PLEASE PRINT OR TYPE L9.

12 (08/2014)

PROJECT MANAGEMENT
CONTRACTOR NEAR-MISS AT WORKSITE REPORT

Department:* OMMPD Division:* GGUPD Div. SAP Orgcode:* 30021001

Observer's Name:* JASPAL SINGH Badge Number:* 2462634282

Contractor Company Name:* ABAJA CONTRACTING ESTABLISHMENT BI Number:* 11-21000-1786-701

BI Number Format: XX-YYYYY-ZZZZ Ex. BI-10-00019-0004

Incident Date:* 03/31/2022 Incident Time:* 08:30 Persons:

PPE: Material: Stacked unsafely/excessive/not protected (choose X

if applicable)
PTW (Permit to Work): Work Procedure:

Elevated Areas: Electrical:

Heavy Equipment: Hot Work/ Welding & Cutting:

Tool: Trenching & Excavation:

Vehicle: Barricade: Confined Space entry:

Ground Level: Environmental & Health Issue:

Note: - Fields with asterisk (*) are mandatory fields and must be filled out.

Observation Area: ABAJA YARD -07 , KHRS ROAD

Describe What While separating the trailer bed from trailer head driver settled down the trailer bed on jacks and then move
Happened? the trailer head forward but due to the failure of "Fifth wheel hitch lock" the trailer bed also slide a little with
trailer head. No injury and property damage happened.

Analysis - Why did It happens due to the poor maintenance of "Fifth wheel hitch lock". The driver informed the maintenance in-
it happen? charge about the malfunctioning of "Fifth wheel hitch lock" but it happened because it did not get rectified on
time due to non-availability of spare parts. Lack of concentration.

Immediate Action Instructed maintenance in-charge to rectify the malfunctioning of "Fifth wheel hitch lock" immediately.
Taken:

Recommended Organise a safety meeting and give proper information regarding the proper way of detaching trailer head
from trailer bed. Ensure proper maintenance of every equipment before every use. Revised truck safety
Future Corrective checklist which incude the condition of "Fifth wheel hitch lock".
Action:

Confirmation of Corrective Action Implementation: On the Next site

✘ Others
spot visit
Other Issues Not
Covered By The Card
(Please Specify)

Positive The worker was worn complete PPEs while doing the work.
Observation
(Please Specify)

Reviewed By (Supervisor Name): Sanal Thomas

USERID:

Company: Abaja Contracting Est.

