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Case Type Incident
Incident Details
Pickup 08 hit a concrete barrier 08J
training area
Date Of Incident
7/17/2014
Time 1:00 PM
Port/Location Port Said
Vessel/Site Yard
Detailed Location
Shipping Line
Master/Supervisor at time of incident
Operating Office OPS
Reported By
OPS
Name Of Company, if 3rd party
Incident Description
Pickup 08 hit a concrete barrier 08J
training area
Equipment involved 8.Pick up
Equipment number 8
immediate action taken
weather condition Clear
road condition Dry
visibility Good
suggestion for improvement
Involved Person/Witness details(if any)
Employment Category
first Name
Surname
Person Involved as
Telephone Number
Job Title
Social Security Number
Home/work Address
If Over the road driver, drivers license no.
Injured persons details
Employee number
National ID
First Name
Surname
Home address
Phone
TWIC No./ID No.
Work address
Social Security Number
Date Of Birth
Gender
age
Employment category
company
Unit/Department
3rd party type
job title
marital status
Actual event type
A.]Occupational health details[caused by working
conditions] (if any)
Enter The details
Severity of illness
Type of illness
Estimated workdays lost
Actual workdays lost
Estimated workdays restricted
Actual workdays restricted
B.]Safety details[caused by working conditions] (If
any)
Accident category
Course of events
Type of injury
Part of body harmed
Estimated workdays lost
Actual workdays lost
Estimated workdays restricted
Actual workdays restricted
Indicate location of medical treatment
Was PPE or safety equipment in place
C.]Fire/explosion details(If any)
Fire Type 1
Fire type
Ignition sources
Primary exinguishing System
volume used
Description
D.]Asset damaged details(If any)
Asset damaged 1
Property/Equipment Type
Property/Equipment number Is The container able to move out via
vessel/rail/chassis
Does The container need M&R to take action
Department
Explain Damage
Damage caused by
Pre-existing damage
Forpre-existing damage,(if cargo/container) eter the
ship name/gate number/date/cargo type.
Must track repair expenses.
Operating office in charge of case
Person in charge
Fire Type 2 Fire Type 3
Asset damaged 2 Asset damaged 3
Contractor
Customer
Employee
Full-time employee
Government Authorities
Hired
Others(Please Specify)
Over the road/external driver
Port employee
Shipping Line/Vessel crew
Substitute
Vendor
Visitor
Involved
Witness
Clear
Fog
Ice/Snow
NA
Overcast
Rain
Sun
Thunder storm
Windy
CHE
1.Chassis/Trailer
2.Empty Handler
3.Mobile Crane
4.Rail-Mounted Gantry(RMG)
5.Reach Stacker
6.Rubber-Tired Gantry(RTG)
7.Ship Crane
8.Ship-To-Shore-Crane
9.Shuttle Carrier
10.Straddle Carrier
11.Terminal Tractor
12.Top Loader
CONTAINER
1.Dry
2.Flat rack
3.Open Top
4.Reefer
5.Tank
MISCELLANEOUS
1.Building/Facility
2.Cargo
3.Chassis Flipper
4.Lashing Gear
5.Leakage Trailer
6.Others(please specify)
7.Over Height Frame
8.Rail Chassis
9.Safety/Lashing Cage
10.Spreader
11.Tug/Boat
12.Vessel
VEHICLE
1.3rd party vehicle
2.Bus
3.Car
4.Emergency Vehicle
5.Fork Lift
6.Fuel Truck
7.Man Lift
8.Pick up
9.Sweeper.
