BRISBANE - Incident/Near Miss Report

• Conducted on

  Date

INCIDENT/NEAR MISS REPORT

Basic Information

• Date & Time of Incident

  Date

• Reported by:

• Person Involved:

• Witness/es:

• Investigated by:

• Team Leader:

• Vessel:

• Berth:

• Location:

• Machine ID:

• Task:

Incident Description (Facts only)

• Near Miss Definition: An incident that under different circumstances had the potential to have caused injury or damage.

• Injury

• Environmental/Spill

• Sugestion

• Damage

• Positive Recognition

• Incident Description:

• Please Attach Pictures of Incident

  Media

Cause Analysis

• Questions that may assist the investigation as well as the identification of future actions to prevent recurrence of the incident Summary of major causes? Eg. Hydraulic oil leak, poor housekeeping, weak lighting.

• Are the written procedures/SWI's for the task being undertaken?

  Yes

  No

  N/A

• Were the procedures/SWI's followed?

  Yes

  No

  N/A

• Was the equipment designed for the task?

  Yes

  No

  N/A

• Was the equipment maintained?

  Yes

  No

  N/A

• Were site or cardinal rules followed?

  Yes

  No

  N/A

• Was the employee trained in the task?

  Yes

  No

  N/A

• Was PPE used?

  Yes

  No

  N/A

• Did housekeeping contribute?

  Yes

  No

  N/A

• Did the work environment contribute?

  Yes

  No

  N/A

Intermit Action

• What immediate intermit action have been completed to ensure a similar incident does not occur in the short term? Eg. Spill cleaned up, trip hazard removed.

Suggestions

• What future actions to be completed to help prevent recurrence of the incident?