NEAR MISS INCIDENT REPORT

IPP-FORM-EHS-SFT-04-00

(A close call, near miss, near hit, or dangerous occurrence is a type of incident. It is a work-related event
during which injury, ill health, or fatality could have occurred, but didn’t actually occur)

1 Date : 23.11.2018 2 Shift : B 3 Time : 18:00 hr

4 Place of incident : AHP, HCSD Ph-I, De-Watering Bin-1

5 Incident related to :
Man Machine Material Fire

6 Name of person / persons who notices in the incident :

Name : Mr. Alin Kumar Nayak Mob .No.: 7628259065 Design.: Sr. Engg., EMD

7 Name of person / persons who involved in the incident :

Name : Paneswar Jaypuriya Mob .No.: Design.: Operator

8 Nature of incident in detail : (With detail of damage)

During running condition, the bin vibrator-2 of dewatering bin-1 fell down from its position and dropped on platform between the
two conveyor after hited to the guarding of conveyor. Due to which little damage occurred to the guarding & the platform got
bend.

9 Immediate Action Taken

Immidiatly informed to concern HOD & informed to mechanical department to check the base arrengment for bin
vibrator fixing for all de-watering bin .

10 Suggested remedial measure to avoid reoccurrence (To be filled by Shift in Charge or Immediate supervisor)

Shift in Charge / Immediate supervisor

Name : Status:

Signature :

Reporting Department:

N.B. (Duly filled format may please may be dropped in near miss boxes or sent to Safety Deptt. By hand/through mail with in 24 hrs)