No
Yes
Undetermined
Cargo
Chassis
Container
No
Yes
Observation
Near Miss
Incident
Building APL
Dock/Quay CMA CGM
Gate COSCO
Inspection Area/CFS CSAV
Off-Site China Shipping(CSCL)
Other(Please Specify) Eimskip
Parking Evergreen Marine Corp
Rail Hamburg Sud
Vessel Hanjin
Warehouse Hapag Lloyd
Workshop(M&R) Horizon Lines
Yard Hyundai(HMM)
Item2
K-Line
MSC
Maersk
Dry Mol_group
Flooded NYK
Ice/Snow OOCL
Muddy Others(Pl Specify)
NA PIL
Oil/Grease Shandong
Sandy UASC
Uneven Wanhai
wet Yang Ming
ZIM
AOM/Shift Manager/Ops Allergic reaction
Clerk/Checker Asbestosis
Driver:3rd Party Cancer
Driver: Company Vehicle(Bus,Car,Pickup,Motorbike) Cardio logical
Driver: Container Handling Equipment Contagious Disease
Driver: Forklift Cumulative trauma
Driver:UTR/Terminal Tractor Diseases caused by biological agents
Flagman/Signalman/Wharf Controller Diseases caused by chemical agents
Foreman/Supervisor Diseases caused by physical agents
Gearman/Lasher(Vessel) Hearing loss
Line Handler/Mooring Crew Heat Prostration/Heat stroke
MESC Mental stress
Mechanic/Engineer/Technician Non Occupational
OCU
Others-3rd party(please specify) Not selected
Others-Employees(please specify) 1.Poisoning
Pinman/Coneman/Lasher(Quayside) 2.Radiation
Security 3.Respiratory
White Collar 4.Silicosis
Abdomen/stomach Abrasion/Bruise/Contusion
Ankle Amutation
Back/spine Burn
Buttock/hip/groin Burn/Scald
Chest Cardiac/respiratory
Ear Concussion
Elbow Contusion/Bruising/contact skin
Ear Crushing
Eye Cut/Open wound
Face/head Cut/Laceration/scratched/punctured
Hand/wrist Damage caused by electricity
Knee Dislocation
Left arm Electric shock
Left foot Emotional Stress
Leg Exposure
Lower arm Fatal
Mental/emotional Foreign body in wound
Neck Foreign object Invasion
Nose Facture
Right arm Fracture/sprain
Right foot Hernia
Shoulder Illness
Skull Injury to internal organ
Throat Internal ache/pain
Thumb Jostling
Toe/nail Multiple injuries
Upper arm Muscle Strain
Whole body Pass-out
Finger Poisoning
Forehead Reaction to Chemical
Others (please specify) Skin Irritation
Smash/Trauma
Soft Tissue Injury
Sprain
Stress
Superficial Injury
Swelling
Traumatic Amputation
Twist/Bend
Unknown
Good
NA
Poor
Satisfactory
Very good
Very Poor
Man
Woman
divorced
domestic partner
living together
married
registered partners
separated
single
unknown
widowed
Contractor
Customer
Government Authorities
Others(Please Specify)
Over the road/external driver
Port employee
Shipping Line/Vessel crew
Vendor
Multiple fatalities
single fatality
LTI
Days away from work
Restricted work
Medical treatment only
first aid only
incident only
yes
no
Other type of fire
Electrical fire
Fire in solid materials
Fluid fire
Hydrocarbon fire
Metal Fire
others(Please Specify)
Auto Sprinkler dry pipe
Auto Sprinkler-wet pipe
Dry Chemicals
Fire water monitors
Fire Truck
Foam system
Halon Release
Hand extinguisher
Overpressure/ventilation fans
Permanent CO2 system
Shutdown
Smoke and Fire doors
Water
Water mist
Water spray-AFFF
water wall
Others(Please Specify)
3rd party
Terminal
-EUR
-Inland Services
Addicks & Kreye - Bremerhaven
APMT Romania - Constantza
Dania Trucking - Aarhus
Maersk Denizcilik- Kemalpasa - Izmir
Neuss Intermodal Terminal - Neuss
Pentalver Cannock - Cannock Rumer Hill
Pentalver Transport - Southampton109 Site
Pentalver Transport - Felixstowe Blofield Road
Pentalver Transport - Felixstowe Nicholas Road
Pentalver Transport - Ipswich West Bank Terminal
Pentalver Transport - Southampton Dock Gate 10
Pentalver Transport - Southampton Dock Gate 20
Pentalver Transport - Southampton Rail Terminal Multiple fatalties
Pentalver Transport -Tilbury 34 Berth single fatality
REMESA - Algeciras LTI
Star Container - Algeciras Days away from work
Star Container - Bremerhaven Restricted Work
Star Container -Fos sur Mer Medical Treatment only
Star Container - Hamburg First aid only
Star Container - Le Havre
Star Container services - Antwerp
Star Container Services - Maasvlakte
Star Container Services - Rotterdam
Star Container Services - Zeebrugge
Star Container - Tunis-Rades
Star Transportation - Bremerhaven
Star Transportation - Hamburg
-Terminals
Aarhus
Algeciras
Bremerhaven
Dunkirk
Port Said
Regional Office(EUR)
Rotterdam
Tangier
Zeebrugge
ADM/MGT
COM/MKTG
ENG/TECH
FIN
HR
HSE
IT
OPS
SECURITY