Near Miss / Incident / Accident
Report & Investigation Form
Particulars of incident:
Date: 03rd Mar 2025 Time: 11:22 hr Location:
Type of incident
First aid Medical treatment Restricted work case LTI
Fatality Fire Explosion Equipment Damage
Environmental Spill
Property damage Vehicle accident Chemical spillage
(Release over 5L)
Air Pollution Water Pollution Land Pollution Near Miss
Other -
What task was being performed at the time of the incident?
Inspection of Tank
What part of employee’s workday?
Entering or leaving work Doing normal work activities During break
Working overtime Other (Specify)
Person(s) Involved
Name: ID Number: Designation:
Department: Contact No: Full Time/Contractor:
Duration of Employment: Months doing this job:
Name: ID Number: Designation:
Department: Contact No: Full Time/Contractor:
Duration of Employment: Months doing this job:
Description of what happened (Describe, step-by-step the events that led up to the incident. Include names of
any machines, parts, objects, tools, materials and other important details):
On 03rd March 2025, at approximately 11:22 hrs, a surveyor accessed the top of a storage tank for inspection while
wearing a safety harness and securing himself to a fall arrestor block. During the inspection, instead of using
designated access routes such as walkways or approved crossing points, he jumped from one tank to another
and then back again, creating a serious risk of falling or losing balance. Despite being secured to the fall arrestor,
the uncontrolled movement could have led to a dangerous swing effect or an unintended fall.
Immediate corrective action take after the incident
A nearby worker/supervisor immediately stopped the surveyor and instructed him to return to a safe position.
The surveyor was reminded of proper work-at-height procedures and the risks associated with unsafe movement.
The unsafe act was reported to the safety team for further review and necessary corrective actions.
A quick safety briefing was conducted with the surveyor and other personnel to reinforce safe access procedures
and proper use of designated walkways.
Inspection work was temporarily halted to ensure compliance with safety protocols before resuming.
Describe the cause of the near miss / incident / accident (What do you think caused or contributed to the
incident?):
Unsafe Behaviour by the surveyor
Lack of Risk Awareness (complacency & under-estimation of hazards associated with the work activity)
Non-Adherence to company’s safety procedures.
Inadequate Supervision (A lack of immediate oversight)
Potential Gaps in Working at Training (The surveyor may not have fully understood or prioritized the importance of
using designated walkways and safe access points)
Contributory Factors (refer to these when identifying the cause of the near miss / incident / accident)
Unsafe workplace conditions: (Check all that apply) Unsafe acts by employee: (Check all that apply)
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Inadequate guard Operating without authority
Unguarded hazard Operating at unsafe speed
Safety device is defective Servicing energized (pressurized) equipment
Tool or equipment defective Removal of guards or making a safety device inoperative
Machinery/equipment failure Lack of proper safety devices
No training or insufficient training Failure to use right/available equipment/tools
Lack of knowledge of hazards present Improper use of tools & equipment
Inadequate or excessive illumination Using defective tools or equipment
Inadequate ventilation Alerting or modifying equipment
Hazardous arrangements Taking an unsafe position or posture
Lack of appropriate equipment/tools Non-use of lock out tag out
Unsafe clothing Inappropriate conduct - Distraction, horseplay
Lack of maintenance Failure to wear PPE or use it improperly
Inadequate warning systems Unnecessary rushing
Excessive noise Unsafe loading/placement
Congestion or restricted action Not following appropriate procedures/procedure error
Adverse weather Improper Handling
Poor working condition (slippery, heat, visibility) Shortcuts
Poor housekeeping Sabotage
Workstation layout is hazardous Drug or alcohol intoxication
Other:____________________________________ Other:____________________________________
Details of injury/damage - Indicate type of injury (put an ‘x’ in one box only):
Bruising, contusion Dislocation Poisoning
Concussion (to the head) Cut Infection
Internal injuries Puncture Burn, scalds and frostbite
Open wound Sprain, strain, torn ligaments Laceration
Abrasion, graze, scrapes Suffocation, asphyxiation Effects of radiation
