An interesting form to motivate crew to report near misses and there fore to contribute to promote a no-blame culture by reporting near-misses (MSC-MEPC. 7/Circ.7 10/10/2008).
Near Miss Observation Card
To be completed by the observer
Unsafe act: __ Unsafe Cond.: ___ Suggestion: ___
Date:________ Time:__________
Location:_______________________________________
Operation/Activity:________________________________
Name of Observer (optional):________________________
Description: _____________________________________
_______________________________________________
_______________________________________________
Potential Risk (s):
___ Injury to Personnel
___ Damage to the enviroment
___ Damage to the Property
___ Stoppage of Operations
Corrective Action (s): ______________________________
_______________________________________________
_______________________________________________
Close out:
Date: _____________
Name: ____________
Signature: __________
Near Miss Observation Card
To be completed by the observer
Unsafe act: __ Unsafe Cond.: ___ Suggestion: ___
Date:________ Time:__________
Location:_______________________________________
Operation/Activity:________________________________
Name of Observer (optional):________________________
Description: _____________________________________
_______________________________________________
_______________________________________________
Potential Risk (s):
___ Injury to Personnel
___ Damage to the enviroment
___ Damage to the Property
___ Stoppage of Operations
Corrective Action (s): ______________________________
_______________________________________________
_______________________________________________
Close out:
Date: _____________
Name: ____________
Signature: __________
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