Near Miss Cases Sample
Near Miss Cases Sample
1. Report Header:
o Title (e.g., "Near Miss Report")
o Report number or identifier
o Date and time of the report
2. Details of the Person Reporting:
o Name
o Job title or role
o Contact information
3. Incident Details:
o Date, time, and exact location of the near miss
o Weather conditions (if relevant)
o Description of the work being carried out when the near
miss occurred
4. Detailed Description of the Near Miss:
o Sequence of events leading to the near miss
o The actual event described in detail
o Potential outcomes had the near miss turned into an
actual incident
5. Involved Parties:
o Names and roles of individuals involved in or witnesses
to the near miss
o Statements or accounts from these individuals, if
possible
6. Immediate Actions Taken:
o Steps taken immediately after the near miss to mitigate
risks or rectify the situation
o Emergency measures or first aid provided, if any
7. Contributing Factors:
o Possible causes or factors that led to the near miss, such
as equipment malfunction, human error, procedural
lapses, or environmental conditions
8. Recommendations/Corrective Actions:
o Suggested actions to prevent a recurrence of such an
incident in the future
o Recommendations for training, changes in procedures,
or equipment modifications
9. Attachments (if applicable):
o Photos or videos of the scene or equipment involved
o Copies of relevant documents, such as equipment
maintenance logs or training records
o Witness statements or other supporting documentation
10. Review and Follow-Up:
o Actions planned or taken as a result of the near miss
report
o Names and designations of personnel responsible for
implementing these actions
o Expected timelines for completion
11. Signatures:
o Signature of the person reporting the near miss
o Signatures of supervisors, managers, or safety personnel
reviewing the report
12. Feedback Loop:
o A section where feedback from the review process is
documented, including any lessons learned or insights
gained
13. Confidentiality Statement:
o If appropriate, a note or section ensuring confidentiality
to encourage honest and open reporting
Corrective / Preventive
Description of Near Miss Root Cause of Near Miss
Measures taken
During the maintenance work a Root Cause: Corrective / Preventive
concrete pipe fell down from a height of 1.Careless Behavior. Measures taken: -
3 meters (approximately). At 2.All the process takes 1.Advised to follow safety
11.4.24@10: 36 hours. And the fallen casually. Instructions
pipe came to the other colleagues 3.pipe were laid vertically 2.Advised use required PPEs
4.Pipes were not well tied 3.AwarenessTraining
with additional ropes or 4.Immediately stop the
other means. activities
5.Pipes should be securely tied
with rope or other means
6. Advised to use additional
rope to protect falling the pipes
7. Ensure PPEs.
Ne NearMiss -1
Ne
Corrective / Preventive
Description of Near Miss Root Cause of Near Miss
Measures taken
Concrete Pump Operator Mr. Surender Root Cause: Corrective / Preventive
(ITDCM) was employed to maintain 3.Careless Behavior. Measures taken: -
concrete pipe lines inside a cage 4.Arrogancy 1.Advised to follow safety
ladder. He was doing the work in the 5.All the process takes Instructions
absence of full body harness and casually 2.Advised use required PPEs
helmet. He was standing on the middle 3.AwarenessTraining
hoop of the ladder. 11.4.24@10 am: 31 4.Immediately stop the
hours activities
4.Ensure PPes.
Near Miss 02
Description: Root Cause: Corrective / Preventive
An employee of Debnath Maiti 1.Careless Behavior. Measures taken: -
(Swadesh) and an Operator of ITD Anil 2.Arrogancy 1.Advised to follow safety
Kumar (Operator ITD) both worked on 3.All the process takes Instructions
the boom placer (15 feet high) where casually 2.Advised use required PPEs
there was no guard rail system, in 3.AwarenessTraining
which case they worked on the boom 4.Immediately stop the
placer without full body harness. activities
On 11.04.24@10:35 hrs 4.Ensure PPEs.
NeaNear Miss -5
Near Miss-05
Description: Root Cause: Corrective / Preventive
A near miss incident occurred when a 1.Careless Behavior. Measures taken: -
worker of VSR was doing welding 2.No arrangement of 1.Advised to follow safety
works on over cable tray. material Instructions
Noticeable thing was that he has worn 3.All the process takes 2.Advised use required PPEs
his safety belt improperly. casually 3.AwarenessTraining
He did not anchored the lanyard as per 4. Ensure adequate anchored
requirement, if he does any mistake, point. Anchored point.
he will come down to the ground
straightway 17.4.24@10:31