Amputation Gassing Electrical injury
Open fracture (i.e. bone exposed) Drowning Foreign object
Closed fracture Contusion Crushing injury
Property damage - specify
Other - Specify
Parts of body injured (Indicate “R”, “L”, or “B”, where applicable):
Head Wrist
Eye Hand
Neck Fingers
Shoulder Hip
Upper back Upper leg
Lower back Knee
Upper arm Lower leg
Elbow Ankle/foot
Lower arm Other
Treatment:
Hospital:
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Type of treatment provided:
Root cause of the incident
Lack of Risk Perception (The surveyor did not fully understand the potential consequences of his actions, such as
the risk of falling or losing balance)
Failure to Follow Safety Procedures (The surveyor unknowingly disregarded established work-at-height protocols
by jumping between tanks instead of using designated access routes)
Complacency & Overconfidence (The surveyor may have assumed the action was safe due to familiarity with the
task, leading to risky behaviour)
Inadequate Supervision (There was no immediate intervention before the unsafe act occurred, indicating a lapse in
monitoring or enforcement of safety rules)
Inadequate mental capability Inadequate physical capability Lack of knowledge
Lack of experience Lack of skills Haste
Stress Boredom Over confidence
Improper motivation Lack of attention Human error
Abuse or misuse Criminal act Inadequate purchasing
Inadequate work order/direction Inadequate planning Inadequate supervision
Lack of standards, procedures or Inadequate standards or Inadequate work environment
work instructions procedures (incomprehensible) investments
Lack of compliance with High workload/insufficient
Inadequate training
standard/procedures manning
Inadequate tools Wear and tear Inadequate maintenance
Inadequate human-machine
Inadequate inspection/quality Previous corrective action not
interface (labels, displays,
control implemented
controls, etc.)
Supposed preventive action (How can future incidents be prevented?)
Mandatory Safety Induction for Third-Party Personnel:
Before accessing the worksite, all third-party personnel must undergo a site-specific safety briefing that covers
work-at-height procedures, fall protection, and prohibited actions such as jumping between tanks.
Strict Access Control:
Ensure that only authorized and trained third-party personnel are permitted to access elevated work areas.
Implement a permit-to-work (PTW) system for high-risk tasks.
Clear Contractual Safety Obligations:
Include safety compliance clauses in third-party contracts, explicitly stating that violations of site safety rules will
lead to immediate removal from the site or penalties.
Supervised Work for Third Parties:
Assign a designated site representative or supervisor to oversee third-party activities and intervene if unsafe
practices are observed.
Toolbox Talks Before Work Begins:
Before any third-party personnel start work, conduct a briefing on specific site hazards and expectations,
emphasizing the importance of using designated access routes.
Written Acknowledgment of Safety Rules:
Require third-party personnel to sign a safety compliance form confirming their understanding of and commitment
to following all site safety procedures.
Immediate Reporting & Escalation Procedure:
Ensure all supervisors and employees are aware of the immediate reporting process for unsafe acts by third-party
workers so that corrective action can be taken promptly.
Stop the activity Guard the hazard Train the employee(s) Train the supervisor (s)
Enforce existing
Redesign task steps Redesign work station Revise work procedure
procedure
Routine inspection for the Personal protective Tools, equipment
Perform risk assessment
hazard equipment replacement
Other (written
Request ergonomics Request environmental
Reassignment of person acknowledgement of safety
assessment assessment
rules)
Witness Details
Witness Statement (Number 1)
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Name: ID: Designation:
Signature: Date: Time:
Witness Statement (Number 2)
Name: ID: Designation:
Signature: Date: Time:
Sketch of the incident
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Details of investigation team members:
S. No. Name Designation Date Signature
Recording on accident register and completion of all corrective actions:
Near Miss / Incident / Accident recorded on Accident Register and all corrective actions completed:
Name:_________________________ Signature: Date:
Details of person completing the report:
Name: Designation:
Signature: Date:
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