HSE OMS OILFIELD SERVICES

BUSINESS UNIT: OMS LOCATION: Saudi Arabia

INITIAL ACCIDENT - INCIDENT VERSION: 0 EFFECTIVE DATE: 23/9/2011
NOTIFICATION REPORT DOCUMENT REF # SHE-AIRI-F004
PAGE 1 OF 2
REV.2

COMPLETE & FORWARD WITHIN 24 HOURS TO PEOPLE LISTED IN SECTION 4

Facility/Location: OMS Saudi / BTC Machine shop opposite. Date & Time of Incident 13-Mar-2014 / 6:15pm

PERSON(S) INJURED AND/OR WORK RELATED ILLNESS WHICH REQUIRES PROFESSIONAL MEDICAL ATTENTION (Doctor, Nurse,
Paramedic)? YES NO
(IF YES GO TO SECTION 1 IF NO GO TO SECTION 2)

SECTION 1 --- FOR FATALITY, INURY(S) AND/OR WORK RELATED ILLNESS WHICH REQUIRE PROFESSIONAL MEDICAL ATTENTION
1. FATALITY PERSON(S) INJURED WORK RELATED ILLNESS NUMBER OF PEOPLE INJURED/ILL : _____________
2. CLASSIFICATION OF INJURED: EMPLOYEE CONTRACTOR THIRD PARTY OTHERS _____________
3. MEDICAL TREATMENT ADMINISTERED: ONSITE LOCAL CLINIC EMERGENCY ROOM HOSPITAL OTHER ________
4. DID THE INJURED RETURN/ CONTINUE TO WORK ON THE DAY OF THE INJURY? YES NO
5. IF (4) IS NO, DID THE INJURED RETURN TO WORK THE NEXT DAY? YES NO UNKOWN AT THIS TIME
6. IF (5) IS YES, WAS THE INJURED ABLE TO PERFORM THEIR FULL JOB FUNCTION? YES NO
7. IF (5) IS NO, THEN INDICATE ESTIMATED NUMBER OF DAYS INJURED WILL BE AWAY FROM WORK ____________
8. INDICATE INIITAL CLASSIFICATION: LOST TIME , RESTRICTED WORK , MEDICAL TREATMENT UNKOWN AT THIS TIME
NATURE AND EXTENT OF INJURY(S) + SUMMARY OF MEDICAL TREATMENT(S)

PEOPLE INJURED AGE: YEARS/MONTHS OF SERVICE (CURRENT EMPLOYER):

SECTION 2

OTHER INCIDENTS, NEAR MISSES, & UNDESIRED EVENTS & ADDITIONAL INFORMATION REGARDING INJURY ILLNESS
ENVIRONMENTAL INCIDENT: SEVERITY: REGULATORY CITATION REGULATORY NOTIFIABLE EVENT
PERONNEL SECURITY THREAT BURGALRY / ROBBERY FIRE MEDIA COVERAGE OF CUSTOMER
MAJOR & SERIOUS NEAR MISSES = EVENTS WHICH POTENTIALLY COULD HAVE CAUSED: FATALITY SERIOUS INJURY
VEHICLE INVOLVED IN THE INCIDENT PROPERTY DAMAGE ESTIMATED > US $ 50,000

SECTION 3
SUMMARY DESCRIPTION OF INCIDENT (WHO, WHAT, HOW, WHEN, WHY):

WHO- MOHAMD SAFDAR / RBT Third party delivery pipe contractor driver / Plate No 5299
WHAT-Pipe unloading to OMSA yard from Dammam Saudi Arabia.
HOW-The truck back hit the connectors stock and fell height 1.5meter from ground.
WHEN-13th March 2014 evening.
WHY-Driver did not manipulate proper the trucks while moving backward.

Witnessed By: Murugan Anantham, M/S Asst SPV

IMMEDIATE ACTION TAKEN: Photos , Interviews & Statements, Legal & Customer Notifications (when required)
Summary Description of Action

PREPARED BY:Marlo Gagarao TITLE: QAQC Asst SPV DATE: 13th March 2014

Form No. SHE-AIRI-F004 Rev.2

 HSE OMS OILFIELD SERVICES
BUSINESS UNIT: OMS LOCATION: Saudi Arabia
INITIAL ACCIDENT - INCIDENT VERSION: 0 EFFECTIVE DATE: 23/9/2011
NOTIFICATION REPORT DOCUMENT REF # SHE-AIRI-F004
PAGE 2 OF 2
REV.2

COMPLETE & FORWARD WITHIN 24 HOURS TO PEOPLE LISTED IN SECTION 4

SECTION 3 - SEND TO ADDRESSEES BELOW WITHIN 7 DAYS OF THE INCIDENT
DEPT CONTACT # EMAIL

SCAS/OMS
SCTPD TOKYO +65 9828 4144 (Michael Pomfret) oms.incident@sumitomocorp.co.jp

DEPT TITLE NAME CONTACT # EMAIL

PRESIDENT & CEO How Meng Hock + 65 9824 4109 menghock.how@omsos.com
SR. GENERAL MANAGER
GROUP OPERATIONS
Lokman Omar + 65 8125 7897 lokman.omar@omsos.com
OMS SGP
GENERAL MANAGER
OPERATIONS
Tham Cheong On + 65 9437 7950 co.tham@omsos.com
HUMAN RESOURCES & ADMIN
MANAGER
Caleb Lee + 65 9770 8414 caleb.lee@omsos.com
QHSE ENGINEER Teo Churn Hong + 65 6415 6836 churnhong.teo@omsos.com

Form No. SHE-AIRI-F004 Rev.2