Date: 04/02/2022 Time: 07:00

 CATEGORIES

FIRE & EXPLOSION

MOTOR VEHICLE ACCIDENT (MVA)
EQUIPMENT/MECHANICAL FAILURE
OTHER INCIDENT
NEAR MISS

SUBCATEGORIES
SubCategory

<<<<< FIRES >>>>>

A.C. UNIT
AIRCRAFT
BUILDINGS-LABORATORY
BUILDINGS-MAINTENANCE SHOP
BUILDINGS-OFFICE
BUILDINGS-WAREHOUSE
BUILDINGS-MEDICAL FACILITY
BUILDINGS-INDUSTRIAL (OTHER)
BUILDINGS-COMMUNITY
BURNING/CUTTING
CHEMICAL
COMPRESSOR
CONTROL ROOM EQUIPMENT
DRILLING RIG/EQUIPMENT
ELECTRICAL GENERATOR
ELECTRICAL MOTOR
ELECTRICAL POLE
ELECTRICAL SUBSTATION
ELECTRICAL SWITCH GEAR/RACK
ELECTRICAL TRANSFORMER
ELECTRICAL-OTHER
ESCAPE CAPSULE
FIN-FAN UNIT
HEAT EXCHANGER
LIFT/ELEVATOR
LOADING ARM-SHIP/PLANT
MARINE VESSEL (BOAT, BARGE, ETC)
OFFICE EQUIPMENT
OFFSHORE PLATFORM
OIL WELL
PIER
PIPELINE RELATED
PLANT/REFINERY
POWER BOILER
POWER PLANT
PRESSURE VESSEL
PROCESS VESSEL
PUMP
PUMP STATION
RESIDENTIAL-BACHELOR
RESIDENTIAL-FAMILY
SEA ISLAND
SHELTER (BUS, SMOKING, ETC)
TANK/SPHERE
TOOLS-POWER/HAND HELD
TRASH/DUMP/SCRUB
TURBINE
VALVE (CONTROL, SAFETY, ETC)
VEHICLE/HEAVY EQUIPMENT (CRANE, BULLDOZER, ETC)
VEHICLE/LIGHT (SEDAN,PICKUP,ETC)
OTHERS
<<<<< MOTOR VEHICLE ACCIDENTS (MVAs >>>>>
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, REAR END SLOW OR STOP
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, REAR END TURN
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, LEFT TURN SAME ROADWAY
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, LEFT TURN CROSS TRAFFIC
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, RIGHT TURN SAME ROADWAY
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, RIGHT TURN CROSS TRAFFIC
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, HEAD ON
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, SIDESWIPE
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, ANGLE
COLLISION OF MOTOR VEHICLE WITH ANOTHER VEHICLE, BACKING
RAN OFF THE ROAD, RIGHT
RAN OFF THE ROAD, LEFT
RAN OFF THE ROAD, STRAIGHT AHEAD
NON-COLLISION, OVERTURN
NON-COLLISION, OTHER IN ROAD
COLLISION OF MOTOR VEHICLE WITH, PEDESTRIAN
COLLISION OF MOTOR VEHICLE WITH, PARKED VEHICLE
COLLISION OF MOTOR VEHICLE WITH, TRAIN
COLLISION OF MOTOR VEHICLE WITH, BICYCLE
COLLISION OF MOTOR VEHICLE WITH, ANIMAL
COLLISION OF MOTOR VEHICLE WITH, FIXED OBJECT
COLLISION OF MOTOR VEHICLE WITH, OTHER OBJECT
NO INFORMATION
<<<<< EQUIPMENT/MECHANICAL FAILURES >>>>>'
A.C. UNIT
AIRCRAFT
BOILER
COMPRESSOR
CYLINDER (GAS, CHLORINE, ETC)
DRILLING RIG/EQUIPMENT
ELECTRICAL GENERATOR
ELECTRICAL MOTOR
ELECTRICAL POLE
ELECTRICAL SUBSTATION
ELECTRICAL SWITCH GEAR/RACK/PANEL
ELECTRICAL TRANSFORMER
ELECTRICAL-OTHER
ESCAPE CAPSULE
FIN-FAN UNIT
FLARE
HEAT EXCHANGER
LIFT/ELEVATOR
LOADING ARM-SHIP/PLANT
MARINE VESSEL (BOAT, BARGE, ETC)
OFFICE EQUIPMENT
OFFSHORE PLATFORM
PIPELINE RELATED
PRESSURE VESSEL
PROCESS VESSEL
PUMP
SPM (SINGLE POINT MOORING)
TANK/SPHERE
TELEPHONE EQUIPMENT
TOOLS-POWER/HAND HELD
TRAY
TURBINE
VALVE (CONTROL, SAFETY, ETC)
VEHICLE/HEAVY EQUIPMENT (CRANE, BULLDOZER, ETC)
VEHICLE/LIGHT (SEDAN, PICKUP, ETC)
WELLHEAD EQUIPMENT
OTHERS
<<<<< OTHER INCIDENTS >>>>>
DEATH
PERSONAL INJURY (NOT CAUSED BY OTHER INCIDENT CATEGORIES)
ILLNESS (HEART ATTACK, ETC)
ANIMAL INCIDENTS
CABLE DAMAGE
OIL SPILL/POLLUTION
POWER CONTACT
POWER OUTAGE
RADIATION RELATED
STRUCTURAL COLLAPSE (NON-WEATHER RELATED)
WEATHER (RAIN, WIND, WAVE, ETC)
OPERATOR/OPERATIONAL ERROR
OTHER NOT ELSEWHERE CLASSIFIED
<<<<< NEAR MISS >>>>>
FIRE
EQUIPMENT/MECHANICAL FAILURE
AIRCRAFT
MARINE VESSEL-BOAT/BARGE/ETC
GAS/HYDROCARBON/TOXIC RELEASE
RADIATION RELATED
OIL SPILL/POLLUTION
EXPLOSIVES
WEATHER (RAIN, WIND, WAVE, ETC)
INJURY/ILLNESS
OTHER NOT ELSEWHERE CLASSIFIED

