Part 1A – Information required within 3 days of an accident, dangerous occurrence or environmental incident General information – all incidents Where did the incident occur? Facility / field / title name Site name and location Latitude/longitude Who is the registered operator/titleholder or other person that controls the works site or activity? Name Business address Business phone no. When did the incident occur? Time and time zone Date Did anyone witness the incident? Yes or no If yes, provide details below Witness details Witness no 1 Witness no 2 Witness no 3 Full name Phone no. (Business hours) no. (Home) (Mobile) Email (Business) (Private) Postal address NB: If more witnesses, copy and insert this section (4) here , and add extra witness numbers appropriately Details of person submitting this information Name Position Email Telephone no. Brief description of incident Work or activity being undertaken at time of incident 8. What are the internal investigation arrangements? 9. Yes or no If Yes, provide details below
Was any loss of containment of any fluid (liquid or gas)? Type of fluid (liquid or gas) If hydrocarbon release please complete item no.15 as well Hydrocarbon Please specify_________________________ Non-hydrocarbon Please specify_________________________ Estimated quantity Liquid (L), Gas (kg) Estimation details Calculation Measurement Please specify______________________________ Composition Percentage and description toxicity to people and/or environment Toxicity to people Toxicity to environment How was the leak/spill detected? F&G detection CCTV Visual Other Did ignition occur? No Yes Immediate Delayed If yes, what was the likely ignition source Hotwork Spark electrical source Spark metallic contact Hot surface Other 10. Has the release been stopped and/or contained? Yes or no Duration of the release hh:mm:ss Estimated rate of release Litres or kg per hour 11. Location of release What or where is the location of the release? What equipment was involved in the release? Is this functional location listed as safety-critical equipment? 12. Weather conditions Please complete as appropriate Ambient temperature C° Relative humidity %
23. What is the current environment plan for this incident? Environment plan 24. Has the incident resulted in an impact to the environment? Yes or no If yes provide details below Incident details e.g. estimated area of impact, nature/significance of impact ENVIRONMENTAL RECEPTORS Open Shoreline Population centre Stakeholders Other sensitivity e.g. conservation area, nesting beach Macroalgae Coral Reef Benthic invertebrates Seagrass Mangrove Further details Details Environment 1 Environment 2 Environment 3 Location of receiving environments Lat/Long Date & time of impact Action taken to minimise exposure Specify each matter protected under Part 3 of the EPBC Act impacted NB: If more environments were damaged, please copy/paste this section (Item E3) and add extra data 25. Are any environments at risk? Including as a result of spill response measures Yes or no If yes, provide details Details e.g. zone of potential impact AT RISK ENVIRONMENTS Open ocean Shoreline Population Centre Stakeholders sensitivity e.g. conservation area, nesting beach Macroalgae Coral Reef Benthic Invertebrates Seagrass Mangrove Details Environment 1 Environment 2 Environment 3 Estimated location of environments Estimated impact date & time Action required to minimise exposure Specify each matter protected Part 3 of the EPBC Act at risk NB: If more environments at risk of damage, please this section (Item E2) and add extra data
26. Was an oil pollution emergency plan activated? Yes or no If yes, what action has been implemented /planned? If yes, how effective is/was the spill response? 27. Was an environmental monitoring program initiated? Yes or no If yes, what actions have been implemented and/or planned? 28. Did the incident result in the or injury of any fauna? Yes or no (If yes provide details of species in the table below) Injured Species 1 Species 2 Species 3 Species name (common or scientific name) Number of individuals killed or injured Killed: Injured: Killed: Injured: Killed: Injured: NB: If more species were injured or killed, please copy/paste this section (Item E4) and add extra data 29. Actions taken to avoid or mitigate any adverse environmental impacts of the incident. Action Responsible party Completion date Actual or intended NB: If more actions, please add extra rows as required 30. Corrective actions taken, or proposed, to stop, control or remedy the incident. Action Responsible party Completion date Actual or intended NB: If more actions, please add extra rows as required 31. Actions taken, or proposed, to prevent a similar incident occurring in the future. Action Responsible Completion date Actual or intended NB: If more actions, please add extra rows as required