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Information
Document No.
Audit Titel
Auftraggeber/Baustelle
Durchgeführt auf
Vorbereitet von
Ort
Lage von Near Miss gemeldet
Teammitglieder Name:
Supervisors Name:
Schwere Verletzungen Fatality (S.I.F.)?
Yes
No
Schwere Verletzungen Fatality S.I.F. (Precursor)
No 1 - Did the event involve exposure to acute failure, override, or a failure to use a critical safety feature on a piece of equipment?
No 2 - Did the event involve exposure to a collapse, overturn or partial/complete failure of equipment/finished goods that was newly erected/built/tested or commissioned?
No 3 - Did the event involve a Team Member exposure to a fall from height?
No 4 - Did the event involve exposure to a release of hazardous energy due to ineffective lockout during maintenance, installation, inspection, repair, service or troubleshooting?
No 5 - Did the event involve exposure to being crushed, trapped entangled or in the line of fire with either a release of significant energy or weight?
No 6 - Did the event involve the movement of long and/or heavy unbalanced objects?
No 7 - Did the event involve exposure to potential fire/explosion during hot work on a finished product or with an oxy-acetylene system?
No 8 - Did the event involve potential or actual contact with "live" electricity?
No 9 - Did the event involve potential or actual harm to a person from a motorized vehicle (includes operator and pedestrian)?
No 10 - Was this an actual life altering, life threatening or fatal event?
Art der Umgebung von Miss gemeldet?
* Wenn andere bitte auflisten hier
Beschreibung der Umgebung von Miss gemeldet:
Legen Fotografie Near Miss, die hier gemeldet
Beschreibung der sofortigen Korrekturmaßnahmen
Gary Meighen-Watts
Deutsche Near Miss Report
Near Miss report form for Field Service Technicians and Operations
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