NEAR MISS / INCIDENT REPORT DC/HSE/NMIR

Project Title : Project :

Near Miss / Incident: Report No. :

Name Card No. Company

Location Date Time

Type of Hazard

Associated Risk

Corrective Action

Root Cause Analysis

1 Substandard Action 2 Substandard Condition

3 Personnel Factor 4 Job Factor

Description

Preventive Action

SITE ENGINEER PROJECT ENGINEER

 NEAR MISS / INCIDENT REPORT DC/HSE/NMIR

CAUSES CHECKLIST

IMMEDIATE CUASES

SUBSTANDARD ACTIONS SUBSTANDARD CONDITIONS

 1.Operating equipment without authority
 2. Failur to secure
 3.Failure to warn
 4.Operating at improper speed
 5.Making safety device inoperable
 6.Using Defective equipment
 7.Using Equipment improperly
 8.Failure to properly use PPE
 9.Improper loading/placement/lifting
 10.Improper position for task
 11.Servicing equipment in operation
 12. Horse play
 1.Inadequate guard or barriers
 2.Improper protective equipment
 3.Defective tools, equipment
 4.Conjection or restrected action
 5.Inadequate Warning System
 6.Fire & Exxplosion Hazards
 7.Poor Housekeeping
 8.Environmental conditions
 9.Noise/Radiation Exposures
 10.Inadequte Ventilation
 11. High or low temperatures
 12. Inadequte illumination

Choose as applicable
BASIC CAUSES:
PERSONAL FACTORS JOB FACTORS
 1.Inadequate Leadership supervision
 1.Inadequate capability  2.Inadequate Engineering
 2.Lack of knowledge  3.Inadequate Purchasing
 3.Lack of skill  4.Inadequate Tools/Equipment
 4.Stress  5.Inadequate Maintenance
 5.Improper motivation  6.Inadequate Workstandards
 7.Wear & Tear
 8.Abuse or misuse

BASIC CUASES

DATE: INCHARGE HSE

RECOMMENDATIONS (BY PROJECT RESPONSIBILITY COMP.DATE

ENGINEER)

DATE: PROJECT ENGINEER

COMMENTS (BY SITE ENGINEER)

DATE: SITE ENGINEER