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Incident / Near Miss Report
Full Name
(Person completing Form)		 Position Vessel/Location
Time of Incident Date of Incident (yyyy/mm/dd) Date Incident Reported 2025-05-08 18:59
Locaion of Incident
Authorisation Code of person completing form Operational Area
Whitness(es)

Non Work Related


Select only if relevant

Report Only


Select only if relevant

Involved or inpacted Person


(Complete if applicable)
Name Personnel Number Date od Birth (yyyy/mm/dd)

Severity
No Injury Minor Injury no treatment First Aid Case
Medical Treatment Restricted Work Case Lost time injury
ShiftDayNight Roster
Days into Roster Hours into shift Mobilisation Date (yyyy/mm/dd)
Persons role

Incident Type


Please tick all relevant boxes below
Incident Environemnt Quality Equipment Emergency Response
Fatal Incident Spill Formal Complaint Defective Fire
Environmental air Informal Complaint Breakdown MOB
Property Incident Noise Management System Maintenance Disease
Personnel Inury Water Work Procedure Lost or Stolen Oil Spill
Abuse / Aggression Odour Policy Design Collision
Near Miss Storm Water Contract Use Grounding
External Issue Sewerage Design Fault Damage Electical Failure
Occupational Exposure Oily Waste Security Issue Corrosion Mecanical Failure
Business Issue Elements Workplace Relations Other
Other

Agency of Incident


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Hazard Hazard Equipmental Equipmental Equipmental
Struck by Foreign Body Air Emission Chemical Storage Rain
Struck against Fracture Chemical Spill Bulk product Tidal / Sea State
Physical Abuse Laceration Fuel Spill Bunkering Third Party
Verbal Abuse Burns Hazardous Waste Recycling Chemical
Slip Trip Electrocution Oily Waste Rubbish Equipment
Fall From Height Chemicals Sewerage Equipment Failure Infrastructure
Over Exertion Vibration Stormwater Corrosion Illness
Sprain / Strain Falling Object Leak Water Noise Poisoning
Cut / Abrasions Other Other Wind Other

Injury / Damage Categories


Please tick all relevant boxes below
Hazard Hazard Equipmental Equipmental Equipmental
Cargo Handling Master Jetty Skin Abdoman
Vessel Operations Engineer Marina Head Internal Organ
Mooring / Berthing Deckhand Vessel Eyes Arm / Shoulder
Maintenance Maintenance staff Boat Yard Ears Hand / Wrist
Cleaning Adminsitration Road / Car Park Face Leg / Hip
Adminsitration Passenger / Visitor Vehicle Neck Knee
Vessel Loading Contractor Accommodation Back Foot Ankle
Vessel Unloading Other Other Other Other

Description of Incident


Stick to the facts that are known, do not make assumptions or place blame!

Physical Causes of Incident


Please tick all relevant boxes below
Did any of the following physical conditions contribute to the cause of the incident?
Inadequate or absent guarding Inadequate fire or explosion risk control
Poor Workstation design or layout Inadequate Noise control
Poor condition of equipment or objects Inadequate Ventilation
Equipment or Objects with unsafe design Inadequate Temperature Control
Unsafe Storage of Equipment or Objects (Housekeeping) Inadequate Fall Protection
Unsafe walking surfaces Inadequate Signage or Warning systems
Unsafe lighting or glare Inadequately controlled use of chemical / substances
Unsafe Clothing or Shoes Other (specify)
Unsafe task or process Not applicable

Behavioural Causes of Incident


Please tick all relevant boxes below
Did any of the following behaviours contribute to the cause of the incident?
Perform task without authoriy Distracting, teasing or abusing a person
Performing task at undafe speed Using unsafe or "Tagged Out" equipment
Performing the task whilst affected by drugs or alchol Using equipment in an unsafe manner
Performing task with improper work technique Unsafe placement of equipment or objects
Performing task without proper PPE Unsafe manual handling technique
Performing task without proper PPE Unsafe position or posture
Failure to warn of hazard Unsafe acts of others
Failure to secure hazardous items Other (specify)
Making safety device inoperable Not applicable
What are the management systems (Procedural) deficiencies that lead to the unsafe behaviours?
Inadequate operating procedure/policies Inadequate workplace inspection
Inadequate supervision Inadequate equipment provided
Inadequate hazard identification Inadequate design or construction of workplace
Inadequate assessment of risk Inadequate task or process design
Inadequate provision of personnel protective equipment Unrealistic scheduling
Inadequate Operator training Other (specify)
Inadequate supervisor training Not applicable