Form 1 BSEE

Reporter Information
Your Name
First name*		Last name*
Contact Information
	I am willing to be contacted for a brief follow-up confidential interview.
Phone Number*
Best Time To Call*	to
Timezone*	Eastern Central Mountain Pacific Alaska
Best Date To Call*	to
Message?	BTS can leave me a voice mail message.
Comment
I Work In
Operation*	Rig Operations Production Operations Pipeline Operations Transportation Operations Lifting and Hoisting Operations Other
Job Position*	[1] SEE BELOW
Work Experience In Oil And Gas
Year(s)*	y(s)	Month(s)*	m(s)

General Event Information
How did you find out about the Near-miss event you are reporting?
Source*	First-hand Personally Involved (It happened to me) First-hand Witness (I saw it happen) Second-hand (I heard about it) Other
When did the Near-Miss event happen?
	I am willing to be contacted for a brief follow-up confidential interview.
Date of Event*
Time of Event*
Timezone*	Eastern Central Mountain Pacific Alaska
Location of Event
Water Depth	ft	Mile to Shore	m(s)
Briefly describe the incident in chronological order. Include what happened, work conditions and any other relevant information.
Description*
Has this kind of near-miss happened before?
Happened Before?*	Yes  No  Don't Know
Please describe
During which operation, did the near-miss event happen?
Operation*	Rig Operations Product Operations Pipeline Operations Transportation Operations Lifting and Hoisting Operations Other

Rig Operations
What is the Rig Type?
Rig Type	Platform Jack-up Semisubmersible Drillship Other
What is the Rig Components/Location on Rig?
Components/Location	Crane Crew / Work Boats Derrick / Mast (Crown, Monkey/Stabbing Board, A-frame) Living / Accommodations Mud Pits / Tanks Rig Floor (Rotary, Pipe Setback Area) Well Control: (BOP) Stack/ Wellhead/Tree Are Other
Did the Near-Miss involve Lifting or Hoisting?
Note: If yes, please fill out the lifting and hoisting form on next page.
Lifting and Hoisting?*	Yes  No  Don't Know

Production Operations
What is the Platform/Facility Type?
Platform/Facility Type	Fixed Floating FPSO (Floating Production Storage and Offloading Unit) MOPU (Mobile Production Unit) SPAR Floating Production System SEMI (Semisubmersible (Column Stabilized Unit) Floating Production System) TLP (Tension Leg Platform) Other Subsea Other
Is the facility Manned or Unmanned?
Manned?	Yes  No  Don't Know
What is the Location on Platform/Facility?
Location	Crew Quarters/Galley Decks Well Bay Headers Production Process Area Other
Did the Near-Miss involve Lifting or Hoisting?
Note: If yes, please fill out the lifting and hoisting form on next page.
Lifting and Hoisting?*	Yes  No  Don't Know

Pipeline Operations
Pipeline Identifying Information
Operator Name		Pipeline Diameter
what material was in pipeline?
Material in Pipeline	Liquid hydrocarbon only Gas Only Comingled Ethylene glycol Other Chemicals Fuel Supply Water CO2 Other
Was the pipeline in H2s service?
H2S Service	Yes  No  Don't Know
Pipeline Activity Equipment
Environment	On sea floor On riser Splash Zone Surface Tie-in Subsurface Tie-in Other
Did the Near-Miss involve diving or ROV?
Diving involved?	Yes  No  Don't Know
ROV Involved?	Yes  No  Don't Know
Did the Near-Miss involve Lifting or Hoisting?
Note: If yes, please fill out the lifting and hoisting form on next page.
Lifting and Hoisting?*	Yes  No  Don't Know

