Doc. No.

DG HSE/FRM-01
Rev: 00
NEAR MISS INCIDENT REPORT 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:____________________

Location:________________________ 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 Incharge Area Incharge
 Doc. No. DG HSE/FRM-01
Rev: 00
Date: 20/12/2016
NEAR MISS INCIDENT REPORT Page 2 of 2

CAUSE CHECKLIST
IMMEDIATE CAUSE
SUBSTANDARD ACTION SUBSTANDARD CONDITION
1. Operating equipment without authority 1. Inadequate guard or barriers
2. Failure to secure 2. Improper protective equipment
3. Failure to warn 3. Defective tools, equipment
4. Operating at improper speed 4. Conjection or restrected action
5. Making safety device inoperable 5. Inadequate Warning System
6. Using defective equipment 6. Fire & Explosion Hazards
7. Using Equipment Improperly 7. Poor Houskeeping
8. Failure to properly use PPE 8. Environmental conditions
9. Improper position for task 9. Noise/Radiation Exposure
10. Improper loading / placement/ lifting 10. Inadequate Ventilation
11. Servicing equipment in operation 11. High or Low temperature
12. Horse play 12. Inadequate Illumination

Choose applicable
BASIC CAUSES:
PERSONAL FACTORS JOB FACTORS
1. Inadequate capabilty 1. Inadequate Leadership supervision
2. Lack of knowledge 2. Inadequate Engineering
3. Lack of skill 3. Inadequate Purchasing
4. Stress 4. Inadequate Tools/Equipment
5. Improper motivation 5. Inadequate Workstandards
6. Inadequate Maintainance
7. Wear & Tear
8. Abuse or mis use

BASIC CAUSES:

DATE: INCHARGE
HSE INCHARGE
SITE HSE

RECOMMENDATIONS (BY AREA) MANAGER RESPONSIBILITY COMP. DATE

DATE AREA MANAGER

COMMENTS (BY SITE MANAGER)

DATE: INCHARGE
SITE MANAGER
SITE HSE