HBR-AA: Report A Safety Issue

• Date And Time Of Report

  Date

• Reported By (Full Name)

• Date And Time Of Issue/Concern/Hazard

  Date

• Location Of Issue/Concern/Hazard

• Select Safety Concern Type

  Personnel

  Other

• Please List Employee(s) Involved:

• In A Few Words, Please Describe The Issue/Hazard

• Please Select The Risk(s) Present As A Result Of The Above

  Select Derailment Crossing Accident Track Collision Death Serious Injury Minor Injury Other

  • Derailment
  • Crossing Accident
  • Track Collision
  • Death
  • Serious Injury
  • Minor Injury
  • Other

• Please State The Risk Present

• If You Did Anything To Remedy The Issue/Hazard, Please Describe Here

• In A Few Words, Please Describe The Issue/Hazard

• Please Select The Risk(s) Present As A Result Of The Above

  Select Derailment Crossing Accident Track Collision Death Serious Injury Minor Injury Other

  • Derailment
  • Crossing Accident
  • Track Collision
  • Death
  • Serious Injury
  • Minor Injury
  • Other

• Please State The Risk Present

• If You Did Anything To Remedy The Issue/Hazard, Please Describe Here

• Step 1 - DETERMINE LEVEL OF LIKELIHOOD<br><br>(1) Improbable/Very Low - has never happened before; would be expected to happen only once every 50 years; safety controls already in place should prevent this occurrence<br><br>(2) Remote/Low - has happened somewhere before; would be expected to happen only once every 20 years; safety controls integral to preventing this risk are in place<br><br>(3) Occasional/Medium - can happen; could be expected to happen one in 2 years; safety controls in place lack redundancy/contain limitations<br><br>(4) Probable/High - has happened to the company before; could happen once a year; safety controls in place contain significant and known limitations to prevent this risk<br><br>(5) Frequent/High - happens often; could happen more than once a year; there are no safety controls in place that provide a realistic possibility of preventing this risk

  (1) IMPROBABLE

  (2) REMOTE

  (3) OCCASIONAL

  (4) PROBABLE

  (5) FREQUENT

• Step 2 - DETERMINE SEVERITY OF CONSEQUENCES<br><br>(1) Minimal/Low - first aid or minor medical treatment; little to no environmental damage<br><br>(2) Marginal - reportable injury; occupational illness; lost workday/minor leak that could be contained<br><br>(3) Serious - serious injury; multiple injuries; environmental damage that requires response and site remediation<br><br>(4) Critical - permanent partial disability; temporary total disability; serious environmental damage requiring site remediation and could cause long term (or large scale) environmental impacts<br><br>(5) Catastrophic - death or permanent disability; severe wide scope of impact with long term serious environmental harm

  (1) MINIMAL/LOW

  (2) MARGINAL

  (3) SERIOUS

  (4) CRITICAL

  (5) CATASTROPHIC

• 

• Based On The Above Scale, Is The Risk Level Low, Medium, Elevated or High?

  Low

  Medium

  Elevated

  High

Please Finish This Report And Notify The Appropriate Manager Immediately Via Phone Call.