® pep-ats ALL alga 2H ol RMLARK ENERGY RESOURCES ULE Near-Miss/ Potential Incident Report ‘near-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: Al— DOV Date and Time of Incident: Obl) [Zor Witnesses (Optional): Adorn Crew Type of Near-Miss: Type of Concern: (8 Near-Miss D Unsafe Act 1D Safety Concern 1D Unsafe Condition of Area 1D Safety idea/Suggestion 1 Unsafe Condition of Equipment 1 other- Describe: Unsafe use of equipment 1D safety Policy Viol Dare. Describe: Describe the potential incident/hazard/concern and possi oes ‘outcome ee scales) oy W Rev yn pe Nn Al- Dovey Pera cae are (he neok ow “ici ot th ves bes was broken eNeM bhrought the puck tived weve Were = oe violated? (describe): No because the birs of Vehicle were new Incident site inspection - Why was an unsafe act committed, or why was the unsafe condition present? becense the Nob weother ond Frichion the bres in Yood the pres bYoken Recommendations/steps to take to prevent a similar incident: Yor hives Showd moke inspection of eee omerepones: O€ /0) /2.022- Os UBC OMEY oe cada fale Signature: