SAB - Incident Report 024-06-13

SALEH AYED BALHARITH EST.
General Contracting & Rig Movers ‫ﻟﻠﻣﻘﺎوﻻت اﻟﻌﺎﻣﺔ و ﻟﻧﻘل ﻣﻌدات اﻟﺣﻔر‬
C.R. 2051018071 ‫ت‬.‫س‬
Incident Report
Incident Number: PDC002-06-25
Division or Country:
WORKSHOP Rig or Facility: SAIPEM or STACK YARD 1
Incident type: PDC- Property Damage Case
Severity: ✔ Minor Serious Major Catastrophic
General Information
SECTION-A
Date of Incident: 13-Jun-2021 Date Incident Reported: 20-May-2021

Time of incident : 10:00AM Weather Conditions:
Time of Report Sent: Rig/Facility operation at time of incident
Equipment involved: CARANE CR 038 (80 TON)
Incident description:
Rig move 14 stock yard saipem, at 7:20 the crane was travelling to another side. With sling and shackle attached.while
moving the crane operator did not notice that some place have a small ditch cover by dust, the Crane starting to
unbalance and the sling started to swing that cause one side of sling eye full out from the hook, and fall into the wind
shield of crane. and the 2 small cable using for boom extension was cut.‌
IFO (First Aid, MTO, RWC, LTI, Fatality) ✔ No Yes

SECTION-B
Illness
First Aid Restricted Work Case Medical Treatment Only Lost Time Incident Fatality
Personal Occupational
Affected individual SAB Employee SAB Supervised Contractor Other
Rotation information 7/7 14/7 14/14 21/21 28/28 35/35 Other:
Day of rotation incident occurred:

Describe illness or injury:
Describe treatment provided on site:

On site treatment provider’s Name/Title:
Describe treatment provided off site:
Name and location of off site treatment facility:
DRUG / ALCOHOL VIOLATION
SECTION-C
Where was test conducted?

Organization/entity who conducted test?
Drug violation? ✔ No Yes Alcohol violation? ✔ No Yes
Type of drug: Alcohol level percentage:
Reason for drug/alcohol test Pre-access Random For cause Post incident
Date Report Sent: 13-Jun-2020 Page 1 of 3
P.O. Box 74590 - Al-Khobar 31952, Kingdom of Saudi Arabia, Head Office Tel.: +966 13 899 1005, Fax : +966 13 894 2311
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‫ﻓﺎﻛس‬ 
: ‫اﻟﻣﻣــــﻠـــﻛــﺔ اﻟﻌـــــرﺑـــﯾــــﺔ اﻟﺳـﻌــــودﯾــــﺔ اﻟﻣﻛﺗب اﻟرﺋﯾﺳﻲ ھﺎﺗف‬ ، ‫ اﻟﺧــﺑــر‬- ‫ب‬.‫ص‬
info@sabalharith.com - rigmove@sabalharith.com w w w . s a b a l h a r i t h . c o m
C.R. 2051018071 ‫ت‬.‫س‬
Document Name: Incident Report Form Incident Number: PDC002-06-25

SPILL / RELEASE
5 Liters or more No Yes
SECTION-D
Type of material spilled/released: Material Safety Data Sheet (MSDS) attached? Yes No
Spill/release quantity: Duration of spill/release:
Location of spill/release:
Media impacted Air Ground Water Plants Animals
Contained? No Yes Describe containment:
Lined containment? No Yes Describe liner material:
Recovered? No Yes Describe how recovered:

Quantity recovered:
Method of clean up (check all that apply)

Absorbent pads Portable vacuum system
S E C TION -E
Bagged for disposal Contaminated soil removed
Drummed for disposal Washed down
Spot Cleanup Other:

Method of disposal (check all that apply)
Reused How reused?
Water treatment Where treated?
Waste disposal Where disposed?
Other
FIRE/EXPLOSION
Check all that apply Smoke only Fire Explosion
Environmental damage? No Yes If `Yes', complete Section D of form

Property damage? No Yes If `Yes', complete Section F of form
Material combusted
SEC TI O N- F
Material Safety Data Sheet (MSDS) attached? Yes No
Describe damage extent
Extinguishing system
Fire extinguisher (specify type)
On site fire brigade
3rd party fire department
Other
PROPERTY DAMAGE
IFO ( > $10,000 USD) ✔ No Yes
Estimated damage amount (USD) 400 $(1200 sar)

