15 Form for Medium Potential Incident Investigation

7/23/2019 15 Form for Medium Potential Incident Investigation

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General Medium Potential Incident Investigation Form

Reporting department: Date of incident: / /

Time of incident:

Incident location: Activity controlled: [ PD!

[ "ontractor

Incident severity #$% &% '% (% ) or *+ : [ ]

[ ] injury

[ ] occupational illness

[ ] environmental

[ ] asset damage

[ ] reputational

[ ] Potential risk rating

[ T,ird party

Activity at t,e time of t,e incident

(See App 6b for guidance)

[ ] Using portable tools or equipment

[ ] Welding / burning

[ ] Manual lifting / handling

[ ] leaning

[ ] !perating plant / machinery

[ ] "igging

[ ] #andling ha$ardous materials

[ ] %ampling

[ ] "ismantling / assembling

[ ] "raining / flushing

[ ] "rilling

[ ] "isconnecting

[ ] limbing / descending

[ ] onnections

[ ] Walking at same level

[ ] "iving

[ ] Working at height &'m

[ ] Piloting

[ ] !ther(

-road description of t,e incident

(See App 6c for guidance)

[ ] %lips/trips/falls )same level*

[ ] +all from height

[ ] +alling objects

[ ] +ire or e,plosion

[ ] -lectrocution/electrical

[ ] %truck by

[ ] %truck against

[ ] rushed by

[ ] .rapped against

[ ] sphy,iation/chemical e,posure

[ ] ssault

[ ] 0oss of containment

[ ] Pollution

[ ] .heft or sabotage

[ ] Unsafe act or condition

[ ] !ther(


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Parties involved

PD! Department/section:

"ontractor . sucontractor:

T,ird party 0ame:

PD! "ustodian :

"ontract 0umer:

Total numer in1ured [

#o1 did the incident occur2

#Attac, s2etc, / p,otograp,s / event treeas appropriate . more paper may e used if re3uired+4

3s the activity and associated ha$ard/controls addressed in the applicable safety case)s* [4/562 [ ]

3f 75o78 state measures proposed to rectify (

What actions 1ere taken to determine if alcohol or drug use contributed to the incident2

3mmediate action taken to prevent incident happening again

"etails of the injured people #in liaison 5it, medical team+(See App 6g for guidance)

0ame:

Date of irt,:

6mployer:

6mployee 0umer:7o title:

Training attended:

Time on s,ift efore t,e incident:

Days into rotation/days of rotation:

Previous incidents involving IP:

Date 1oined company8

69perience in current role8

In1ury classification: #if R" state alternate 5or2 assigned+

0ature of t,e in1ury or illness:

Part of t,e ody in1ured:

6st4 return to 5or2 date: / / #if ;TI+


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"etails of the non injured person involved in causation of the incident

0ame:

Date of irt,:

6mployer:

6mployee 0umer:7o title:

Training attended:

Time on s,ift efore t,e incident:

Days into rotation/days of rotation:

Previous incidents involving IP:

Date 1oined company8

69perience in current role8

ost incurred as a result of this incident#+ :

PR!P6RT? DAMAG6: PR!D


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Immediate cause

(See App 6d for guidance)

[ ] 3nformation error or omission

[ ] 3nfluence of into,icating substances[ ] +ailure to follo1 rules / procedures9

[ ] 3nadequate equipment / tools

specify (:

[ ] Misuse of equipment / tools

[ ] Procedure not documented

[ ] Work environment

[ ] Procedure considered impractical

[ ] Poor housekeeping

[ ] Procedure not communicated

[ ] ccess

[ ] !ther

[ ] -,ternal factors8 ;rd party8 1eather

[ ] 3nadequate 1arning8 safety devices

[ ] !ther(

[ ] +ailure to observe / use 1arning safety devices

[ ] 0ack of due care and attention

[ ] 3mproper manual handling

[ ] ttack by animal

[ ] 3nadequate PP-

[ ] +atigue / stress

[ ] +ailure to 1ear PP-

[ ] 0ack of safety a1areness

[ ] 5one of the above8 specify(:


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Action ta2en to prevent recurrence

IT6M

0!4"orrective action Action

partyTargetdate

=tatus

Report 5riters name: Ref Ind4

=IG06D:

Report 5riter =upervisors name: Ref Ind4

=IG06D:

PD! Incident !5ners name : Ref Ind4

=IG06D :

Date report completed : / /

Furt,er recommendations

Date of incident : / /

Incident description:

5umber "escription of recommendation ction party "ue by


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%ignature of report 1riter:

Documents

15 Form for Medium Potential Incident Investigation