RIG SUPPLEMENTAL INCIDENT REPORT (SIR) FORM

8. CHECK EQUIPMENT TYPE: (check only one item)

Complete one SIR form for each Recordable Incident.
Complete each line or check applicable box. 1 Tongs 15 Stairs
2 Elevators 16 Well Control Stack
3 Slips 17 Material
COMPANY NAME: SAIPEM SPA 4 Spinning Chain 18 Pressure Hoses / Lines
5 Iron Roughneck, Pipe Spinner, etc. 19 Crane / Forklift / Cherry Picker
COMPANY ID NUMBER: 6 Rotary 20 Ladders
7 Pipe / Collars / Tubulars / Csg. 21 Decks
1. RIG NAME/NUMBER: 8 Cathead / Drawworks 22 Welding, Cutting, Grinding Equipment
9 Slings (rope, cable, chain, web) 23 Sack Chemicals
2. CHECK ONE: 1 Medical Treatment Only (MTO) 10 Hand Tools: Manual 24 Top Drive
2 Restricted Work Case (RWC) 11 Hand Tools: Power 25 Anchor Chains / Cables / Winches
3 Lost Time Accident (LTA) 12 Engines / Pumps / Machinery 26 Rig Floor Winch / Deck Winch (air / hydraulic)
4 Fatality (FTL) 13 Vehicles / Transportation 27 Boat Cargo (Skids, Tubulars, Containers, Etc.)
14 Kelly Bushings 28 Other___________________
3. DATE OF INCIDENT:
9. CHECK OPERATION AT TIME OF INCIDENT: (Check only one item)

Month Year 1 Tripping in / out 12 Cementing

2 Making Connection 13 Special Operations (wireline, perforating, etc.)
4. THIS REPORTED INCIDENT OCCURRED: 3 Routine Drilling Operations 14 Walking
4 Running Casing / Tubing 15 Training
1 US Land 8 European Water 5 Laying Down / Picking up Pipe / Tubulars 16 Well Testing
2 US Water 9 Africa Land 6 Material Handling Manual 17 Abrasive Blasting / Paint / Scale Removal
3 Canada Land 10 Africa Water 7 Material Handling Crane / Forklift / Cherry Pic 18 Painting
4 Canada Water 11 Middle East Land 8 Rigging Up / Down 19 Running / Retrieving Anchors
5 Central / SA Land 12 Middle East Water 9 Well Control Stack Install / Maintenance 20 Handling Riser
6 Central / SA Water 13 Asia Pacific Land (Asia / Australia) 10 Rig Repairs / Maintenance 21 Jacking Up / Down Operations
7 European Land 14 Asia Pacific Water (Asia / Australia) 11 Mud Mixing / Pumping 22 Other___________________

5. CHECK POSITION OF AFFECTED PERSON: (Check only one) 10. CHECK PRIMARY LOCATION AT TIME OF INCIDENT: (Check only one item)

1 Roustabout 12 Truck Driver 1 Rig Floor 13 Work Room (Change House, Storage House)
2 Floorman 13 Rig Helper 2 Pipe Rack / Pipe Deck 14 Living / Camp Areas / Accommodations
3 Derrickman 14 Truck Helper 3 Catwalk / V-door 15 Crew / Work Boats
4 Driller (Asst. Dr.) 15 Welder 4 Derrick 16 Cellar / Substructure / Moonpool
5 Toolpusher (Asst. TP) 16 Maintenance Supervisor 5 Well Control Stack Area 17 Truck
6 Electrician 17 Catering Personnel 6 Mud Mixing Tank / Area 18 Machinery Spaces
7 Motorman 18 Radio Operator 7 Shale Shaker 19 Mud Pump Room
8 Mechanic 19 Deck Supervisor 8 Mud Pits / Tanks 20 Pontoon
9 Crane Operator 20 Subsea Engineer 9 Engine Room / Generator Room 21 Fuel / Water Storage Tanks
10 Barge Engineer/Ballast Control Op. 21 Medic 10 SCR / Electrical Room 22 Jacking House
11 Superintendent/other Supervisors 22 Other__________________ 11 Stairs / Ladders 23 Forklift / Cherry Picker / Crane
12 Rig Pad / Rig Decks (General) 24 Other___________________
6. CHECK PART OF BODY: (check only ONE: major body part affected)
11. CHECK TIME IN SERVICE FOR COMPANY: (Check only one item)
1 Eyes 10 Toes
2 Head 11 Neck 1 0 months < 3 months
3 Back 12 Shoulder(s) 2 > 3 months < 6 months
4 Trunk / Torso 13 Elbow(s) 3 > 6 months < 1 year
5 Arm(s) 14 Knee 4 > 1 year < 5 years
6 Hand(s) / Wrists 15 Skin 5 > 5 years < 10 years
7 Finger(s) 16 Lungs / Respiratory Problems 6 10 + years
8 Leg(s) 17 Digestive / Internal Problems
9 Feet / Ankles 18 Other___________________ 12. CHECK TIME OF DAY: (Check only one item)

7. CHECK INCIDENT TYPE: (check only one type) 1 01:00 Hours 13 13:00 Hours
2 02:00 Hours 14 14:00 Hours
1 Struck By 11 Cut 3 03:00 Hours 15 15:00 Hours
2 Struck Against 12 Exposure to Weather 4 04:00 Hours 16 16:00 Hours
3 Caught Between / In 13 Jump 5 05:00 Hours 17 17:00 Hours
4 Slip / Fall Same Level 14 Vehicle 6 06:00 Hours 18 18:00 Hours
5 Slip / Fall Different Level 15 Exposure to Gas 7 07:00 Hours 19 19:00 Hours
6 Strain / Overexertion 16 Chemical Inhalation 8 08:00 Hours 20 20:00 Hours
7 Contact With Chemicals / Fluids 17 Sprain 9 09:00 Hours 21 21:00 Hours
8 Electrical Shock 18 Heat Exhaustion / Stroke 10 10:00 Hours 22 22:00 Hours
9 Flame / heat/ steam (contact / exposed) 19 Caught On 11 11:00 Hours 23 23:00 Hours
10 Debris 20 Other__________________ 12 12:00 Hours 24 24:00 Hours

MAKE ADDITIONAL COPIES AS NEEDED.

Issue date: Jan 2004