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INC-2026-0108

HIGHClosed

Reported by Craig Wilson — Inspector

15 January 2026 at 06:45 amProcessing Plant — Level 1Near Miss — Confined SpaceDay Shift

Incident Description

Gas monitor alarmed for H2S during tank inspection. Reading peaked at 15ppm (action level 10ppm). Crew evacuated immediately. Ventilation fan had been positioned incorrectly.

Immediate Actions Taken

  • 1Immediate evacuation
  • 2Area ventilated for 4 hours
  • 3Re-entry only after clearance readings
  • 4Fan positioning procedure updated

Likelihood x Consequence Matrix

InsignificantMinorModerateMajorCatastrophic
Almost Certain
Likely
Possible
Unlikely
Rare

Likelihood

3 / 5 — Possible

Consequence

4 / 5 — Major

Risk Score

12/25

Failed / Breached Controls

Exclusion Zone Signage

Signage not visible in dusty conditions

HIGH
Effectiveness
15%

Spotter Positioning

Spotter not in designated position

HIGH
Effectiveness
0%

Controls That Held

Vehicle Speed Limits

LV was within speed limits when entering zone

Effectiveness
80%

Operator Awareness

Haul truck operator noticed LV and stopped

Effectiveness
85%

Incident Reporting

Reported immediately via radio

Effectiveness
95%

Priority Questions

  • What were the direct and contributing causes of this incident?
  • Were all relevant procedures followed by personnel involved?
  • Was there adequate supervision at the time of the incident?

Follow-Up Questions

  • Were there any similar incidents in the past that could have predicted this?
  • Were all personnel adequately trained for the task being performed?
  • Were environmental conditions a contributing factor?

Systemic Questions

  • Does this incident indicate a gap in the current risk management framework?
  • Are there systemic issues with procedure adherence in this area?
  • Would additional engineering controls reduce the likelihood of recurrence?
06:30 am

Pre-start meeting completed

06:45 am

Incident occurred

06:50 am

Incident reported to supervisor

06:55 am

Area secured and barricaded

07:05 am

HSE team notified and on-scene

07:30 am

Initial investigation commenced

07:45 am

Report filed in SafetyScribe AI

Incident Details

Date & Time

15 January 2026 at 06:45 am

Location

Processing Plant — Level 1

Type & Category

Near Miss

Confined Space

Severity
High
Status
Closed
Shift

Day Shift

Reported By

Craig Wilson — Inspector

  • Inspector — Craig Wilson
  • Process Operator — Ryan Cooper
IndoorConfined space entry
Storage TankGas MonitorVentilation Fan

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