NEAR MISS REPORT (AEC-HSE-PM-02-03)

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Engineering & Construction Co. L.L.C
Client Name: …………………………………
Project No.: ………………………………….
Poject Name: ………………………………. NEAR MISS REPORT
Sub-contractor Name: ……………………
Location: ……………………………………..

Date observed: ……………………………………………….

Location: ……………………………………………………..

HAZARD DESCRIPTION (Please write what you saw and where it took place):

WERE YOU ABLE TO CORRECT THE PROBLEM?

YES NO

WHAT ACTION WAS TAKEN SUGGESTED

OBS ERVER NAME/ I.D. NO. (optional):

Please complete reverse side. This portion to be completed by the Project HSE / Sub-contractor's HSE
IS DETAILED INVES TIGATION REQUIRED?

YES NO
Procedure No. AEC-HSE-PM-02 Form:03 Revision No.: 00 Effective Date: 01/08/2012
 NEAR MISS REPORT (AEC-HSE-PM-02-03)
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TICK WHERE APPROPRIATE
What Hazardous act/ condition did you see?
A. PPE
1) Head protection not w orn ………………………..
2) Eye protection not w orn …………………………..
3) Face protection not w orn …………………………
4) Ear protection not w orn …………………………..
5) Protective clothing not w orn ………………………
6) Safety shoes not w orn …………………………….
7) Hand protection not w orn ………………………….
8) PPE in bad condition ………………………………..
9) Wrong PPE for the job ……………………………..
10) Substandard PPE ………………………………….
B) TOOLS/EQUIPMENT
1) Wrong tool for the job ………………………………
2) Tools in bad condition ………………………………
3) Tools not inspected ………………………………..
4) Misuse ……………………………………………….
C) MATERIAL HANDLING
1) Too heavy for manual lifting ……………………….
2) Wrong mechanical manual lifting ………………….
3) Lifting tool not inspected ……………………………
4) Chemicals not properly handled ………………………
D) POSITIONS OF PEOPLE
1) In danger of struck by……………………………….
2) In danger of striking against ……………………….
3) In danger of caught by …………………………….
4) In danger of fall/ slip / trip ………………………….
5) In danger of burnt ………………………………….
6) Wrong position ……………………………………..
7) In danger of electricity ……………………………..
E) HOUSEKEEPING
1) Access block by obstruction ……………………..
2) Tools/materials discorganized …………………….
3) Poor/ improper roping off ………………………….
4) Accumulation of rubbish ………………………….
F) PERMIT / PROCEDURES
1) Work w ithout permission …………………………..
2) Wrong permit ………………………………………..
3) Procedure not follow ed ……………………………
4) Wrong intruction on permit …………………………
5) Permit procedure not follow ed …………………….
Procedure No. AEC-HSE-PM-02 Form:03 Revision No.: 00
Engineering & Construction Co. L.L.C
G) ENGINEERING
1) Moving parts not guarded ………………
2) Electrical substandard ……………………….
3) Chemical substandard ……………………………..
4) Pressure substandard ……………………………..
5) Maintenance substandard …………………………
H) ENVIRONMENT
1) Water is being polluted ……………………………..
2) Air is being polluted …………………………………
3) Too much noise …………………………………….
4) Radiation exposure …………………………………
Why did the hazardous act / condition occur?
J) NOT AWARE
1) Not informed ………………………………………..
2) Language problem ………………………………….
3) Not reading permit …………………………………..
4) Wrong interpretation of risk ……………………….
5) Wrong instruction ………………………………….
6) No procedure ……………………………………….
7) Forgotten …………………………………………….
K) AWARE
1) Negligence …………………………………………..
2) Working condition (including w eather) …………..
3) Worksite layout ……………………………………..
4) The design of equip./tools …………………………
5) Work habits ………………………………………….
6) Lack of skill ………………………………………….
7) Time pressure ………………………………………
8) Not requested ………………………………………
9) Physical limitations ………………………………….
10) Not supplied / available …………………………..
Effective Date: 01/08/2012