NEAR MISS REPORT

A near miss is potential hazard or incident that has not resulted in any personal injury. Unsafe working conditions, unsafe employee work
habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s
responsibility to report and / or correct these potential accidents / incidents immediately.

Project Date and Time of Incident Location

KAP-2B-P-132
Check all appropriate conditions

 Unsafe Act  Unsafe equipment  Safety Concern

 Unsafe Condition  Unsafe use of equipment  Other
Description of near miss incident
For instance, how did an accident/incident nearly occur, what stopped the incident from causing harm?

Reported By (Name, Designation and Signature)

Reported To (Name and Designation)

Date Reported

Near Miss Investigation

Primary Cause Contributing Cause

Root Cause:
Proposed Correction and Corrective Action
(Removing the hazard, replace, repair, or retrain in the proper procedures for the task)
1.
2.
3.
4.
Investigation Conducted By (Name, Designation and Signature)
Reviewed by (Name and Designation and Signature)
Date Completed

Could this incident happen again if safety measures are not improved/action is not taken?  Yes  No
To be closed after implementation of corrective action
Corrective Action
Responsibility Timeframe Status (Open/Closed) Verified by
Reference Number

Distribution
 HSE Manager  Site Team  Contractors  Safety File  Project Manager  Document Controller  HSE Committee