileage be reimbursed for this journey?

  Yes

  No

• Was the employee traveling between facilities and not to and from work?

  Yes

  No

• Was our driver improperly licensed or had no license for the vehicle?

  Yes

  No

• Did our driver strike a stationary object?

  Yes

  No

• Did our driver exceed the posted speed limit or was excessive speed a factor?

  Yes

  No

• Was our driver fatigued?

  Yes

  No

• Was our driver distracted due to electronic devices, etc?

  Yes

  No
Tap to enter information

• What was the source of distraction?

• Was our driver in violation of any local laws?

  Yes

  No

• Did our driver receive a citation

  Yes

  No

• Was a poorly secured load a factor in this incident?

  Yes

  No

• Did our driver or any occupants fail to wear seatbelts?

  Yes

  No

• Did our driver fail to complete all required driver training?

  Yes

  No

  Unknown

• Did our driver fail to meet all expectations of the Journey Management policy at the time of the incident (if required)?

  Yes

  No

  Unknown

• Were preventable vehicle defects a factor?

  Yes

  No

• Add pictures of vehicle defects if possible (click the button to the right):

  Media

• Were any vehicle towed from the scene?

  Yes

  No

• Did any individual leave the incident scene in an ambulance?

  Yes

  No

• Were there any fatalities?

  Yes

  No

• Did any UPSL (Aegion) employee sustain a recordable injury?

  Yes

  No

• Direction of travel:

  Backing

  Forward motion

  Parked

  Stopping

• Roadway type:

  Select Flat Highway/Freeway Lease road On grade Parking lot Paved Rural Unpaved Urban

  • Flat
  • Highway/Freeway
  • Lease road
  • On grade
  • Parking lot
  • Paved
  • Rural
  • Unpaved
  • Urban

• Road conditions:

  Select Dirt/sand Dry Ice Mud Snow Wet

  • Dirt/sand
  • Dry
  • Ice
  • Mud
  • Snow
  • Wet

• Weather conditions:

  Select Clear Cloudy Foggy Freezing Other Raining Snowing

  • Clear
  • Cloudy
  • Foggy
  • Freezing
  • Other
  • Raining
  • Snowing

• Add pictures of road type/weather/traffic flow (click the button to the right):

  Media

• Condition of our driver:

  Select Asleep Blinded Fatigued Inattentive Rested Sick

  • Asleep
  • Blinded
  • Fatigued
  • Inattentive
  • Rested
  • Sick

• Incident type:

  Select Animal Backed into Backing Bicycle Boarding Fire Fixed object Glass breakage Head on Hit while occupied Jacknife Non-collision Other vehicle Pedestrian Railroad train Ran off road Rear ended Roll over Struck by another Trolley

  • Animal
  • Backed into
  • Backing
  • Bicycle
  • Boarding
  • Fire
  • Fixed object
  • Glass breakage
  • Head on
  • Hit while occupied
  • Jacknife
  • Non-collision
  • Other vehicle
  • Pedestrian
  • Railroad train
  • Ran off road
  • Rear ended
  • Roll over
  • Struck by another
  • Trolley

• Manner of collision

  Select Angle Backing Head on Rear end Sideways

  • Angle
  • Backing
  • Head on
  • Rear end
  • Sideways

• Traveling in convoy?

  Yes

  No

• Location of incident:

• Street or route:

• Nearest intersection:

• City/county/state:

• If you need to add more than one driver or vehicle scroll up and click add for each additional item. Once you are done with this section slide left to access the next step.

Forms

• For motor vehicle incidents complete:
  
  Auto Loss Notice Form
  Members statement
  Supervisor Incident report
  
  For Personal injury complete:
  
  Employee's 1st report (DWC-1)
  Employer's 1st report (5020)
  Supervisors Incident report
  Members statement
  Letter to medical provider
  Restricted duty form
  
  Others:
  
  Property Loss Damage report
  General Liability form
  
  Employee injuries that require a doctors visit and all motor vehicle incidents require a drug and alcohol screening with a quick test result.
  

• Have all sections been complete?

  Yes

  No
Tap to enter information

• Once all sections are complete sign below and email your incident investigation to your HSSE department.

• Type your name below and click the sign button to the right.

  Sign