Rumaila Operating Organization

Initial Incident Notification Form V9

REPORTING DETAILS
ROO Accountable
S ROO Work Related Incident Accountable Company
Department
E
C
T
Yes / No Yes Al-Karrar Projects/Oil System
I
O Person Reporting Time of Incident Date of Incident
Position/ Job Title Primary Incident Location
N (Full Name) (hh:mm) (dd/mm/yyyy)
A Amjed Hameed Ghargn CoW Advisor 10:00 06-Dec-22 DS4
Specific location
DS4/Outside/ projects / Hot work to the construction of new Flow line R-760 (HU26)
(Number of Well / Vessel / Tank, etc.)
INCIDENT INITIAL CLASSIFICATION (TO BE APPROVED BY ROO HSE MANAGER)
High Potential Loss of Primary
Fatality Line Strike Near Miss
Incident Containment
S Day Away From Process Safety Asset
E Major Incident Unsafe Act X
Work Case Event Damage
C
T Restricted Work Severe Vehicle Well Control or Well Unsafe
Fire
I Case Accident Integrity Condition
O
N Medical Treatment Minor Vehicle
Leak Period Explosion UXO
Case Accident
B Occupational Spill / Leak Volume Origin of Environmental
First Aid Case
Illness (bbl. or scf) Leak Incident

For LOPC incident, is the leak within 500 meters of facility:

INCIDENT DESCRIPTION
The contractor team (Al-Karrar) lifted a pipe with one sling attached to one of the ends and on the other end the Oxygen
cutting machine was attached to the pipe.PTW Number: DS4-HWN-0070978
S
E
C
T
I
O
N

S PRELIMINARY CAUSE(S)
E
C 1- Lack of supervision on site.
T
I
2- PA and Work Team didn't follow the ROO CoW/HSE Procedures for Lifting Operation.
O 3- Noncompliance with the Safety Rules.
N

D
IMMEDIATE ACTION TAKEN
S Work has been Stopped Immediately By myself and GCMC HSE Team Lead.
E
C
T
I
O
N

E
Stop Work Authority used for observing unsafe condition / behaviour: Yes
PICTURES

S
E
C
T
I
O
N