Transportation Operations
Did the Near-Miss involve a rig?
Rig Involved?	Yes  No  Don't Know
Did the near miss involve a platform?
Platform Involved?	Yes  No  Don't Know
At the time of the near-miss, was the motor vessel/helicopter in radio contact with the facility?
In Radio Contact?	Yes  No  Don't Know
Transportation Mode
Transportation Mode	Helicopter Instrument Flight Rules (IFR) Visual Flight Rules (VFR) Motor Vessel Work Boat Crew Boat Oil Spill Response Vehicle Lift Boat Barge Fishing Boat Other
Event Location
Event Location	Moored to the facility Docking/Undocking to the facility Approaching/departing the facility In transit to/from shore or in transit between facilities Other
Work Activity
Work Activity	Transporting pipe or other materials Transporting passengers Servicing the facility (delivering fuel, water, mud, etc) Responding to a spill or drill Responding to other emergency or drill Transiting to/from the facility and shore or transiting between facilities Transferring personnel, pipe, or other materials to/from the facility Other
Did the Near-Miss involve Lifting or Hoisting?
Note: If yes, please fill out the lifting and hoisting form on next page.
Lifting and Hoisting?*	Yes  No  Don't Know

Lifting And Hoisting Operations
Lifting/Hoisting Activity
Lifting From and To	Deck-to-Deck on Platform Platform or Rig-to-Marine Vessel Marine Vessel-to-Platform or Rig Vessel-to-Vessel Between Rig Floor/VDoor /Well Pipe rack to derrick Hoisting in derrick Between Subsea and Platform or Rig Other
Material in Pipeline	Crane Other
Device Location	Rig Platform Motor vessel Other
Communication Method Used	Hand Signal/Standard Hand Signal/Special Radio/VHF Relay Other
Crane Information
Crane Installation	Fixed (Permanent) Rental Crane (Temporary /Moveable) Other
Crane Type	Mechanical Non-mechanical Electrical Other
Crane Inspection/Maintenance
Equipment Type	Gin pole Jib crane Overhead hoist Chain fall Other
Combination of Devices
Pre-Use Inspection?	Yes  No  Don't Know
Last Inspection Date
Load Information
Load Type	Personal Pipe/tubular Other
Safety Harness Used?	Yes  No  Don't Know
Life Line Used?	Yes  No  Don't Know

Other Operations
Please describe the Near-Miss Event as detail as possible.
Description*

[1]:

Job Positions (depending on response to “I work in:”)

“I work in”: Rig Operations

Barge Engineer/Ballast Control Operator

Catering Personnel, Camp Staff

Cement Equipment Operator

Crane Operator, Forklift Operator

Deck Supervisor, Deck Coordinator

Derrickman

Coil Service Equipment Operator

Driller (Crew Chief, Coil Service Operator

Driller (Asst Driller)

Floorman

Floorhand (Crew Worker, Coil Service Helper)

Electrician, Electronic Technician

Foam Air Equipment Operator

Heavy Equipment Operators (crane, forklift, excavation)

Maintenance Supervisor

Marine Crew

Mechanic

Mechanic, Repair Technician

HSE (Health Safety and Environment Personnel)

Motorman

Motorman / AD (Coil Service Fluid Pump Operator)

Nitrogen Equipment Operator

Radio Operator

Reverse Unit Operator

Roustabout (Leashand)

Special Service Operator

Stimulation Equipment Operator

Superintendent

Tool Dresser

Tool Pusher (Rig Supervisor, Coil Service Supervisor

Wireline Equipment Operator

Other

“I work in”: Product Operations

Production Operator

Mechanic

Electrician

I&E (Instrumentation)

Welder

Crane Operator

Other

“I work in”: Pipeline Operations

Pipeline Operator

Scada/Leak detection technician

Production Operator

Mechanic

Electrician

I&E (Instrumentation)

Welder

Crane Operator

Other

“I work in”: Lifting and Hoisting Operations

Rig Supervisor

Production Operator

Crane Owner/Representative

Qualified Inspector

Crane Operator

Engineer

Rigger

Signal Person

Vessel Captain or Crew Member

Other

“I work in”: Support Services Operations

Cook

Galley hand

Housekeeping

Other

“I work in”: Helicopter / Motor Vessel Operations

Helicopter pilot-Co-Pilot

Helicopter passenger

Motor Vessel captain

Motor Vessel crew

Motor Vessel passenger

Other

Form No: BTS-0030