FORM B
RISK BASED ASSESSMENT OF OIL SPILL INCIDENCE
Note: This report must be submitted within 2 weeks of Spill Incidence
Company Name
*
Date of Assessment
*
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Month
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Day
Year
Date
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Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date of Incidence
*
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Month
-
Day
Year
Date
1
2
3
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5
6
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9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date spill was stopped
*
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Month
-
Day
Year
Date
1
2
3
4
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11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Method Used
*
Clamping
Well Shut‐in
Valve Shut‐in
F/Station Shut down
Other
Estimated quantity spilled
*
Estimated quantity recovered
*
Cause of Spill
*
Corrosion
Equipment Failure
Third Party Interference
Accident
Operational Error
Other
Site Details
Site Name
*
OML
*
GPS FIELD POINTS
*
Total Length in meters
Length Surveyed in meters
Differential GPS
*
Yes
No
Spill Start Point GPS
*
Total Length in meters
Length Surveyed in meters
Spill End Point GPS
*
Total Length in meters
Length Surveyed in meters
Site area
*
Land Swamp
Freshwater
Mangrove
Coastline
Near Shore
Offshore
Other
Facility
*
Pipeline
Flow line
Wellhead
Manifold
Flow Station
Rig
Storage Tank
Compressor Plant
Other
Site Characterization (Sea Conditions)
*
Calm
Rough
Not Applicable
Low Tide
High Tide
Current direction
*
Swell Height
*
Current Strength
*
Site Characterization (Weather Conditions)
*
Bright Sunny
Party Cloudy
Slight rain
Other
Temperature
*
Wind Direction
*
Wind Speed
*
Relative Humidity
*
Visual Observation of Impacted area
Any oil sheen on water
*
Yes
No
N/A
Receptor Assessment
Rows
Pathway to
Impacted
Area(m2)
Distance to
Impacted
Area(m2)
Estimated
Area of Impact
Area(m2)
Receptor Impacted
(Yes/No)
Remarks
Farmland
Fish Pond
Vegetation
Surface Water
Ground Water
Venerable Object
Human Habitation
Livestock
Plantation
Swamp
Any Casualties
Yes
No
If Yes, give details below.
Give details for casualties
Method of clean‐up
*
Time frame for clean‐up
*
General Remarks
Reporting officer
*
Officer's name is accepted as Signature.
Designation
*
Date
*
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Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Clean‐up program report must be submitted within 2 weeks of spill incidence.
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Please verify that you are human
*
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