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1GNIFICANT INCIDENT REPORT
This forts is t be used for first notice reporting f all incidents Involving
pr cess upsets, near miss accidents (no Injury) and chemical r leases of a nature
deemed t be significant. It Is t be completed by the supervls r(s) f the ares.
Significant fire damage Incidents should be called Into Loss Prevention. Vehicular
damage Incidents should be called i/nto the Guards.
GEOGRAPHIC LOCATION: Plant A
C Complex____
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RECEIVEDn
AUG 0 8 W
INCIDENT DATE
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SPECIFIC LOCATION: V/OfW
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WEATHER ^Cle.7)- Cloudy - Holu - Wind - Etc.)
TYPE OF INCIDENT: (Could be more than one) Near Miss Accident Operational Upset Chemical Releaie
DESCRIPTION OF INCIDENT: Detail what occurred; Immediate action taken, l.e., clean up, evacuation, etc. How injury was avoided If a near miss accident occurred.
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ESTIMATED DEGREE OF SEVERITY: (Your best estimate of equipment down time, quantity
f material released. Injury potential.) <3,J&kirTrt OP OUtfyvikA.A
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FOLLOW-UP ACTION TAKEN OR RECOMMENDED:
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INVESTIGATED BY:'
Distribution: Originator maintains a copy. Send a copy to the appropriate riant E.R. Supervisor (Manager of Safety ft Health for the Complex Group).
Further notification or distribution will be made by the E.R. Supervisor after review with the Department Superintendent. Loss Prevention will be Informed of chemical process and property Insurance Incidents-by the E.R. Supervisor. The Manager of Safety and Health will be sent a copy of alj!) completed reports.
APPROVED : Rev. 3/84
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