SUCO Acc./Inc.

Investigation Serial Number: HSE Cairo Reference Number:

Description of Accident Losses : Injury - Health - Environment - Process loss Damage - Other

Date: Location: Description of actual losses:

Description of Event: 3 MMSCF Gas + 5250 $

12 tons LPG + 13200 $
40 BBL condensate + 4200 $
Area
Authority Total estimated cost of losses

+ 22650 $

Losses Category: M
Actual: M Potential: M
Investigation

Immediate causes List Basic Causes

Corrective Actions for Immediate Causes

Area Number Action Person Completion date Completed?
Authority

Area Authority Name: Signature: Date:

Corrective Actions for Basic Causes

Number Action Person Completion date Completed?

HSE

HSE Name: Signature: Date:

Name : Signature: Date:

Field/Division
Manager

Reporting Guidelines

Accident/Incident Scale Injury Property Damage/ Environmental Reporting

Process Loss
Major or High Potential Fatality More than $50000 Long term (>2 year) damage and poor potential Immediate Report verbally to MDs.
Accident or Incident Broken Bones for recovery to normal state and costing more
Disabling Injuries than $50000 in direct loss or clean up costs. A/I written report faxed to MDs/O-1/HSE
Invoke major emergency plan. within 1 day.

Serious or Potential Serious LTIs, Strains, MTCs $5000 to $50000 Leads to immediate environmental damage A/I written report faxed to MDs/O-1/HSE
Accident or Incident Serious Cuts lasting for up to 2 years and costing $5000 to within 1 day.
$50000 in immediate clean up or control costs.
Non-compliance with legal requirement.

Minor Accident or Incident Small cuts self treated Less than $5000 Monitoring or clean up costs less than $5000 A/I written report sent to O-1/HSE within 3
without Lost Time days