Near Hit Reporting Form - Smith & Sons (Bletchington) Ltd.

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Doc no:

HEALTH & SAFETY (examples).

• UNSAFE ACTS:
  1. Not Following rules.
  2. Not wearing PPE.
  3. Not Isolating equipment (LOTOTO).
  4. Housekeeping/untidy work area.
  6. Not wearing of seat belts.
  7. Not reporting an incident.
  8. Taking shortcuts or rushing.
  9.Not holding handrails.
  10.Not inspecting mobile plant.

• UNSAFE CONDITIONS.
  1. Guards not fitted.
  2.Spillages of material.
  3. Safety devices devices not working,
  4. Untested/certified lifting equipment.
  5.Damaged racking.
  6.Broken mirrors or reversing alarms.
  7. Fire exits blocked.
  8.Electrical Panels Open
  9. defective scaffolding.
  10. Poor welfare conditions.
  11. Damaged Tyres.
  12. Defective hand rail/working platform.

ENVIRONMENTAL (examples).

• ACTS:
  1. Not following rules/procedures.
  2. Wasting Water.
  3.Wasting Energy.
  4.Incorrect waste management.
  5.Incorrect waste segregation.
  6. Disturbing wildlife.
  7. Traffic (ignoring weight limits).
  8.Breaching permit conditions.
  8. Carrying mud/spillage onto the highway.

• CONDITIONS:
  1. Air & dust emissions.
  2. Fuel & chemical spills/storage.
  3.Noise.
  4.Housekeeping.
  5. Lighting.
  6.Water pollution.
  7. Odour, smoke and or fumes.
  8. Vibration & blast complaint.
  9.Visual Impact.
  10 Soil handling/contamination.

QUALITY (examples).

• Yes

  No

  N/A

• ACTS:
  1.Not following procedures/rules.
  2. Discharging into wrong silo bin.
  3. Missed sampling.
  4.Incorrect analysis.
  5.Not cleaning shovel buckets.

• CONDITIONS:
  1. Contaminated materials.
  2. Missing stockpile signs.
  3. Faulty weigh gear.
  4.Uncalibrated equipment.
  5. worn through bin partitions.

Report form.

• Business Line (e.g Transport)?

  Yes

  No

  N/A

• Full location?

  Yes

  No

  N/A

• Reported to?

  Yes

  No

  N/A

• Significant hit?

  Yes

  No

• was the incident an? (select both if applicable)

  Select

• Description of Near Hit. (photos can be added at this point by pressing the media button).

• Immediate action taken?

• Sign off as accepted.

  Sign

• Corrective and Preventative Action (CAPA). Complete CAPA in the notes section include photos (in the media section if required.) Sign off when complete.

  Sign