Near Miss Checklist

The job task that was being performed at the time of the incident?

• Yes
• No
• N / A

What happened?

• Yes
• No
• N / A

Where and when it happened?

• Yes
• No
• N / A

The equipment or material involved?

• Yes
• No
• N / A

The individuals who were present?

• Yes
• No
• N / A

Equipment malfunction or failure

Equipment in need of repair or maintenance

Facility factors, like poor visibility, damaged walking/working surfaces, or slip-and-trip hazards

Operator error

Unauthorized personnel in a work area or performing a job task

Production pressures

Failure to take time to do the job properly

Failure to inspect equipment or missed inspection items

Horseplay

Lack of training

Any warning signs observed before the incident

The consequences

What the consequences might have been, including property damage, injury to workers, coworkers, or members of the public