INCIDENT REPORT FORM

AREA (PLANT OR JOBSITE)

JACKFISH 2

LOCATION (EQUIPMENT / BLDG)

AA- PAD

DATE OF
OCCURRENCE
2015 / 01/ 14
YR /

NAME OF EMPLOYEE INVOLVED

AZEEM KHAN

OCCUPATION
QA/QC INSPECTOR

MO /

TIME
11:30 AM

DATE REPORTED
2015 / 01/ 14
YR /

MO /

TIME
11:30

AM
PM

DAY

DAY

INJURY/ILLNESS
VEHICLE INCIDENT

PROPERTY/ EQUIPMENT
FIRST AID

NEAR MISS/HIT
ENVIRONMENTAL

SUMMARIZE THE INCIDENT HERE WITH PRELIMINARY DETAILS.

BEFORE START HYDRO WE HAD A GOOD TOOL BOX MEETING

WITH CONTRACTORS, WE WENT THROUGH PROCEDURE AND BEST PRACTICES.

20L/MIN .IT WILL TAKE ABOUT 40 MINUTES TO FILL THE LINE,

WE EXPLAINED THE HYDRO TEST INSTRUCTION TO OTHER CONTRACTOR AND IN DETAIL, FIRST WE FILL THE LINE WITH
THEN

11000 KPA(G) WE WILL STOP FOR 5 MIN TO CHECK LEAK.

23100 KPA(G). EVERY HIGH POINT VENT LOCATION WE HAD A STAND BY CREW WITH RADIO FOR

AFTER FILLING THE LINE WE WILL START THE PRESSURE AND WHEN WE REACH HALF OF THE TEST PRESSURE
AFTER SATISFACTION WE WILL PUMP AGAIN TO REQUIRED PRESSURE
COMMUNICATION

AFTER DETAIL TOOL BOX MEETING WE START FILLING THE LINE

WITHIN A MINUTE AFTER FILL THE LINE CREW NOTICED THAT PRESSURE GAUGE WAS SHOWING
PRESSURE ON GAUGE

S
U
M
M
A
R
Y

4000 PSI (27920 KPA(G)

I WENT INSIDE THE PRESSURE TRUCK OPERATOR CABIN AND HIS DIGITAL READOUT WAS SHOWING
OUR BOTH LOW POINT AND HIGH POINT PRESSURE GAUGE WAS SHOWING
TRUCK
AND IT WAS ALSO SHOWING
WHILE

4000

69 PSI PRESSURE BUT

PSI(27920KPA(G) PRESSURE, I CHECKED THE SECONDARY PRESSURE GAUGE IN PRESSURE

4000 PSI (27902 KPA(G). THEN I NOTIFIED TO DEVON

AI AND HE TOLD ME THAT I WILL TALK TO ENGINEER ABOUT THIS OVER PRESSURE SYSTEM MEAN

YOU TAKE THE PRESSURE DOWN TO REQUIRED PRESSURE AND HOLD FOR REQUIRED TIME AND I WILL INFORM YOU OUTCOME AFTER CONSULT WITH ENGINEER.. AFTER WE DE
PRESSURIZED
THE SYSTEM UP TO REQUIRED PRESSURE AND INSPECTED FOR LEAK.

RECOMMENDATIONS

1)
2)

IF WE CAN WE SHOULD HAVE PRV ON HYDRO SYSTEM TO AVOID OVER PRESSURE

WE SHOULD HAVE CALIBRATED AND EXPERIENCE PRESSURE TRUCK OPERATOR

NAME OF EMPLOYEE REPORTING INCIDENT

AZEEM KHAN

SIGNATURE

DATE:
2015 / 01 / 15

SUPERVISORS INVESTIGATION
INJURY INFORMATION
SUPERVISOR

PART OF BODY INJURED (LEFT OR

RIGHT)

TREATMENT RENDERED BY:

BASIC CAUSE (FSE045)

C
O
R
R
E
C
T
I
V
E

A
C
T
I
O
N

DID THIS AGGRAVATE A PREVIOUS

INJURY?
YES
NO

(BRUISE, CUT, FRACTURE, STRAIN)

TYPE OF TREATMENT

WITNESS TO INCIDENT

ATTACH ALL PERTINENT DOCUMENTATION, INCLUDING:

INCIDENT COST?
$ _________________ESTIMATE
ATTACH ESTIMATES, IF APPLICABLE

A
N
A
L
Y
S
I
S

NATURE OF INJURY

PICTURES/DIAGRAMS
PTA CARDS
CLIENT REPORT

TOOLBOX MEETINGS
W ORK PERMIT
ALL OTHER INFORMATION

SCHEDULED WORK HOURS OF EMPLOYEE:

DAYS

START TIME: _________

FINISH TIME: __________
NIGHTS

RATIONALE:

CORRECTIVE ACTIONS:
W HAT CORRECTIVE ACTION HAS BEEN ASSIGNED?

ASSIGNED TO:
NAME

DUE:
TARGET DATE:

COMPLETE:
DATE:

W HAT CORRECTIVE ACTION HAS BEEN ASSIGNED?

NAME

TARGET DATE:

DATE:

W HAT CORRECTIVE ACTION HAS BEEN ASSIGNED?

NAME

TARGET DATE:

DATE:

SIGNATURE OF INVESTIGATOR:

DATE:

FOR CORPORATE OFFICE USE ONLY:

WAS ALL DOCUMENTATION INCLUDED? YES
NO
WAS DISTRICT SAFETY NOTIFIED?
DRUG AND ALCOHOL TESTING COMPLETED? YES NO WHY?
___________________________________________________________
HAS GPS DATA BEEN DOWNLOADED? YES NO
ENVIRONMENTAL FORMS

YES

NO

N/A

YES

VEHICLE INCIDENT REPORT?

NO

YES

NO

N/A
INCIDENT CLASSIFICATION:
AID
27/06/14 Rev. 2

REPORT ONLY

NEAR MISS

FIRST

DETAILED INVESTIGATION REQUIRED?

NO

YES

INCIDENT REPORT FORM

PARKLAND FOOTHILLS X LAKELAND OTHER: __________________________
OCCUPATIONAL
DISTRIBUTION: COPY HSE Administrator (RMH)

COPY Site Office

OCCUPATIONAL INCIDENT

COPY Corporate Safety

COPY District Safety

INCIDENT REPORT MUST BE COMPLETED AND DISTRIBUTED WITHIN 24 HOURS OF THE INCIDENT OCCURRING

27/06/14 Rev. 2

NON