REPORT REPORT of INJURY
INCIDENT SEVERITY:
1
IMPACTED ELEMENT: ELEMEN T:
P
E
A
1
Project e!t "#on$tti Contr$ctor%
HQ / SUBSIDIARY:
FUNCTION AND DEPT.
JOB CENTER
INJURED PERSON NON NAME
SURNAME
RE!ISTRATION
EVENT LOCATION
COMPANY
in case o INJURY
EVENT N" &0'(-INC-'5
A) JOB #AREHOUSE #OR$ER
#IRE% LINE PERSON.% #/O
A!E
ELECTRICAL &AINT.
&ANA!E&ENT
&ECHANICAL &AINT.
SUPERVISOR
HIRED in YEAR
INST NSTRU&E RU&ENT NTA ATION &AIN &AINT T.
TECHN ECHNIC ICIIAN
JOB SENIORITY SENIORITY
Bona88i S8o2a7e Ya25
LABORATORY PERSONNEL
VISITOR
OFFICE PERSON
DRIVER
&ARINE CRE#
OTHER *S+eci,-
in ITINERE YES
(;/'
INCIDENT DATE
ABANDON&ENT DATE
TI&E
<):>
(;%'<%(<'=
#OR$ SHIFT ' ( ACTIVITY COVERED , #OR$ PER&IT / RIS$ ASSESS&ENT YES
PRODUCTION PERSON.
NO
)
D NO
EVENT DESCRIPTION
A con8aine2 oa5e5 ?i8@ ne? +i+es o2 3i8i7a8ion +2oec8 *a++2oi3a8e, (= 8ons- ?as coa+se5 592in7 @an5in7 an5 i8in7 +2ocess , c2ane a8 Bona88i S8o2a7e Ya25 . T@e i3+2o+e2 i8in7 8ec@ni9es *i.e. s@o28ness o sin7s0 9naance5 oa5 cen8e2 an5/o2 s82ess ?i8@in 8@e con8aine2 o5,- ?e2e a3os8 8@e 3ain 2easons. T@e2e ?e2e no in92ies. So3e 5a3a7e ?as occ92e5 8o 8@e con8aine2 o5, an5 829c. T@e a88ac@e5 a88ac@e5 +ic892es +ic892es i9s82a8e 8@e si89a8ion.
B) EVENT LOCATION
C) EVENT SITE
D) ACCIDENT TYPE
E) CONTINGENT EVENT
!AS / OIL PLANT
#ELL HEAD AREA
COLLISION #ITH
FALL o OBJECTS
DRILLIN! SITE
PROCESS PLANT
HIT BY
OBJ. I&PROPERLY PLACED
ELECTRICAL EQUIP&ENT #ELDIN!/CUTTIN!
CONSTRUCTION SITE PRODUCTION PTF.
TAN$ AREA RI! FLOOR
CRUSHED BY RUN OVER BY ...
HAND TOOLS &ATERIALS HANDLIN!
ADVERSE #EATHER #HEELS0 DRILLS0 LATHES
DRILLIN! PTF.
YARD
CUT
INSTRU&ENT &AINTEN.
VEHICLES/EQUIP&ENT
PTF. IN CONSTRUCTION
#OR$SHOP
E1CESSIVE PHISICAL STRAIN
DESCEND 2o3 VEHICLES
#OR$IN! SURFACE/FLOOR
MAIN OFFICE
INSTRU&ENTAL/CHE&. LAB.
FLAT FALL
OPERATIONS in ELEVAT.
ROAD ACCIDENT
ROAD
ELET: CAB/CONTROL ROO&
FALL FRO& HEI!HT
STAIRS 4 SCAFFOLDIN!
ROAD CONDITIONS OTHER *S+eci,-
#ELL
#AREHOUSE
SLIPPED / TRIPPED
TRANSFERRIN! FLUIDS
SUPPLY BASE
$ITCHEN/QUARTERS
INHAL0 IN!EST0 ABSORB.
