A near miss incident report form documents an event where a worker carrying materials on an unstable improper access into a building lost his balance but was prevented from falling by a fellow worker assisting him. The immediate actions taken were to replace the unsafe access with scaffolding steps and conduct a toolbox talk (TBT) to prevent recurrence. The report records details of the event such as classification, date, description, immediate actions, and reporting party.

1. KFAA Project Abnormal Event Report Form
Ref: Rev: Page 1 of 1
Near Miss Report
Report Reference No. 20220808-094-BSS-ABC-NMS-19-035
Contractor BSS JV Contract No. 152245
Programme / Project KFAA Location. CW07
Details of any Involved Person
First Name Trade
Last Name *
Company BSSJV Nationality
Initial Details of the Event
Current Classification of Event (see Definitions Section of Form for details). Tick all which apply
Days Away from Work Restricted Workday Fatality First Aid Medical Treatment
Motor Vehicle Accident Near Miss (NM) Property Damage Recordable
Actual Severity 1 2 3 4 5 Worst Potential Severity 1 2 3 4 5
Date: 03/08/2022 Time: 10:00 Day of Week: Tuesday
Brief Description of the Event:
Due to unstable improper access into the building, A worker carrying materials & lost his balance, a fellow worker was able to assist him,
thus preventing him from falling.
What immediate actions were taken to make safe and/or prevent recurrence:
The Unsafe access was immediately replaced with the scaffolding steps.
TBT was conducted
Reported by: – BSSJV HSE Team