Near Miss Identification

Observers name

Email

Unique reference number

IDENTIFICATION - Summarise the nature of the near miss/hazard

DISCLOSURE - How has the employee's report been acknowledged?

ROOT-CAUSE ANALYSIS CATEGORY - Select root-cause of this report

Materials-defective, unsuitable for the job or insufficient in quality Third party asset poor condition or fault Manpower-lack of competence, improperly motivated, under excessive pressure Plant & equipment-incorrect tool selection for the job, poor maintenance, poor placement, defective equipment Environment-housekeeping, layout, surface maintenance, forces of nature Management-inattention, lack of involvement, lack of communication, stress and demands Methods-poor procedures, discrepancy between practice and written procedure Management system-lack of training/ education of hazard recognition, employee engagement, hazard elimination

DETAILED ROOT-CAUSE ANALYSIS AND SOLUTION IDENTIFICATION

DISSEMINATION, COMMUNICATING FINDINGS

Resolution

Does this incident require escalation/ further reporting?

Yes No