DEPARTMENT NAME

PM/Plng & Admin Staff/30003770

PM/Special Projects/30012188

K&TPD/Residential & Cmnty Fac Projects/30017654

K&TPD/CMORC & Incubator/30017655
K&TPD/KAUST IT & Security Sys Projects/30017858
K&TPD/KAUST Campus Projects/30017859
K&TPD/Thuwal Develop & Flood Control Projects/30019578
K&TPD/KAUST Research Park & Sec Fence Projects/30019601
K&TPD/Nat Guard Housing Projects/30024176
K&TPD/Project Controls & Support Div/30024177
K&TPD/KAUST & Thuwal Projects Dept Admin Staff/30019672

KAPS&RCPD/Site Dev & Utilities Project/30019853

KAPS&RCPD/Res Complex Project/30019854
KAPS&RCPD/Research&Office Complex Proj/30019855
KAPS&RCPD/Plng & Admin/30019852

KASCPD/Operations & Govt Affairs/30026601

KASCPD/Main Stadium Construction/30026602
KASCPD/Sports Hall, External Works & Support/30026603
KASCPD/Planning & Admin/30026604
KACFWCPD/Projects Interface & Support Div/30023683
KACFWCPD/Admin Staff/30023702
KACFWCPD/Building Façade & External Proj Div/30023703
KACFWCPD/Exhibits & Technology Projects Div/30023704
KACFWCPD/Building MEP & Finishing Proj Div/30028102

JSPD/Project Execution Metrics/30023954

JSPD/Project Execution Support/30024204
JSPD/Government & Public Relations/30025355
JSPD/Quality & HSE/30023951
JSPD/Construction/30023952
JSPD/Engineering/30023953

MACDMC/Engineering Consultancy/30025326
MACDMC/Project Management/30025327
MACDMC/Operations Services/30025329
MACDMC/Governance/30025328
MACDMC/Business Admin/30025330

ACEPD/Infrastructure Development Projects Div/30027064

ACEPD/Residential Development Projects Div/30027065
ACEPD/Commercial Development Projects Div/30027066
ACEPD/Project Controls Div/30027067
ACEPD/Business Staff/30027068

PSPM/Planning Staff/30026152

NAPD/RTR Clean Fuels & Aromatics Div (OSBL)/30003832

NAPD/NA Oil Facilities Projects Div/30003832
NAPD/Inter-Connection & 3rd Party Proj Div/30003832
NAPD/Business Mgmt/30020936
NAPD/ RTR Clean Fuels&Aromatics Div (ISBL)-N&A/30023712
NAPD/Project Controls Div/30026104
NAPD/RT Refinery & Terminal Projects Div/30027134
NAPD/Gas & NGL Projects Div/30027135
NAPD/RTR Clean Fuels&Aromatics Div (ISBL)-Pxy/30027136

MPD/Manifa Central Processing Facl Projs Div/30017430

MPD/Manifa Water Supply Div/30017431
MPD/Manifa Utilities Div/30017432
MPD/Manifa Off-Shore Projects Div/30017433
MPD/Manifa Causeway & Offshore Projects Div/30017434
MPD/Manifa Cogeneration Project Div/30018001
MPD/Manifa Infrastructure & Ind Fac Proj Div/30018428
MPD/Manifa Projects Business Mgmt/30019679

WPD/Gas Processing Fac Projects Div/30021427

WPD/SRU & Utilities Projects Div/30021428
WPD/Early Work & Prog Coord Projects Div/30021430
WPD/NGL Fractionation Project Div/30021436
WPD/Cogeneration & Steam Generation Div/30022701
WPD/Project Control & Support Div/30023601
WPD/Admin Staff/30021426

SNGLPD/Admin Staff/30021431
SNGLPD/NGL Recovery & Utilities Div/30021432
SNGLPD/Increase Gas Handling Div/30021433
SNGLPD/Early Works & Infrastructure Div/30021434
SNGLPD/Power Generation Div/30021435
SNGLPD/Gas Treat Division/30022729
SNGLPD/Proj Cnts & Precommissioning Support Div/30025576
SNGLPD/Crude Increment Div/30025577

