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    Blank Incident Report

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    case013
    - Ryan Mandell, an employee of Coastal Drilling Company, was injured on July 14, 2007 while assisting in pumping cement to an offshore rig from a cement barge. A vent line became plugged and whipped around, hitting Mandell and knocking him back into a cement tank. - Mandell experienced pain in his lower to left mid back, pain in his legs, dizziness, and shoulder pain after the incident. He was not hospitalized but required medical attention. - The incident occurred at 0940 hours on a cement barge while the rig, located off Broussard Bro.'s dock, was in clear weather conditions under a 7 day on/7 day off work

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    Blank Incident Report

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    case013
    236 views2 pages
    - Ryan Mandell, an employee of Coastal Drilling Company, was injured on July 14, 2007 while assisting in pumping cement to an offshore rig from a cement barge. A vent line became plugged and whipped around, hitting Mandell and knocking him back into a cement tank. - Mandell experienced pain in his lower to left mid back, pain in his legs, dizziness, and shoulder pain after the incident. He was not hospitalized but required medical attention. - The incident occurred at 0940 hours on a cement barge while the rig, located off Broussard Bro.'s dock, was in clear weather conditions under a 7 day on/7 day off work

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    - Ryan Mandell, an employee of Coastal Drilling Company, was injured on July 14, 2007 while assisting in pumping cement to an offshore rig from a cement barge. A vent line became plugged and whipped around, hitting Mandell and knocking him back into a cement tank. - Mandell experienced pain in his lower to left mid back, pain in his legs, dizziness, and shoulder pain after the incident. He was not hospitalized but required medical attention. - The incident occurred at 0940 hours on a cement barge while the rig, located off Broussard Bro.'s dock, was in clear weather conditions under a 7 day on/7 day off work

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xls, pdf, or txt
    236 views2 pages

    Blank Incident Report

    Uploaded by

    case013
    - Ryan Mandell, an employee of Coastal Drilling Company, was injured on July 14, 2007 while assisting in pumping cement to an offshore rig from a cement barge. A vent line became plugged and whipped around, hitting Mandell and knocking him back into a cement tank. - Mandell experienced pain in his lower to left mid back, pain in his legs, dizziness, and shoulder pain after the incident. He was not hospitalized but required medical attention. - The incident occurred at 0940 hours on a cement barge while the rig, located off Broussard Bro.'s dock, was in clear weather conditions under a 7 day on/7 day off work

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xls, pdf, or txt
    of 2

    COASTAL DRILLING COMPANY, L.L.C.

    5319 Port Road New Iberia, Louisiana 70560 Ofc: (337) 560-4446 Fax: (337) 560-4469

    INCIDENT REPORT
    RIG NO.: 22 X X Injury ___X___ Employee FA-Med (Dr./Hospital Attention Required) Report Only LT (Lost Time) Full Duty NLT (No Lost Time) Light Duty DATE: 07/14/07 Third Party

    Check One

    Illness ______

    Employee's Name:

    RYAN MANDELL

    Date of Birth: Date of Hire: St: LA Zip:

    10/06/81 03/28/07 02/13/93

    Employee's Address: 3105 WEST WILLOW City: Employee Social Security No.: Data Home Phone No.: Job Classification: Employer: Employer Address: Time And Place Date of Incident: Date Incident was Reported: Location of Incident (Place on Rig): SCOTT 433-67-8738 337-233-5707 ROUSATBOUT COASTAL DRILLING 5319 Port Road New Iberia La. 70560 07/14/07 07/14/07 CEMENT BARGE Time: Time:

    Phone: 0940 0940

    337-560-4446 X A.M. X A.M.


    P.M. P.M.

    This Section to be completed and Signed by Person Claiming Incident: Describe how incident occurred: ASSISTING IN PUMPING CEMENT TO THE RIG, WHILE PUMPING

    CEMENT FROM ONE TANK, NOTICED THAT THE VENT LINE WAS PLUGED, VENT LINE STARTED TO WHIP, TRIED TO ALERT CO-WORKER WHEN LINE BECAME UNPLUGED, LINE CAME Incident AROUND AND HIT ME, IT KNOCKED ME BACK, BY THE CEMENT TANK, IT WAS CLOUDY WITH Description CEMENT, TRYING TO GET AWAY FROM AREA, WHEN HE WAS CLEAR FROM AREA HE LAID and Nature of Incident DOWN UNTIL HELP ARRIVED Describe Injury: PAIN IN LOWER TO LEFT MID BACK, PAIN IN LEGS, DIZZINESS, AND SHOLDER PAIN Employee Signature 2 Where? N/A 4 Doctor's Name? N/A Mound Point Operator: McMoran 07/18/07 Date

    I agree that the description of the incident and my injury(ies) are correct. 1 Was employee hospitalized? Status 3 Did he return to the rig? Rig No.: 22 N/A N/A

    Rig Location:

    Dock: Broussard Bro.'s I.C.C. Rig Rig Work Schedule: 7&7 Information Toolpusher at Time of Incident: Immediate Supervisor of Employee: Weather Weather Conditions at Time of Incident: Conditions Clear Rain

    Crew Change Date: RANDY PERTUIT JERRY HODGES

    Fog

    Other

    Name of Parties contributing to this Report: Contributing Parties To Report 1 Neil Etheridge 2 Toolpusher's Signature

    Form Rev: 08/20/04

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