Near Miss and Accident Form
Near Miss and Accident Form
Near Miss and Accident Form
For accidents involving injury to personnel, this Report must be completed by either the injured party or
the First Aider, and must be checked by the supervisor/manager. It should be signed / dated and
delivered by hand to the HSE Department.
Details of Injured Party/Person performing the task: Date & Time of incident:
12/04/2014 16:00hrs
Job Title:
Staff / Contract:
Home Phone No: Project Name (if applicable):
Date of Birth :
Circumstances Surrounding the incident: (attach diagrams, photographs extra sheets, as appropriate)
There was an electric short circuit from the Aircon voltage stabilizer input socket at the clean
room in W/S. The socket was completely burnt and damaged the stabilizer input plug
In the investigation , it is observed that the copper wires in the socket are corroded due to
moisture built up in the room. The Aircon voltage stabilizer plug is connected to a general 16
amp socket which is not preferable for Aircons .Aircons are connected to MCB socket
which is made of ceramic.
The aircon runs 24/7 in the clean room . the switch board panels are not sealed properly .
Due to that, Dust and reptiles(lizards) are in the switch board panels.
Was person able to continue working after treatment during same shift? Yes / No
Own Duties? - Yes / No Alternative Duties? - Yes / No
If alternative duties, give details:- NA
If not able to continue working same shift, give estimate of return date:-
At the time of the incident, was the person:
Document: 10000602876-PDC-000
HSE accident / near miss report form Version: 01 - IFC
Issue date: 14.04.2014
India Procedure Page: 2 of 6
Aker solutions ,KKD base ,INDIA Aker solutions ,KKD base ,INDIA
Signature: Date: Signature: Date: 14-04-2104
Job Title W/S technician Job Title : workshop Manager
Details of corrective measures taken: