P07.

1 EHS - AMERICAS PROCEDURES MANUAL

P07.1-A120 (Ref. ID: 002-00228) INCIDENT REPORTING FOR PROJECTS
APPENDIX 1 INCIDENT REPORT FORM
1.0 Initial Information
Project: Santo Domingo de Los Olleros Incident type, tick one or more boxes
Date: 26.01.16 1. Loss Time Accident (LTA)
2. Restricted Workday Case
Time of Incident: Near Miss
(RWC)
Location of Incident: Explanada de Central
3. Medical Treatment Case (MTC)
trmica Santo Domingo de Los Olleros
Site Manager notified? Si Time: 11.30 a.m. 4. First Aid Case (FAC)
Name of injured person: No aplica 5. Near Miss (NM)
Occupation: No aplica 6. Environmental Event (EE)
Employer: No aplica 7. Fire
Time with employer: N/A Time on Site: N/A 8. Property Damage
Supervisor: Mimer Escobedo 9. Other (Describe below)
Name of person initiating report: Guzman Diaz

2.0 Description of Incident

Personal de perforacin FZA, expuesto a riesgo de aplastamiento (de manos pies)
originado por acto inseguro, colocacin improvisada de taco de madera sobre en el cabezal
de perforacin para suspender la perforadora y colocar los durmientes debajo de la misma.

Stand Down.pdf

3.0 Corrective Actions

Action to be taken Responsible person Completion date
Se paralizo maniobra insegura Jimmy Zavala 26.01.16

Se solicit y utiliz camin gra para realizar la Jimmy Zavala 26.01.16

maniobra de forma segura Mimer Escobedo
Se realiz Charla sobre Izajes Jimmy Zavala 27.01.16

For Near Miss

Name Signature: Date:

COMPLETE SECTIONS 1.0, 2.0, 3.0 FOR NEAR MISS

Siemens Energy, Inc. Siemens Energy, Inc. 2013 All Rights Reserved. TQ:372111902.DOC
Hard Copies of this procedure are uncontrolled.
 P07.1 EHS - AMERICAS PROCEDURES MANUAL
P07.1-A120 (Ref. ID: 002-00228) INCIDENT REPORTING FOR PROJECTS
APPENDIX 1 INCIDENT REPORT FORM
4.0 Possible Immediate Cause
Failure in communication Poor housekeeping Inadequate/ Inappropriate PPE
Failure to follow rules / Substance abuse Failure to use safety devices
procedures
Failure to properly plan work Failure to wear PPE Faulty tools / equipment
Inadequate warnings / safety Work environment Inadequate / misuse of tools /
devices equipment
Insufficient time for task Fatigue / illness Insufficient equipment / personnel
Poor lighting Improper material handling Other, specify:
Comments:

Despus de dicha observacin, inmediatamente la contratista utilizo el camin gra

para el trabajo.

5.0 Injured Employee

5.1 Injured Body Part
Head Hand, Finger and Thumb Neck & Spine
Eyes Shoulder, Arm, Elbow, Forearm Chest & Abdomen
Ears Knee, Ankle, Leg Buttock & Pelvis
Lung Foot and Toe Internal
Multiple Injuries
Comment:
5.2 Nature of Injury
Fatality Fracture / Broken Bone Irradiation
Amputation Dislocation Ingestion
Laceration Sprain/Strain Electric Shock
Cut / Punctured skin Crushed / Caught between Object in eye
Impalement Bruising with intact skin Concussion / blow to head
Asphyxiation Fainting / loss of consciousness Others, specify:
Burn Exposure to hazardous substances
5.3 Medical Treatment Received:

Medical Provider:
Location:
Physician:
Treatment Received:

5.4 Instructions to Injured Person:

Return To Work Work Restrictions (detail below) Follow-up Treatment (detail below)

DETAILS:

6.0 Investigation
Investigation Team Members:
Siemens Energy, Inc. Siemens Energy, Inc. 2013 All Rights Reserved. TQ:372111902.DOC
Hard Copies of this procedure are uncontrolled.
 P07.1 EHS - AMERICAS PROCEDURES MANUAL
P07.1-A120 (Ref. ID: 002-00228) INCIDENT REPORTING FOR PROJECTS
APPENDIX 1 INCIDENT REPORT FORM

6.1 Investigation findings

(Add additional sheets where necessary) COMPLETE CORECCTIVE ACTIONS IN SECTION 3.0

Registro de Charla
sobre izaje inadecuado

Attachments (e.g. safety reports, permits, training records etc.):

6.2 Witnesses (Attach Witness Reports)

Name: Company: Signature: Date:

Name: Company: Signature: Date:

Name: Company: Signature: Date:

7.0 Approvals
SITE MANAGER AND SIEMENS TO CLOSE

Contractors Site manager name: Signature: Date:

SIEMENS HSE DEPARTMENT

Siemens EHS Engineer name: Signature: Date:

Siemens Site manager name: Signature: Date:

This form is for the information and use of the Siemens Site Manager as an example only. This example is typical of the
type of form/procedure that the contractor is expected to have. This form is definitely NOT to be given to the contractor for
Siemens Energy, Inc. Siemens Energy, Inc. 2013 All Rights Reserved. TQ:372111902.DOC
Hard Copies of this procedure are uncontrolled.
 P07.1 EHS - AMERICAS PROCEDURES MANUAL
P07.1-A120 (Ref. ID: 002-00228) INCIDENT REPORTING FOR PROJECTS
APPENDIX 1 INCIDENT REPORT FORM
use. For liability and insurance reasons the contractor must utilize their own guidelines and procedures, not ones from
Siemens.

Siemens Energy, Inc. Siemens Energy, Inc. 2013 All Rights Reserved. TQ:372111902.DOC
Hard Copies of this procedure are uncontrolled.