NEAR MISS REPORT

Project: Peacock BOM 062 Date: 08/08/2019

Project manager: Mr. yogesh Time: 03:15 PM
rd
Exact location of near miss: 03 Floor
Name of the person who witnessed: Mr. Prakash Mishra
Description of Near-Miss Incidence (Who, What, Where, When, Why & How):
Today on 08/08/2019 approximately 3:15 PM safety personal saw wooden ply suddenly falls
from height front of Mr. Mishra (safety Personal) ply which was used in shuttering and size was
12mm thickness and width 02 feet length 03 feet already had informed to civil team don’t use any
damaged materials in any work but Shri Ram (Civil Contractor) did negation work

What Could Have Happened: -

Damaged ply can fall on any worker and impact of serious injury

Probable Causes: -
1.avoid of method statement
2.worked done without any adequate supervision
3.brought damaged materials on job location

Photos:

Suggested Remedial Action:

Take strict action against contractor company and again conduct induction training of safety and
Quality

Responsibility: - Shri Ram contractor Time Estimated: Immediate

Signature of site safety Officer Signature of Project manager

Name: Name:

To be filled by person responsible to complete the task:

Format No: SW /HSE/F20 Rev00

Issue Date: 01.04.2018
 NEAR MISS REPORT

Task completed on:

Signature & Name:

Format No: SW /HSE/F20 Rev00

Issue Date: 01.04.2018