Doc. No.

DG HSE/FRM-
01
NEAR MISS INCIDENT REPORT Rev: 00
Date:
20/12/2016
Page 1 of 2
Project Title: DG Khan Cement Plant, Hub Project No: 0568

Near Miss Incident Title: Report No.

Name: Card No: Company:

Date: Time:

Hazard Type:

Associated Risk:

Corrective Action:

Root Cause Analysis:

1. Substandard Action 3 Personal Factor

2. Substandard Condition
4 Job Factor
Description:

Preventive Action:

Name: Name: Name:

Reporting HSE
Officer Site (Section) HSE In charge Area In charge
 Doc. No. DG HSE/FRM-01
Rev: 00
Date: 20/12/2016 Page 2 of 2
NEAR MISS INCIDENT REPORT

CAUSE CHECKLIST
IMMEDIATE CAUSE
SUBSTANDARD ACTIONSUBSTANDARD CONDITION
Operating equipment without authority1. Inadequate guard or barriers
Failure to secure2. Improper protective equipment
Failure to warn3. Defective tools, equipment
Operating at improper speed4. Conjection or restrected action
Making safety device inoperable5. Inadequate Warning System
Using defective equipment6. Fire & Explosion Hazards
Using Equipment Improperly7. Poor Houskeeping
Failure to properly use PPE8. Environmental conditions
Improper position for task9. Noise/Radiation Exposure
Improper loading / placement/ lifting10. Inadequate Ventilation
Servicing equipment in operation11. High or Low temperature
Horse play12. Inadequate Illumination

Choose applicable
BASIC CAUSES:
PERSONAL FACTORSJOB FACTORS
Inadequate capabilty1. Inadequate Leadership supervision
Lack of knowledge2. Inadequate Engineering
Lack of skill3. Inadequate Purchasing
Stress4. Inadequate Tools/Equipment
Improper motivation5. Inadequate Workstandards
Inadequate Maintainance
Wear & Tear
Abuse or mis use

BASIC CAUSES:

DATE: HSE INCHARGE

RECOMMENDATIONS (BY AREA) R RESPONSIBILITY COMP. DATE

DATE AREA MANAGER

COMMENTS (BY SITE MANAGER)

DATE: SITE MANAGER