Personal Injury Near Miss Report Form

Who, what, when and where?
Please tell us when and who was involved.

01/04/2023
3:30 PM
780
GEORGE ACHESON
JUSTIN GRIMM
*NOTE: The name entered in this box will be the name that receives credit toward their MBO
GEORGE ACHESON
TOW

Conditions at time of Near Miss
Try your best to select the conditions during the Near Miss.

Near Miss description
Give as much detail as you can.

While checking tow, tripped over a wire and lost balance carrying tightening tools in left hand
resting on left shoulder. Tried to break the fall with left hand.. Unsure if tightening tools smashed and
cut finger or the barge cut finger. All PPE was being worn at the time.
BE WHERE YOUR FEET ARE. IN OTHER WORDS, ALWAYS LOOK WHERE YOUR STEPPING BEFORE YOU STEP

Near Miss evaluation
Select the best possible choices. You will have an opportunity below to give more detail and request to add categories or suggest improvements to this form.

Policies & Procedures

Near Miss Reporting Program

CANAL BARGE COMPANY, INC.

Purpose
To identify and analyze near miss occurrences to reduce the likelihood of similar incidents and to promote continual improvement.
Near Miss: An event that did not result in an injury or physical damage but had the potential to do so under slightly different circumstances.
Responsibility
The Master/Pilot on watch or Shore Side Supervisor is responsible for promoting the reporting of near miss occurrences using this procedure.
  • To encourage near miss reporting
  • Discourage blaming individuals
  • Provide the resources to investigate and analyze High Learning Value (HLV) Near Misses to promote continual improvement.
  • Employees are responsible to report all near miss occurrences.
Scope
This procedure applies to all near misses that involve CBC employees, authorized visitors, and contractors (vendors) on CBC vessels, and property and anywhere employees are conducting Company activities.
Procedure
Working safely and complying with all federal, state and local regulations governing environmental protection is a condition of employment.
Scope
This procedure applies to all near misses that involve CBC employees, authorized visitors, and contractors (vendors) on CBC vessels, and property and anywhere employees are conducting Company activities.
Procedure
  1. A near miss occurs
  2. The near miss is reported using the Company software.
  3. The software identifies potential High Learning Value Near Misses.
  4. The potential HLV Near Misses are reviewed by the Operations Team Safety Committee, if in the judgment of the team the Near Miss offers a HLV. It is analyzed for cause, and resultant corrective and preventive actions.
    Feedback to the fleet regarding the High Learning Value Near Misses is provided be by one or more of the following:
    • Safety Bulletins
    • Corrective and Preventive action (system changes)
    • E-mail

    Non HLV Near Misses may be analyzed for trends annually to further opportunity for increased actions to prevent incidents.

Employees will not be "second guessed" or punished for reporting near misses.

About the Near Miss Reporting Program
Accident/Incident/Near Miss Investigation

One of the best ways to avoid further accidents is to understand how an accident occurred and how to avoid that type of accident in the future. The accident investigation is a tool.

The goal is not to lay blame.

ACCIDENT -an undesired event or sequence of events causing injury, ill-health or property damage.

NEAR MISS -near misses describe incidents where, given a slight shift in time or distance, injury, ill-health or damage easily could have occurred, but didn't this round.

INCIDENT -an incident is an unplanned, undesired event that hinders completion of a task and may cause injury or other damage.

Statistics