Near Miss / Improvement Opportunity Investigation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Personnel on Site

Classification

• Type of Incident

• Choose all that apply

  Select Health Safety Environmental

  • Health
  • Safety
  • Environmental

• Who was affected

• Choose all that apply

  Select Main Contactor Sub Contractor Third Party / Public

  • Main Contactor
  • Sub Contractor
  • Third Party / Public

Details of Incident

Potential Outcome

• Choose All that Apply

  Select Personal Injury Property or equipment damage Environmental Issues

  • Personal Injury
  • Property or equipment damage
  • Environmental Issues

Potential Severity

• Tick One

  Negligible

  Slight

  Moderate

  High

  Very High

Lessons Learned (immediate and root causes)

Work Environment

• Choose All that Apply or leave blank

  Select Defective Workplace Design/Layout Lighting Lack of Workspace Noise/destraction Access / Egress Weather

  • Defective Workplace
  • Design/Layout
  • Lighting
  • Lack of Workspace
  • Noise/destraction
  • Access / Egress
  • Weather

Management

• Choose All that Apply or leave blank

  Select System of Work Supervision Training Communication

  • System of Work
  • Supervision
  • Training
  • Communication

Plant / Equipment

• Choose All that Apply or leave blank

  Select Construction / Design Installation Safety Device Operation / Use Mechanical Failure Maintenance

  • Construction / Design
  • Installation
  • Safety Device
  • Operation / Use
  • Mechanical Failure
  • Maintenance

Human Factors

• Choose All that Apply or leave blank

  Select Failure to Follow Rules Instruction misunderstood Error of Judgement Lack of Experience Unsafe attitude Undue Haste Horseplay Lapse of Concentration Fatigue Working Without Authorisation

  • Failure to Follow Rules
  • Instruction misunderstood
  • Error of Judgement
  • Lack of Experience
  • Unsafe attitude
  • Undue Haste
  • Horseplay
  • Lapse of Concentration
  • Fatigue
  • Working Without Authorisation

PPE

• Choose All that Apply or leave blank

  Select Design Wrong Type Used Maintenance Not Provided / unavailable Not Used

  • Design
  • Wrong Type Used
  • Maintenance
  • Not Provided / unavailable
  • Not Used

Other

• Add any other relevant factors

Follow Up Action

Actions Required. Add as many as necessary

• Outline Action Required

• Allocated to

• Date Due

  Date

• Add signature

  Sign

• Select date

  Date

• Job Title