©) p-p.ats Able age ILL a AMLARK ENERGY RESOURCES LLC Near-Miss/ Potential Incident Report ‘Anear-miss is a potential hazard or incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. Near misses also may be referred to as close calls, near accidents, or injury-free events. For the sake of a safe work environment, the company asksthat all employees report and correct any of these potential hazards immediately. Please use this form to report near-misses and assist us in preventing future incidents andmaking the Company a safer workplace Department: Location: Dye oi J -SOUF Date and Time of incident: $5 /j2/2 02) Witnesses (Optional): Tet even ‘Type of Near-Miss: Type of Concern: ONear-Miss Unsafe Act 1D Safety Concern 1D Unsafe Condition of Area D Safety Idea/Suggestion 1D Unsafe Condition of Equipment 1 other- Describe: DD Unsafe use of equipment 1 Safety Policy Violation 1D other- Describe: Describe the potential incident/hazard/concern and possible outcome (be. detailed): a Intwe pring atthe Siarrok Woyk, one oF the WorkKeys was worlliaa OY Wargls + Bet he was not Cote Fed and telKing wi Parcet Pays “arveuridws Which Led to his Ley Sipping . BecactS> he Wes wee! Atal] SaSety harness, he vas quickly fescued wierd Mjuries iS Were safety procedures violated? (describe): Yes. We wes not cateted when Welle a+ Wighs Incident site inspection — Why was an unsafe act committed, or why was the unsafe condition present? ecaise wwe Worier Piet 85 wor Carefat cbt Poca how to be in Safe way. Recommendations/steps to take to prevent a similar incident: Shed wear PPE eomey every time Name: [econ Date Reported: | 5 /}2/ 2021 signe: Mg ! Reported to: {7 ammo 2 pate: | o'/12/ 2021 Signature: