HSEP 5.1f3, Rev.

0 Injury Incident Report

t Event Type: Injury Incident

t Date of Incident:

t Time of Incident:

t Date Reported to Jacobs:

t Project Number:

t Performance Unit:

Project References

t Joint venture: Yes No

t Immediate Supervisor (Full Name):

t Reported By (Full Name):

Number of Employees Supervised By

Immediate Supervisor:

Second Level Supervisor:

Third Level Supervisor:

Forth Level Supervisor:

Affected Individual

t Full Name:

t Jacobs Office / Field Staff Yes No

Department of the Affected:

Managing Contractor of the Employer:

Assigned Performance Unit:

Employee Reference:

t Type of Person:

Job Description:

Service Length In Company:

 Experience In Role:

Experience At Site:

Age:

Female Male
t Gender:

Shift:

Hours into shift when incident occurs:

Drug Test Performed No Not Permitted Yes

Alcohol Test Performed No Not Permitted Yes

Incident References

Location Details:

t Sub Event:

Classification -
No Yes
E-1

Recordable: No Yes

Indemnity No Yes

Worker's Compensation Claim No Yes

Local Regulatory: No Yes

Incident Work Related: No Yes

Applicable Country Regulation:

Witness 1 (Full Name):

Contact Details:

Other Witness (Full Name):

Contact Details:

1
t Worst Potential Severity:
(See Matrix)

1
Actual Severity

Investigator Section

Lead Investigator (Full Name):

 Date of Investigation:

Incident Detail

Equipment Involved:

Project Phase:

Scheduled Unscheduled
Turn Around:

Casual Analysis:
(See Casual Analysis Tab)

Description of Injury incident

t Summary Description:

t Description:

Photographs
if any

Source of Illness

Nature of Illnesses

Body Part Abdomen Back

Ear (External) Chest
Foot Ankle Face
Forearm Groin
Hearing Knee
Mouth Neck
Organs Respiratory
Shoulder Thigh
Upper Arm

Appropriate PPE Not Used Face/Eye Protection ; Fall Protection ;

Hand Protection; Head Protection ;
Respiratory Protection ; Other PPE;

Treatment Date:

Treatment Description Butterfly Strips; Cast;

Extraction; Fluid Draining;
Hot/Cold Therapy; Non-prescription;
Prescription; Splint;
Tetnus Shot;

Treatment Facility

Permanent Disability Yes No

Expected Restricted Days

Actual Restricted Day

 Expected Days Away

Actual Lost Days

Actual Return to work Date

t SPA Completed: N/A No Yes

t Critical Risk Category Confined Space Driving Electrical Work

Energy Isolation Excavation Hazardous Substan
Lifting Operations Mobile Equipment Work at Elevation
✘ N/A

t Immediate Action Taken:

Investigation Complete: ✘ Click

Follow Up Action Plan

Assignee Target Date Action Description

ncident Report
Yes

Yes
Buttocks
Eye
Finger/Thumb
Wrist/Hand
Lower Leg
Nose
Scalp
Toe(s)

Foot Protection;
Hearing Protection;

