05_15_2023_Incident Report_Pender Co_Property Damage

INCIDENT REPORT
Conti v2018.01
Incidents must be reported by Telephone to the Safety & Health Department within one (1) hour of occurrence .
Incident Reports must be submitted within 24-Hours of Incident Occurrence to [e-mail]

Date of Incident: unknown Time of
Incident:
am pm
unknown
Time
of Shift:
am pm
unknown
Date Reported: Not Reported – Discovered on 5/12/23 Incident Occurred on Site: Yes No – BOTH
Direct Supervisor: Greg Blythe Project Name: NC-417 Hampstead Bypass Project #: 2200101
Supervisor’s Phone #: [phone] Company Name: C.M. Mitchell Subcontractor
EMPLOYEE INFORMATION
Employee Name: Stephen Smith Employee ID#: N/A - Subcontractor
Home Phone #: [phone] Other Phone #:
Home Address:
Sex: Male Female Date of Birth: Employment/Hire Date: Unknown
Job Title: Operator Union #: N/A Site Orientation: Yes No Date of Site Orientation: 6/20/2022
INCIDENT INFORMATION
Incident Classification: Injury Illness Vehicle Accident/Damage Utility Break Equipment Damage Fire/Explosion Property Damage

Theft/Vandalis m Near Miss Fatality Other:
Type of Incident: Fall Struck By Caught In or Between Contact With Slip/Trip Exposure To Lifting/Carrying Other
Task/Activity Performed Prior to Incident: Clearing off of Holiday Drive
“Take-5” Performed: Yes No N/A If Yes, By Who (name and title):
Equipment Involved: Yes No Type of Equipment: Conti Fleet #:
INJURY/ILLNESS INFORMATION
Type: No Injury/Illness Sprain Strain Laceration Contusion Foreign Body Fracture Burn Fatality Other
Object or Substance that Resulted in Injury/Illness:
Body Part: Side of Body: Left Right Other: Returned to Work: Yes No Unknown
Treatment Required: None Medical Attention Declined First-Aid Only Medical Evaluation at Clinic or Doctor’s Office Emergency Room

In-Patient Hospitalization Other
Name of Person that Provided First Aid or Medical Treatment: N/A
Treating Facility Name and Address: N/A
PROPERTY DAMAGE INFORMATION
Nature of Damage/Loss: No Property Damage Vehicle Equipment Property Utility Fire Theft Vandalism Other
Property Description: Wetlands and Private Property Conti Fleet #: N/A
Owner’s Name: Scott Gere Address: 198 Holiday Drive, Hampstead, NC 28443 Phone #: [phone]
Insurance Company: N/A Policy #: N/A Expiration Date: N/A
VEHICLE / DRIVER INFORMATION
Year: Make: Model: Color:
VIN #: License Plate #: License Plate State:
Driver Name: Date of Birth: Phone #:
Address:
Driver’s License #: Expiration Date: State of Issue:
INCIDENT DESCRIPTION
Description: On May 12, 2023, Conti Superintendent , Bryce Locke, discovered that C.M. Mitchell, the clearing subcontractor, had tracked through the
wetland and ri ght-of-way boundaries that Conti had surveyed, marked, and delineated with silt fence. Employees working for C.M. Mitchell also
participated in a guided walkthrough before gaining entry to the area. Conti Engineer, Michael Sullivan, walked the perimeter of the mistakenly cleared
area with a GPS Rover, then, Greg Jones, Survey Project Manager, plotted the highlighted area of disturbance on permit drawing sheet 56 (see
attached). The property owner has been contacted. On Monday, May 15, 2023, Conti foreman, Anthony Demma, was directed to take his crew and
reinstall the silt fence in its original locations.

No equipment damage and no injuries occurred as a result of the incident.
Incident Reporter Name and Phone #: Zac Wilson, 910 -622-3966
Witness Name and Phone #:
Report Prepared By:
Kate Keller
Title:
Safety Engineer
Phone #:
910-970-0687
Signature: Kate Keller Date: 5/15/2023

Supervisor: Title: Phone #: Signature: Date:

Employee: Signature:

Date:
INCIDENT REPORT
Conti v2018.01
Incidents must be reported by Telephone to the Safety & Health Department within one (1) hour of occurrence .
Incident Reports must be submitted within 24-Hours of Incident Occurrence to [e-mail]

Witness Statements:
No written witness statements were collected in regard to this incident.
Photos

INCIDENT REPORT
Conti v2018.01
Incidents must be reported by Telephone to the Safety & Health Department within one (1) hour of occurrence .
Incident Reports must be submitted within 24-Hours of Incident Occurrence to [e-mail]

INCIDENT REPORT
Conti v2018.01
Incidents must be reported by Telephone to the Safety & Health Department within one (1) hour of occurrence .
Incident Reports must be submitted within 24-Hours of Incident Occurrence to [e-mail]