A1 General Event & Near Miss Form
SAR-012-100-4-017
Issue 1
Date:30 August 2018
HAS THIS EVENT BEEN REPORTED TO THE TRAIN CONTROLLER?
Y/N
Type of event
Station overrun
Failure to call
Collision
Derailment
Speeding
Dispatch / door error
Depot irregularity
Platform,/train interface events
Event date
15/05/2022
Event location
Event time
2:51 Am
Location Manager
Other (describe)
An alarm appeared in the Vicos system and the cause
of a malfunction in the signal transmission channels.
√
Between BS17 and BS19 line 1+2
Department
About the location (tick, circle or highlight)
Location
Station, outdoors
Station, indoors
Trackside
Depot or siding
On board train
Other
Detail
On train
Platform/train interface
Platform
Ramp/path
Stairs/steps
Concourse/indoors
Car park/forecourt
Office
Workshop/shed
Walking route
Yard/siding
Inspection pit
Lighting
Daylight
Dark, no artificial light
Artificial light, adequate
Artificial light, inadequate
Handlamp
Other
About the person primarily involved in the event
Person type
SAR employee
Contractor
Public
Other
Name
Muneer Hamzah
Job Title
Technician
Home location
Dammam
Line manager
Mohammad Bamusalam
SAR ID umber
Contact Number
About the train (if applicable)
tick or circle
Passenger in service
Passenger not in service
Freight loaded
Freight empty
Dangerous goods
Locomotive only
Train ID
Driver’s name
Time
Driver’s depot
From
Captain’s name
To
Captain’s depot
Train
number(s)
Other staff
name
Vehicle
/Wagon
number(s)
Other staff
depot
About you, the person completing this form (if you are not the person named above)
Name
Location
S&T Maintenance Dammam
Contact number / via
0138714025
Time report completed
8:30 Am
Muhammad Al Wadie
Job Title
S&T Specialist
Date this report completed
16/05/2022
Function
Dept.:
Form No:
Health, Safety & Environment
Operations Management
SAR-012-100-4-017 Rev#00
A1 General Event & Near Miss Form
SAR-012-100-4-017
Issue 1
Date:30 August 2018
Description of event
Describe what happened in as much detail as you can remember. Concentrate on the event itself and the circumstances leading
up to it, not how it was managed afterwards unless this was relevant. Use pictures, copies of social media or maps if they are
relevant as it helps understand the event and / or the location.
There is an alarm in the Vicos system that is in fibre optic cable cut And the Contractor technicians and line maintenance
inspectors arrived at the site to found the cable cut.
A contractor (Chinese company CRCC) has possession doing work. And he caused that cut.
If a Safety Inspector is at your location have you notified them
of the incident?
Y / N / Not Applicable
Date and time advised
On completion please scan and email this form to the Health and Safety team:
Safety - sarsafety@sar.com.sa and inform your line manager/ supervisor/team leader.
For assistance contact SKAnazi@sar.com.sa or Mob: 0500155872 or +966 11 525 0000 Ext: 210298
Function
Dept.:
Form No:
Health, Safety & Environment
Operations Management
SAR-012-100-4-017 Rev#00