OPD/Oil Maintain Potential Projects Div/30003827

OPD/Safaniya Offshore Projects Div/30003829
OPD/Arabiyah/Hasbah Offshore Fac Projs Div/30021429
OPD/Arabiyah/Hasbah P/Lines & Util Projs Div/30026860
OPD/Project Controls Div/30027107
OPD/Gas Maintain Potential Projects Div/30027108
OPD/ Marine Projects Div/30027109
OPD/Hook-up/Tie-in Support Div/30027110
OPD/Offshore Upgrade Projects Div/30027111
OPD/Business Management/30027106

FGPD/Projects Controls Div/30027006

FGPD/Engineering Design Div/30027007
FGPD/Infrastructures & Camp Fac Projects Div/30027008
FGPD/Gas Processing Facilities Projects Div/30027009
FGPD/Cogeneration & Steam Generation Proj Div/30027010
FGPD/Site Preparation & Early Works Proj Div/30027011
FGPD/SRU & Utilities Projects Div/30027012
FGPD/Upstream & Downstream Pipelines Proj Div/30027013
FGPD/Hasbah Offshore Facilities Div/30027014
FGPD/Business Management/30027005

NAPM/GM Staff/30006966

SAPD/Southern Area Oil Projects Div/30003599

SAPD/Community & Infrastructure Projects Div/30003602
SAPD/Southern Area Mega Proj Completion Div/30007568
SAPD/Design Services Div/30008129
SAPD/Southern Area Gas Projects Div/30015816
SAPD/Plng & Admin Group/30019733
SAPD/Home Ownership Projects Div/30019734
SAPD/Khurais AL Crude Increment Proj Div/30026831
SAPD/Dhahran Community Housing Proj Div/30026832
SAPD/Khurais&Udh Village Relocation Projs Div/30026833

P&CPD/Cross Country Pipeline Projects Div/30003603

P&CPD/Communications Projects Div/30013480
P&CPD/Admin Staff/30018232
P&CPD/Distribution Pipelines Projects Div/30020001
P&CPD/Pipeline Rehabilitation Projects Div/30020100
P&CPD/Security & Control Systems Projects Div/30022854
P&CPD/Shaybah & Wasit Pipelines Projects Div/30023003
P&CPD/East West Pipeline Projects Div/30026076

C&WRPD/Jeddah Area Projects Division/30003684

C&WRPD/Distribution Projects Div/30003688
C&WRPD/Central Region Projects Div/30019188
C&WRPD/Eastern/Central Region Dist Projts Div/30024487
C&WRPD/Yanbu & Jeddah Area Projects Division/30024491
C&WRPD/ Midyan Gas Plant Project Div/30025420
C&WRPD/Yanbu Terminal Projects Div/30027225
C&WRPD/New Bulk Plant Projects Div/30027226
C&WRPD/Shoaiba Project Div/30027227
C&WRPD/Wasea Bulk Plant Projects Div/30027228
C&WRPD/Dept. Staff/30019581

JR&TPD/Admin Staff/30022276
JR&TPD/Crude Division/30022277
JR&TPD/Naphtha & Aromatic Division/30022278
JR&TPD/Hydrocracker Division/30022279
JR&TPD/Terminal Division/30022280
JR&TPD/Infrastructure Division/30022281
JR&TPD/Interface & Start up Division/30022282
JR&TPD/Utilities Division/30024778
JR&TPD/Power Block Division/30025978
JR&TPD/Off Sites Division/30025979
JR&TPD/Gasification Block Division/30025980
JR&TPD/Tank Farm Division/30025981
JR&TPD/Infrastructure & Economic City Supp Div/30027105

OMPPD/Southern Area Oil Upstream Projects Div/30003600

OMPPD/Gas Upstream Projects Div/30021001
OMPPD/Business Administration/30025955
OMPPD/Northern Area Oil Upstream Projects Div/30025956
OMPPD/Oil Increment Projects Div/30025957
OMPPD/Design & Material Div/30025958

JIGCCPD /Interface & Start-Up Div/30027072

JIGCCPD /Power Block Div/30027073
JIGCCPD /Utilities & Common Area Div/30027074
JIGCCPD /Gasification Div/30027075
JIGCCPD /Sea Water System Div/30027101
JIGCCPD /Sulfur Recovery Div/30027102
JIGCCPD /Third Party Div/30027103
JIGCCPD /Administration Staff/30027104