Clean/Bandage;
Flushing;
Physiotherapy;
Sutures/Staples;
 Yes

Electrical Work
Hazardous Substance
Work at Elevation

n Description
1 Direct cause
1.1 Unsafe acts
1.1.1 Individual behavior/attitude
✘
1.1.1.1 Poor decision making or lack of judgement ;
1.1.1.2 Negative attitude towards HSE / lack of belief ;
1.1.1.3 Improper lifting ;
1.1.1.4 Inattention or distraction (i.e. footing, surroundings, external sources, etc.) ;
1.1.1.5 Horseplay ;
1.1.1.6 Improper reaction to change ;
1.1.1.7 Victim of another person's actions ;
1.1.1.8 Personal goals vs. safety goals (ie. Perceived inappropriate reward system) ;
1.1.1.9 Taking unsafe position (line of fire) ;
1.1.2 Tools or Equipment Use
1.1.2.1 Operating equipment without authority or required training ;
1.1.2.2 Improper placement of tool or equipment ;
1.1.2.3 Unsafe mixing of chemicals ;
1.1.2.4 Disabling guards or warning systems ;
1.1.2.5 Using known defective tool or equipment ;
1.1.2.6 Loss of control of tool or equipment ;
1.1.2.7 Using tool or equipment improperly ;
1.1.2.8 Improper use or failure to use proper Personal Protective Equipment ;
1.1.2.9 Using improper or modified tool or equipment ;
1.1.3 Procedures implementation
1.1.3.1 SPA not followed ;
1.1.3.2 Safety Standards/ Procedures/ Guidelines not followed ;
1.1.3.3 Conscious risk taking (by group or individual) ;
1.1.3.4 Improper loading of materials or equipment ;
1.1.3.5 Working too quickly or in a hurry ;
1.2 Unsafe conditions
1.2.1 Workplace Hazards
1.2.1.1 Exposure to elevation change / heights ;
1.2.1.2 Inadequate illumination ;
1.2.1.3 Inadequate housekeeping (including obstacles,access) ;
1.2.1.4 Slippery surfaces ;
1.2.1.5 Lack of signage or poor marking (emergency exits, warning signs, etc.) ;
1.2.1.6 Abnormal biological presence ;
1.2.1.7 Inadequate ventilation ;
1.2.1.8 Inadequate/defective work surfaces ;
1.2.2 Process Hazards
1.2.2.1 Fire and explosion hazards ;
1.2.2.2 Deficient hazardous substance labeling ;
1.2.2.3 Process system/equipment failure ;
1.2.2.4 Inadequate isolation of process or equipment ;
1.2.2.5 Unsegregated hazardous substances ;
1.2.2.6 Excess or uncontrolled - radiation, noise, chemicals, etc. ;
1.2.3 Tools & Equipment Condition
 1.2.3.1 Defective tool or equipment (defect unknown to user) ;
1.2.3.2 Insufficient or lack of anchor points ;
1.2.3.3 Improperly prepared tool or equipment ;
1.2.3.4 Inadequate tool or equipment for the task ;
1.2.3.5 Maintenance of tool or equipment inadaquate ;
1.2.4 Protective Defences
1.2.4.1 Inadequate guards/protective devices ;
1.2.4.2 Defective guards/protective decices ;
1.2.4.3 Inadequate warning systems ;
1.2.4.4 Defective warning systems ;
1.2.4.5 Defective Personal Protective Equipment ;
1.2.5 Weather conditions
1.2.5.1 Extreme temperatures ;
1.2.5.2 Abnormal wind conditions ;
1.2.5.3 Precipitation, fog, etc. ;
2 Indirect cause
2.1 People Factors
2.1.1 Physical Capabilities
2.1.1.1 Fatigue ;
2.1.1.2 Substance sensitivities or allergies ;
2.1.1.3 Inability to use/wear PPE ;
2.1.1.4 Overexertion ;
2.1.1.5 Self medication, perscription drug use ;
2.1.1.6 Alcohol or drug abuse ;
2.1.2 Mental Capabilities
2.1.2.1 Fears and phobias ;
2.1.2.2 Emotional disturbance / stress ;
2.1.2.3 Poor judgement ;
2.1.3 Physiological
2.1.3.1 Mental fatigue due to lack of rest ;
2.1.3.2 Atmospheric pressure variation ;
2.1.3.3 Incapacatitated (Blood sugar, blood pressure, vision, other personal health con
2.1.3.4 Emotional overload ;
2.1.3.5 Extreme concentration/perception demands/mental task load or speed ;
2.1.3.6 Routine, monotony, demand for uneventful vigilance ;
2.1.3.7 Conflicting demands, frustration ;
2.2 Execution Factors
2.2.1 Engineering / Design
2.2.1.1 Unsafe design ;
2.2.1.2 Engineering or design related failure ;
2.2.1.3 Improper materials used, specified ;
2.2.1.4 Poor ergonomic design ;
2.2.2 Project level execution
2.2.2.1 Inadequate performance measurement, evaluation and feedback ;
2.2.2.2 Inadequate job placement (wrong worker assigned to the job) ;
2.2.2.3 Unclear or conflicting reporting relationships ;
2.2.2.4 Improper delegation ;
2.2.2.5 Inadequate accident reporting or investigation ;
2.2.2.6 Deficient review of SPA by supervisor ;
2.2.2.7 Lack of coaching or monitoring ;
2.2.2.8 Lack of supervisory task/job knowledge ;
2.2.3 Communication
2.2.3.1 Unclear or incomplete instructions, to injured ;
2.2.3.2 Unclear or incomplete instructions between others (supervisors, contractors, cli
2.2.3.3 Non-standard terms, phrases, etc. ;
2.2.3.4 Deficient handover process (between shifts, workers, etc.) ;
2.2.3.5 Language barriers ;
2.2.4 Skill & Knowledge
2.2.4.1 Lack of experience by worker(s) ;
2.2.4.2 Infrequently performed task ;
2.2.4.3 Inadequate training, knowledge or skill for task ;
2.2.5 Tools & Equipment Provision
2.2.5.1 Inadequate assessment of tools or equipment needs ;
2.2.5.2 Inadequate availability of tools or equipment ;
2.2.5.3 Inadequate maintenance of tools or equipment ;
3 Root Cause
3.1 Management Aspects
3.1.1 Resource Management
3.1.1.1 Inadequate evaluation of change in work scope / plans ;
3.1.1.2 Insufficient communication of safety expectations ;
3.1.1.3 Shortage of resources to perform the task safely ;
3.1.1.4 Lack of evaluation of hazards or mitigation options ;
3.1.1.5 Lack of clear roles and responsibilities ;
3.1.1.6 Inadequate job placement- supervisory level (wrong supervisor for the job) ;
3.1.1.7 Lack of reinforcement of proper behaviours or lack of disciplanary actions ;
3.1.1.8 Cultural issues not recognized, understood, respected, etc. ;
3.1.2 Leadership
3.1.2.1 Improper performance rewards (actions other than safety being rewarded) ;
3.1.2.2 Lack of or ineffective safety incentives ;
3.1.2.3 Avoided confronting client or others about safety ;
3.1.2.4 Inappropriate peer pressure ;
3.1.2.5 Lack of lessons learned sharing and implementing ;
3.1.2.6 Inadequate performance feedback ;
3.1.2.7 Failure to follow recomendations of HSE personnel ;
3.1.2.8 Failure to implement corrective actions, identified earlier ;
3.1.2.9 Inadequate attempt to save time, money, labor, etc. - by supervision or management ;
3.1.3 Contractors & Subcontractor Mgt.
3.1.3.1 Inadequate safety specification / contract clauses ;
3.1.3.2 Inadequate receiving, inspection, acceptance of work, equip., etc. ;
3.2 Program/System Aspects
3.2.1 Work Standards / Procedures
3.2.1.1 Inadequate/absent regulations or procedures ;
3.2.1.2 Inadaquate requirements for PPE ;
3.2.1.3 Inadequate reference documents, directives, or guidance manuals ;
3.2.2 Risk Evaluation
3.2.2.1 Inadequate job safety/hazard analysis ;
3.2.2.2 Failure in Management Of Change ;
3.2.2.3 Risk evaluation not performed ;
3.2.3 Task Planning
3.2.3.1 SPA not developed ;
3.2.3.2 SPA written but not reviewed by all involved ;
3.2.3.3 SPA did not involve all concerned workers ;
3.2.3.4 SPA did not address all task steps/activities ;
3.2.3.5 SPA did not address all hazards associated with the task ;
3.2.4 Training
3.2.4.1 Lack of initial orientation ;
3.2.4.2 Inadaquate orientation provided ;
3.2.4.3 Lack of required training ;
3.2.4.4 Inadequate training provided ;
3.2.4.5 Inadequate refresher / update training ;
3.2.5 Inspection and Audit program
3.2.5.1 Failure to perform required inspections / audits ;
3.2.5.2 Hazard not identified on audit (but could have been) ;
3.2.5.3 Missing program element not identified on inspection / audit ;
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Actual or
Economic/
Potential
Injury / illness Environment Material/ Motor Vehicle Incident (MVI)
Severity
Production
Level

Collision with another vehicle or

Serious off-site
object with at least one vehicle
Fatality or total impact,
USD$ moving at high speed; > 50mph
5 permanent significant
> 3 million (80kph) or an incident involving
disability remediation
vehicle roll-over or striking a
required
pedestrian, bicycle or motorcycle

Significant off- Collision with another vehicle or

Partial disability; site impact, object with at least one vehicle
USD$
4 life changing; some moving at medium speed;
300k-3mil
intensive care remediation > 40mph and < 50mph
required (> 65kph & < 80kph)

Release
Collision with another vehicle or
significantly
object with at least one vehicle
Urgent treatment; above USD$
3 moving at medium speed;
surgery reportable limit 30k-300k
> 30mph & < 40mph
or some local
(< 48kph & < 65kph)
impact

Medical treatment Release above Low speed collision (< 30mph or

USD$
2 to prevent reportable limit 48kph) with another vehicle or
3k-30k
deterioration or minor impact object

Small release
Minor collision while stationary or
Simple, immediate contained USD$
1 moving at slow speed while
treatment onsite and no < 3k
parking, backing, or maneuvering
impact