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GI 6.

004, Supplement 1- Near Miss Report Form


INCIDENT DETAILS
Date: 12 May 2011 Time: 0830 Location/Plant/Equipment: Site !""i#e
Dept: Construction Org. Code: Division/Unit: NES! / S" E#C
Near iss Description $E%plain &'at 'appened ( use attac'ment i) needed*
$ In %ri&er
ESTIMATE OF LOSS POTENTIAL (What injuries or losses might have ourre!"#
+n,uries:
Serious '(ysi#al In)ury
Propert-/Equipment Damaged:
Ma)or 'roperty *ama+e
Environmental Damage: N$
Ot'er: N,$
Anal$sis (Wh$ !i! it ha%%en (List unsa&e ats' unsa&e on!itions' (rong %roe!ures)e*ui%ment or
other &ators"#
-(e roa% is t.o .ay &e(i#ular tra""i#.
No spott &e(i#ular tra""i#.
-(e a##ess.
CO++ECTI,E ACTION ( What must -e !one to %revent reurrene . list reommen!ations#
/i%en an% repair t(e a# #omplian#e.
Ne&er start any ) i" ne#essary to #omply.
'ro&i%e re"le#to !""i#er.
!rientation to 0 near miss.
+E,IEWE+ INFO+MATION
Re&ie.e% 1y Sup&r. or (i+(er 2 Name,-itle,1a%+e34
$15
S$'M- Sa"ety $%&isor

12 May, 2010