INCIDENT
NOTIFICATION
Report Date (YYYY-MM-DD):
Incident Date (YYYY-MM-DD):
Operator:
Time (24 hr):
Operator’s Internal Reference #:
Operator’s Representative Name:
Operator’s Contact Phone #:
Location (latitude and longitude):
Well/Field (if applicable):
Installation/Vessel/Aircraft Name:
Installation/Vessel/Aircraft Type:
Revised Notification (yes/no):
OTHER AGENCIES NOTIFIED:
JRCC
CCG
TCMS
TCA
RCMP
EC
WHSCC/WCB
Certifying Authority
Other (Please Specify):
INCIDENT CLASSIFICATION (refer to Incident Reporting and Investigation Guidelines for definitions and details)
1.
2.
3.
Select all actual classifications that occurred as a result of the Incident
Select all potential classifications that could have occurred as a result of the Incident (select the same or higher consequence)
To report a Near Miss, select “None” in the actual classifications and select all potentials that apply
Actual
Potential
MEDEVAC?
Actual
Personnel
Potential
Damage/Threat
Fatality
Fire/Explosion
Missing Person
Collision
Occupational Illness
Loss of Well Control
Major Injury
Well Control Incident
Lost/Restricted Workday Injury
Major Hydrocarbon Release
None (< Lost/Restricted Workday Injury)
Significant Hydrocarbon Release
Yes
Potential
Actual
Non-Occupational
Leak of Hazardous Substance
Environment
Adverse Environmental Conditions
Unauthorized Discharge
Security
Spill
Implementation of Emergency Response Plans
None
Major Impairment/Damage
Potential not yet determined
Impairment/Damage to Critical Equipment
Non-Reportable
(Use only if information to date shows that an
incident does not meet reporting criteria)
Contact with Active Fishing Gear
JOHSC Notified (yes/no):
Helicopter Occurrence
Other Comments:
Diving Incident (also submit the Diving Incident Report)
None
Description of Incident (including events leading up to the Incident and any other relevant information)
Description of site operations and relevant environmental factors at time of Incident
Immediate response action(s) taken
Planned response action to be taken
Potential for Incident Escalation:
Yes
No
For Occupational Injuries/Illnesses, and Non-Occupational MEDEVACs:
Name of Affected Worker:
Nationality:
Occupation:
Employer:
Nature and Severity of Injury:
For Hydrocarbon Releases, Leaks of Hazardous Substances, Unauthorized Discharges and Spills:
Material released:
Volume (kg, L, etc):
Concentration (%, mg/L,
ppm, etc):
For Damages:
Type of equipment involved:
Severity of damage:
Incident notifications are to be provided to the CNSOPB and the Committee or Representative as soon as reasonably practicable but no later than 24 hours after
the Operator becomes aware of any incident. The incident notification form shall be submitted to the CNSOPB by email to [email protected] along with a
short descriptive title and the Operator’s incident identification number. An Incident Investigation Report is to be submitted no later than twenty-one days
following an incident.
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CNSOPB January 2014