SAPM/GM Staff/30021926

PMOD/Estimating Svcs Div/30003144

PMOD/Project Execution Support Div/30003153
PMOD/Surveying Services Div/30003158
PMOD/Project Execution Optimization Div/30012601
PMOD/Project Execution Metrics Div/30021812
PMOD/Enterprise Project Management Div/30023176
PMOD/Project Mgmt HR Group/30021811
PMOD/Business Admin Group/30021876

FPD/Ngl Recovery/30012190
FPD/Hawiyah Gas Plant Expansion/30012191
FPD/Juaymah/Yanbu Expansion/30012192
FPD/Shaybah Expansion/30012193
FPD/Gas Pipelines/30012194
 Report Status

Preliminary
Final

Person

Doing unsafe act

Line of fire-Pinch/Crush, Struckby potential
Working without permit/authority
Working in unsafe condition

PPE

Not used/not available/not issued

Not as stipulated in permit/Not fit for the job
Damage/Bad quality

Material

PTW (Permit to Work)

Permit not valid

Insufficient for activity
Documents deficiency

Work Procedure

Not followed
Wrong procedure for work
Not informed to worker
Risk assessment not done

Elevated Areas

Scaffold not inspected

Objects/tools not secured
Access and egress not safe
Fall Protection not provided/not adequate
Fall hazard overlooked
Safe Work Platform not provided

Electrical

Exposed wire on powercord ext cord

Work on equip without lockout tagout
GFCI not used or not working
Electrical cords used in wet conditions
Lighting Inadequate

Heavy Equipment

Used with defect

Operator not certified
Operating without banks man

Hot Work/ Welding & Cutting

No or inadequate spark containment

Scaffold planks not protected
Improper grounding
No fire extinguisher

Tool

Damaged
Unauthorized use/not right for job
Used in an unsafe manner

Trenching & Excavation

Use of mech. Equip near utilities

Inadequated side wall protection
Cable detection not used
Inadequated pedestrian access
 Vehicle

Overspeeding
Use of cellphone
Reckless operation

Barricade

Not provided
Insufficient

Confined Space Entry

Not identified
Access not controlled
Worker not trained
CSE permit violation

Ground Level

Access and egress not safe

SIMOPS/Overlapping works

Environmental & Health Issue

Housekeeping
Waste
Contamination
Noise
Hazardous atmosphere
Temperature
Hazardous posture
Overexertions
 ROOT CAUSES

DESIGN INPUT LTA

DESIGN OUTPUT
EQUIPMENT DESIGN RECORDS LTA
EQUIPMENT OPERATING/MAINTENANCE HISTORY LTA
NO PROGRAM
PROGRAM LTA
CORRECTIVE MAINTENANCE LTA
PREVENTIVE MAINTENANCE LTA
PREDICTIVE MAINTENANCE LTA
PROACTIVE MAINTENANCE LTA
FAILURE FINDING MAINTENANCE LTA
ROUTINE EQUIPMENT ROUNDS LTA
STANDARDS, POLICIES, OR ADMINISTRATIVE CONTROLS (SPACs) LTA
STANDARDS, POLICIES, OR ADMINISTRATIVE CONTROLS (SPACs) USED
SAFETY/HAZARD/RISK REVIEW
PROBLEM IDENTIFICATION/CONTROL
PRODUCT/MATERIAL CONTROL
PROCUREMENT CONTROL
DOCUMENT AND CONFIGURATION CONTROL
CUSTOMER INTERFACE/SERVICES
NOT USED
MISLEADING/CONFUSING
WRONG/INCOMPLETE
WORKPLACE LAYOUT
WORK ENVIRONMENT
WORKLOAD
INTOLERANT SYSTEM
NO TRAINING
TRAINING RECORDS SYSTEM LTA
TRAINING LTA
PREPARATION
SUPERVISION DURING WORK
NO COMMUNICATION OR NOT TIMELY
MISUNDERSTOOD COMMUNICATION
WRONG INSTRUCTIONS
JOB TURNOVER LTA
PROBLEM DETECTION LTA
SENSORY/PERCEPTUAL CAPABILITIES LTA*
REASONING CAPABILITIES LTA*
MOTOR/PHYSICAL CAPABILITIES LTA*
ATTITUDE/ATTENTION LTA*
REST/SLEEP LTA (FATIGUE)*
PERSONAL/MEDICATION PROBLEMS*