Format No. : 13.02.

07/F-03
DANGEROUS OCCURRENCE Rev: 01
(DO) / NEAR MISS REPORT Report No:
(NMR) 500049/NM&DO/00085
Incident Date & Time: 28/May/2022 DO/NM Reporting Time: 31/May/2022 04:26
Shift: Day
04:15 PM PM
Type of Incident Near Miss
Exact Location: ON SHORE MEG FACILTY (OMF)
Project Name: Kakinada
ODALAREVU – Sub Location:
Site Details
SBG: SBU:

Description of Incident

Activity involving Incident

De-shuttering
Nature of Incident

Causes of Incident Personal Factor

Sub-cause of Incident Behavioural issue.

1. Full lanyard should be use 2. Awareness training provided to among the workmen. 3.
Corrective Action Taken
Communicate this NEAR MISS in tool box talk to avoid the reference.

DO Reported By Name & Designation Of Employee: PALLETI KAMESWARARAO

Photographs if any

Distribution Project management / RO / HO

*Note: This report should be filled in by any Employee who is reporting the Dangerous Occurrence / Near Miss soon after the
observation. This Form shall be submitted to Site Safety Officer.