Preliminary Incident Report

GENERAL INFORMATION
LOCATION: TASK BEING CONDUCTED:
DEPARTMENT:
REPORTED BY: SUPERVISOR :
DATE OF INCIDENT TIME:
(DD-MMM-YY):
COMPANY: HUNT LNG / PLNG CONTRACTOR CONTRACTOR/OTHER:

IDENTIFY THE INCIDENT

NEAR MISS: INJURY: PROPERTY DAMAGE: ENVIRONMENTAL:
Injured Part: Fire SPILL:
Equipment Failure Spilled product:
Low Potential Injury Type: Equipment Damage Water Hydrocarbon
High Potential Chemical
Other (Specify) Facilities damage
Affected component:
Vehicular Accident Water Soil Concrete

Plate number: ________ GAS LEAK:

Released gas:______________

Other:______________
PERSONNEL/GOVERNMENT AGENCIES NOTIFIED (IF MORE SPACE REQUIRED, PLEASE LIST ON SEPARATE SHEET)
AGENCY CONTACT AGENCY/HUNT LNG
DATE NOTIFIED: CONTACT PHONE #:
PERSON: DEPARTMENT:

PRELIMINARY DESCRIPTION OF INCIDENT

Briefly describe how the incident occurs; photographic evidence can be included in this Section.

INMEDIATE ACTIONS TAKEN ACTION BY

PARTICIPANTS
Title NAME DATE
Company / Contractor Representative:
Other / QHSE Representative

Rev.03 09-May-16 Page 1 of 1 HSE-000-FOR-0005