Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-7051

2. Registrant Information.

Registrant Reference Number: MRR-0215

Registrant Name (Full Legal Name no abbreviations): Baker Hughes Canada Company

Address: Gulf Canada Square, 1000-401 9th Ave. SW

City: Calgary

Prov / State: Alberta

Country: Canada

Postal Code: T2P 3C5

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

26-JAN-15

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

26-JAN-15

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No. 27928      PMRA Submission No.       EPA Registration No. 10707-10

Product Name: MAGNACIDE B MICROBIOCIDE

• Active Ingredient(s)
  • ACROLEIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Industrial / Industriel

Préciser le type: Well site

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Watery eye

• General
  • Symptom - Lightheadedness
  • Specify - Employee began to feel light-headed.

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Eye

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

An employee at a job site was allegedly exposed to the product vapor. He began to feel light-headed and his eyes began to water. He was immediately moved into fresh air and taken to the emergency shower where his eyes were flushed for 15 minutes. He was monitored for an additinal 10 minutes, prior to being taken to the local hospital. He was examined by the doctor, with his vital signs and x-rays being taken, as well as given oxyen. After examination, the doctor released him with conditions: 1) Stay in hotel close to the hospital for 24 hours; 2) Be monitored by coworker/roommate for the full 24 hours before returning to base; and 3) If his condition changed, transport back to hospital.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.