SAFETY ALERT REPORT FORM
This form is to be used for the reporting of safety incidents for publication on the IOGP website. The form should be completed as fully as possible and returned to IOGP. Ideally the form should be completed electronically.
DATE FORM SUBMITTED:1.
/CONTACT:
The contact details you give us will remain strictly confidential. If you wish to provide contact details on the published report use item 1.A. below.YOUR NAME:
COMPANY:
POSITION IN COMPANY:
PHONE:
EMAIL:
1.A. / CONTACT DETAILS - OPTIONAL:
(to appear on published report)
2.
/THE INCIDENT
DESCRIPTIVE TITLE:DATE AND TIME:
(when the incident occurred)
COUNTRY AND REGION:
(where the incident actually occurred)
INCIDENT DESCRIPTION:
WHAT WENT WRONG? (main root causes)
CORRECTIVE ACTIONS AND RECOMMENDATIONS: (actions being taken to prevent recurrence and lessons learned)
FUNCTION – tick ONE ONLY: / Exploration / Drilling
Production / Other
ACTIVITY– tick ONE ONLY:
CAUSE – tick ONE ONLY:
LOCATION (On/offshore):
LOCATION – tick ONE ONLY: / Construction, Commissioning, Decommissioning
Diving, Subsea, ROV
Lifting, Crane, Rigging, Deck operations
Maintenance, Inspection, Testing
Office, Warehouse, Accommodation, Catering
Seismic / Survey operations
Transport - Air
Transport - Land
Transport - Sea, incl. Marine activity
Unspecified - other
Assault or Violent act
Caught In, Under or Between
Confined Space
Cut, Puncture, Scrape
Explosion / Burn
Exposure Electrical
Exposure Noise, Chemical, Biological, Vibration
Falls from Height
Other
Overexertion, Strain
Pressure release
Slips and Trips (at same height)
Struck by
Water related, Drowning
Onshore
Offshore
Camp ie survey, seismic geophical operations
Construction/rig repair yard
Fixed Installation
Floating Production Storage Unit
Floating Production Storage & Offloading Unit
Floating Storage Unit
Mobile Drilling Unit
Office, support base, heliport
Shuttle Tanker
Specialist vessel e.g. diving, construction, survey
Supply base, warehouse, workshop, dock
Terminal
Fixed Installation
OTHER CATEGORIES – tick as many as apply
Human Error / System/Equipment Failure
Failure of Permit to Work System / Structural Failure
Weather Related
IOGP REPORTING CATEGORIES – tick as many as apply
(used for email registration/distribution system)
Air transport / Caught between
Electrical / Explosion/burn
Fall / Struck by
Structural Failure (Onshore) / Structural Failure (Offshore)
Vehicle incident
PICTURES:
Pictures should be provided electronically, preferably as either .gif or .jpg files, and named ‘img1’, ‘img2’, etc. Please contact Wendy Poore at IOGP in advance if sending in pictures by email.
(number pictures or diagrams then enter the number below and any related text to the right)
pic. number / text
3. /
IOGP USE ONLY:
AUTHORISED BY:DATE:
Please return this form to IOGP:
209-215 Blackfriars Road, London SE1 8NL, United Kingdom UK
Tel +44 (0)20 7633 0272 Fax +44 (0)20 7633 2350 email:
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