Format No. : 13.02.

07/F-03
DANGEROUS OCCURRENCE Rev: 01
(DO) / NEAR MISS REPORT Report No:
(NMR) 500049/NM&DO/00083
Incident Date & Time: 23/May/2022 DO/NM Reporting Time: 31/May/2022 03:06
Shift: Day
03:03 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

Vehicle Movement
Nature of Incident

Causes of Incident Personal Factor

Sub-cause of Incident Behavioural issue.

1.Water sprinkling on that access and compacted by roller. 2. Communicated this near miss
Corrective Action Taken among the operator to avoid the recurrence. 3. Awareness training has been conducted among
operator.

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.