SECTI ON- G
Motor vehicle incident Yes No

List equipment/facilities affected
Additional details sensor wire repaired at no cost


‫ﻓﺎﻛس‬ 
C.R. 2051018071 ‫ت‬.‫س‬
Document Name: Incident Report Form Incident Number: PDC002-06-25
NEAR MISS/HAZARD ID
Potential to cause (check all that apply)
SECTION-H
Damage to property? No ✔ Yes
Damage to the environment? No ✔ Yes
Harm to people? No ✔ Yes
HIPO NEAR MISS

Potential to cause (check all that apply)
S E C TI O N - I
Loss of life? ✔ No Yes
Serious injury to three or more people? No Yes
Property damage in excess of $100K USD? No Yes
Environmental damage in excess of $100K USD? No Yes

SECURITY
Theft No Yes
Estimate amount/value of stolen item (s) (USD)
Provide detailed list of item(s) stolen
SECTION-J
Report filed with authorities? No Yes
Agency name Case number
Agency contact Name/Title
Other security incident Description of security incident

Additional information
INCIDENT ANALYSIS
Immediate cause(s)
Hold Imediate Safety Meeting to intruct all crews that : Having set the load down correctly, the empty sling legs should be manually withdrawn by the slinger and hooked back on to the crane hook.
Initial Recommendation(s)
SECTION-K
Paste warning stickers on all cranes to ensure this does not repeat ,punitive mesures
Additional investigation required? ✔ No Yes If ‘Yes’, complete ES.FOR.004 Investigation Report
PIC signature/date Muaz Mubeen
BU/QHSE Manager signature/date Amri Mohammed

BU Country Manager signature/date
SUBMIT INCIDENT REPORT WITHIN 24 HOURS OF INCIDENT OCCURRENCE.
CONFIDENTIAL – SAB USE ONLY
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‫ﻓﺎﻛس‬ 

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SALEH AYED BALHARITH EST.

Incident type: PDC- Property Damage Case

Severity: ✔ Minor Serious Major Catastrophic

Date of Incident: 13-Jun-2021 Date Incident Reported: 20-May-2021

Time of Report Sent: Rig/Facility operation at time of incident

Equipment involved: CARANE CR 038 (80 TON)

IFO (First Aid, MTO, RWC, LTI, Fatality) ✔ No Yes

Aﬀected individual SAB Employee SAB Supervised Contractor Other

Rotation information 7/7 14/7 14/14 21/21 28/28 35/35 Other:

Day of rotation incident occurred:

Describe treatment provided on site:

Where was test conducted?

Date Report Sent: 13-Jun-2020 Page 1 of 3

Document Name: Incident Report Form Incident Number: PDC002-06-25

Spill/release quantity: Duration of spill/release:

Contained? No Yes Describe containment:

Lined containment? No Yes Describe liner material:

Recovered? No Yes Describe how recovered:

Method of clean up (check all that apply)

Bagged for disposal Contaminated soil removed

Drummed for disposal Washed down

Spot Cleanup Other:

Reused How reused?

Water treatment Where treated?

Waste disposal Where disposed?

Environmental damage? No Yes If `Yes', complete Section D of form

Material Safety Data Sheet (MSDS) attached? Yes No

Describe damage extent

Estimated damage amount (USD) 400 $(1200 sar)

Motor vehicle incident Yes No

Additional details sensor wire repaired at no cost

Date Report Sent: 13-Jun-2020 Page 2 of 3

Document Name: Incident Report Form Incident Number: PDC002-06-25

Damage to property? No ✔ Yes

Damage to the environment? No ✔ Yes

Harm to people? No ✔ Yes

HIPO NEAR MISS

Loss of life? ✔ No Yes

Serious injury to three or more people? No Yes

Property damage in excess of $100K USD? No Yes

Environmental damage in excess of $100K USD? No Yes

Report ﬁled with authorities? No Yes

Agency name Case number

Agency contact Name/Title

Other security incident Description of security incident

PIC signature/date Muaz Mubeen

BU/QHSE Manager signature/date Amri Mohammed

SUBMIT INCIDENT REPORT WITHIN 24 HOURS OF INCIDENT OCCURRENCE.

CONFIDENTIAL – SAB USE ONLY

Date Report Sent: 13-Jun-2020 Page 3 of 3

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