TRANSFERRIN! PEOPLE
OTHER *S+eci,-
OFFICE
CONTACT DAN!EROUS SUBST.
O#N VEHICLE G) TREATMENT SITE CO&PANY SUR!ERY E1TERN. &EDICAL SUR!. HOSPITAL
F) INCIDENT TYPE
CONTACT H/L TE&P.
CO&PANY VEHICLE PIER THIRD PARTY PARTY VEHICLE OTHER *S+eci,-
ELECTROCUTION ON BOARD / DRIVIN!... OTHER *S+eci,-
FIRE E1PLOSION TO1IC SUBSTANCES SUBSTANCES RELEASE STRUCTURES COLLAPSE SPILL/DISCHAR!ED
PLANE CRASH NAVAL ACCIDENT TRIPS/SLIPS AND FALLS FALLS OTHER *S+eci,OTHER *S+eci,-
Da3a7e o con8aine2 o5,
H) INJURIES LOCATION
I) INJURIES TYPE
HEAD
HAND/#RIST/FIN!ER
RESPIRATORY SYSTE&
#OUNDS
INJURIES 2o3 FOREI!N BODIES/SUBST.
FACE
BAC$/SPINAL COL.
CARDIO VASC. SYSTE&
ABRASIONS
INJURIES 2o3 HEAT/COLD
EYE
AR&/SHOULDER
DI!ESTIVE SYSTE&
BRIUSES an5 CRUSHIN!
INTO1ICATION
EAR
FOOT/AN$LE
&ULTIPLE HEAD/LI&BS
DISLOCATION0 SPRAIN0 STRAIN
A&PUTATION
NOSE
CHEST RE!ION
&ULTIPLE HEAD/CHEST
BAC$LASH
ELECTROCUTION
&OUTH
LU&BAR%SACRAL RE!ION
&ULTIPLE CHEST/LI&BS
FRACTURE / INFRACTION
IONI6IN! RADIATION
NEC$
ABDO&INAL RE!ION
&ULTIPLE UPP/LO# LI&BS
CONCUSSION/ INTERNAL TRAU&A
SUFFOCATION / DRO#NIN!
LE!
!ROIN
OTHER *S+eci,-
STRAIN INJURY
&EDICAL TREAT&ENT CASE
&ULTIPLE INJURIES
OTHER *S+eci,-
No In92ies
FATAL ATAL ACCIDENT ACC IDENT CASE
REMARKS
'% I8 is @i7@, 2eco33en5e5 2eco33en5e5 8o i3+e3en8 a cose s9+e2ision +2o72a33e +2o72a33e o2 an, oa5in7 an5 9+oa5in7 ac8ii8i, in 9892e , co3+e8en8 +e2son. +e2son. (% Li8in7 +an 39s8 e +2e+a2e5 an5 c@ece5 , co3+e8en8 +e2son. )% Ca2ne 52ie2s 39s8 e ce28ie5 an5 82aine5 a++2o+2ia8e, 8o aoi5 an, si3ia2 inci5en8 in 9892e. G% A +eo+e 39s8 e e+8 a2 a?a, 2o3 an, i8in7 ac8ii8ies.
WITNESSES
#OR$IN! TEA&
O OC CCASIONAL
/
INJURED PERSON Si7na892e *i +ossie-
REPORT CO&PILER
Si7na892e
/
Si7na892e
/
SF&
DIAGNOSIS
FIRST PRO!NOSIS
DEPART&ENT DEPART&ENT &ANA!ER
$a3a A8a,a2i
HSE REPRESENTATIVE
Nai Ae3a2i
SUBSIDIARY !EN. &ANA!ER
A593onai3 Fa2@a8
REPORT CO&PILATION DATE DATE
SUPERVISOR
&)/'0/&0'(
MOG-HSEQ-F-085 Rev A4 Accident/Incident
Si7na892e Si7na892e Si7na892e
3
