Confirmation of alert/notification to Petroleum Safety Authority Norway about situation of hazard and accident E-mail: varsling@ptil.no The incident Operator/the responsible: Reporting person: GPS position occurred: Field: Name: (by acute Date: Installation/onshore facility: Telephone: pollution): Time: E-mail: Confirmation of alert according to Management a) death Regulation, b) serious and acute injury Sct. 29, 1st paragraph c) acute life-threatening illness situations that have led to: d) serious impairment or discontinuance of Sct. 29, 1st paragraph safety functions or other barriers, so that situations that under slightly altered the integrity of the offshore or onshore facility is circumstances could have led to: threatened e) acute pollution Notification according to Management b) injury Regulation, c) illness Sct. 29, 3st paragraph d) impairment or discontinuance of safety situations as mentioned in the first functions or other barriers, so that the subsection, litera b through e, but of a integrity of the offshore or onshore facility is less serious or less acute nature threatened e) acute pollution Description of incident/near-miss: Supplementary information: 1.Non-ignited HC leak (sea/air) 9. Leak from 17. Acute pollution not HC – 2. Ignited HC leak 18. Diving Incident 3. Well incident 10. Damage to 19. H2S emission 4. Fire/explosion in areas, 20. Crane and lifting not HC 11. Evacuation operations 5. Ship on collision course (Precautionary/emergency 21. Falling objects 6. Drifting object evacuation/ down manning) 22. Other incidents 7. Collision, field related 12. Helicopter incidents (Terror/threat/criminal vessel/facility/tanker 13. Man over board acts/radioactive source etc.) 8. Damage to installation/ 14. Personnel injury structure/anchoring/DP 15. Illness 16. Power failure Contractor: Company: Drilling contractor Catering contractor Sub sea contractor Well service Helicopter company Painting/insulation/ scaffolding Production contractor M&M contractor Other Diving contractor Rig owner Additional information: Emergency preparedness organization Area closed and activated: Y N evidence secured Y N Personnel mustered: Y N Production/activity NOFO mobilized Y N shut-down Y N Other measures taken: Number of injured or fatalities: Other institutions notified: Joint Rescue Coastal Administration Radiation Protection Civil Aviation Authority Coordination Centres Fire brigade Authority Others Police
Confirmation of alert/notification to Petroleum Safety Authority Norway about situation of hazard and accident E-mail: varsling@ptil.no The incident occurred: Date: Time: Operator/the responsible: Field: Installation/onshore facility: Reporting person: Name: Telephone: E-mail: GPS position (by acute pollution): Confirmation of alert according to Management Regulation, Sct. 29, 1st paragraph situations that have led to: Sct. 29, 1st paragraph situations that under slightly altered circumstances could have led to: a) death b) serious and acute injury c) acute life-threatening illness d) serious impairment or discontinuance of safety functions or other barriers, so that the integrity of the offshore or onshore facility is threatened e) acute pollution Notification according to Management Regulation, Sct. 29, 3st paragraph situations as mentioned in the first subsection, litera b through e, but of a less serious or less acute nature b) injury c) illness d) impairment or discontinuance of safety functions or other barriers, so that the integrity of the offshore or onshore facility is threatened e) acute pollution Description of incident/near-miss: Supplementary information: 1.Non-ignited HC leak (sea/air) 2. Ignited HC leak 3. Well incident 4. Fire/explosion in areas, not HC 5. Ship on collision course 6. Drifting object 7. Collision, field related vessel/facility/tanker 8. Damage to installation/ structure/anchoring/DP 9. Leak from 10. Damage to 11. Evacuation (Precautionary/emergency evacuation/ down manning) 12. Helicopter incidents 13. Man over board 14. Personnel injury 15. Illness 16. Power failure 17. Acute pollution – not HC 18. Diving Incident 19. H2S emission 20. Crane and lifting operations 21. Falling objects 22. Other incidents (Terror/threat/criminal acts/radioactive source etc.) Contractor: Company: Drilling contractor Well service Production contractor Diving contractor Catering contractor Helicopter company M&M contractor Rig owner Sub sea contractor Painting/insulation/ scaffolding Other Additional information: Emergency preparedness organization activated: Y N Personnel mustered: Y N Production/activity shut-down Y N Number of injured or fatalities: Area closed and evidence secured Y N NOFO mobilized Y N Other measures taken: Other institutions notified: Joint Rescue Coordination Centres Police Coastal Administration Fire brigade Radiation Protection Authority Civil Aviation Authority Others
Varslingsskjema%20-%20engelsk%20-%20REVISJON%20Juli%202014.docx