Near Miss Report 险兆报告

• Project No 项目编号

• Document No. 文件号

• Report by 编制

• Conducted on 创建于

  Date

• Near Miss Defined
  “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”
  险兆的定义
  没有造成伤害，疾病或损害的计划外事件--但有潜力这样做

• Project 项目

• Date & Time 日期，时间

  Date

Near Miss Location and Circumstances 险兆事件位置及环境

• Near Miss Location and Circumstances<br>险兆事件位置及环境

  Office 办公室

  Factory 工厂

  Site Installation安装工地

  work related off-site location 工作相关外区域
• Location of Near Miss. 地点
  Address

Near Miss Details 详细情况

• Type of concern 涉及类型

  Select unsafe act 不安全行为 Unsafe work condition 不安全工作环境 unsafe equipment 不安全设备 unsafe use of equipment 不安全的设备使用 unsafe material handling 不安全的材料搬运

  • unsafe act 不安全行为
  • Unsafe work condition 不安全工作环境
  • unsafe equipment 不安全设备
  • unsafe use of equipment 不安全的设备使用
  • unsafe material handling 不安全的材料搬运

• Severity<br>严重程度

  Potentially fatal 有可能致命的

  severe 严重

  moderate 中等

  minor 轻微

• Describe how the Near Miss occurred 事件描述

• picture 图片

  Media

Immediate Action 立刻采取行动

• Were there any Immediate actions taken<br>是否立刻采取行动

  yes 是

  No 否

• Describe actions details 描述具体行动

Preliminary Investigation 初步调查

• Describe (details) how and why the incident happened 描述事件是如何/为何发生的

Where there any hazardous conditions and/or behaviors that could have contributed to the incident? （check that all apply） 有没有可能造成事故的危险条件和/或行为？(可多选）

• System factors 系统因素

  Select leadership or supervision 领导或监督 inadequate training 培训不足 inadequate communication 缺乏沟通 unsafe working condition 不安全作业环境 inadequate work standards / methods 作业标准，方法欠缺 Non-compliance to Group operational processes 不符合公司操作流程 Inadequate tools or equipment 不适当的工具或设备 inadequate assessment of operational readiness 战备评估不足 None 没有 Uncontrolled risks caused by others (Example - Multi-employer work site) 其他不受控风险因素 （如多单位协同作业） Inadequate maintenance 缺乏维护 Unclear / inadequate standards specifications or design criteria 不清晰/不足标准规格或设计标准

  • leadership or supervision 领导或监督
  • inadequate training 培训不足
  • inadequate communication 缺乏沟通
  • unsafe working condition 不安全作业环境
  • inadequate work standards / methods 作业标准，方法欠缺
  • Non-compliance to Group operational processes 不符合公司操作流程
  • Inadequate tools or equipment 不适当的工具或设备
  • inadequate assessment of operational readiness 战备评估不足
  • None 没有
  • Uncontrolled risks caused by others (Example - Multi-employer work site) 其他不受控风险因素 （如多单位协同作业）
  • Inadequate maintenance 缺乏维护
  • Unclear / inadequate standards specifications or design criteria 不清晰/不足标准规格或设计标准

• Person factors 个人因素

  Select Employee misconduct 员工不当行为 lack of knowledge 缺乏知识 None 没有 lack of skill 缺乏技能 improper motivation 不正确对待动机 abuse or misuse 滥用或误用 physical capability 物理性质 mental or psychological stress 精神或心理应激 under the influence of a controlled substance 受到控制物质的影响 per-existing medical condition 预存在的医疗条件 other 其他

  • Employee misconduct 员工不当行为
  • lack of knowledge 缺乏知识
  • None 没有
  • lack of skill 缺乏技能
  • improper motivation 不正确对待动机
  • abuse or misuse 滥用或误用
  • physical capability 物理性质
  • mental or psychological stress 精神或心理应激
  • under the influence of a controlled substance 受到控制物质的影响
  • per-existing medical condition 预存在的医疗条件
  • other 其他

• Report by 报告人

  Sign