Near Miss Investigation Form

• Accident - Incident - Near Miss
  Investigation Form

• Audit Title

• Document No.

• Project

• Project number

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Who was involved?

• Reported to Supervisor?

Causation

• Date

  Date

• Time

  Date

• Immediate or direct causes.
  Immediate direct causes of accidents/incidents may be attributed to substandard practices or substandard conditions. Immediate direct causes are symptoms of deeper problems.
  
  Substandard Practices
  - Is "any departure from an accepted, normal, or correct procedure or practice that permits the occurrence of an accident/incident."
  
  Substandard condition
  - Is "any hazardous arrangement which, if left uncorrected, may lead to an accident/incident."

• What was the immediate or direct cause?

• Underlying or indirect causes.
  
  The following maybe used as a guide:
  - Worker unsuitable for assignment
  - Lack of adequate training
  - Safe job procedure not developed
  - Safe job procedure not followed or enforced
  - Safety equipment not provided
  - Lack of proper instruction
  - Deliberate disregard for safety regulation
  - Lack of regular safety inspection
  - Hazards not recognized
  - Lack of maintenance system
  - Lack of a lock out system
  - Substandard design
  - Use of drugs / alcohol

• What were the underlying or indirect causes?

• Was a hazard assessment done?

  No

  Yes

• Why was a hazard assessment not completed?

• Did the hazard assessment recognize the hazard?

• Was training given for the task?

  No

  Yes

• Describe the training worker received for assigned task.

• Explain why training was not given.

• Was instructions provided before the near miss?

  No

  Yes

• What instructions have been provided?

• Explain why training was not given.

• Were cautions given?

  No

  Yes

• What cautions were given?

• Explain why training was not given.

Prevention and Recommendations

• How can similar scenarios be prevented in the future?

• Recommendations for further action

• Recommendations completed by:

• When will the recommendations be completed?

  Date

Accident - Incident - Near Miss Scene

• Tap for picture of scene

  Media

• Drawing not to scale
  North ^

• Tap to draw the scene

  Drawing

Sign off

• Worker

  Sign

• Supervisor

  Sign

• Reviewed by senior management.

• Date:

• Comments or recommendations.