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    Incident / Accident / Near Miss Report: Type of Injury

    Uploaded by

    Praise Sam Abraham
    A water drain pipe was broken during offloading of steel material from a forklift. The forklift tire slipped due to poor traction from worn out tires, causing it to hit the pipe. This resulted in minor property damage to the pipe. It was determined the primary causes were poor traction from worn tires and lack of protection for the downpipe. The recommended actions were to change the forklift tires, repair the pipe, and install protections to prevent future similar accidents.

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    © All Rights Reserved
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    Incident / Accident / Near Miss Report: Type of Injury

    Uploaded by

    Praise Sam Abraham
    33 views4 pages
    A water drain pipe was broken during offloading of steel material from a forklift. The forklift tire slipped due to poor traction from worn out tires, causing it to hit the pipe. This resulted in minor property damage to the pipe. It was determined the primary causes were poor traction from worn tires and lack of protection for the downpipe. The recommended actions were to change the forklift tires, repair the pipe, and install protections to prevent future similar accidents.

    Original Title

    Accident Report - Jan-25

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    A water drain pipe was broken during offloading of steel material from a forklift. The forklift tire slipped due to poor traction from worn out tires, causing it to hit the pipe. This resulted in minor property damage to the pipe. It was determined the primary causes were poor traction from worn tires and lack of protection for the downpipe. The recommended actions were to change the forklift tires, repair the pipe, and install protections to prevent future similar accidents.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    33 views4 pages

    Incident / Accident / Near Miss Report: Type of Injury

    Uploaded by

    Praise Sam Abraham
    A water drain pipe was broken during offloading of steel material from a forklift. The forklift tire slipped due to poor traction from worn out tires, causing it to hit the pipe. This resulted in minor property damage to the pipe. It was determined the primary causes were poor traction from worn tires and lack of protection for the downpipe. The recommended actions were to change the forklift tires, repair the pipe, and install protections to prevent future similar accidents.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    INCIDENT / ACCIDENT / NEAR MISS REPORT

    Incident Reference

    001-FZE-2014

    Date

    22 /01 /2015

    Location

    Near Gate No-2

    Time of Incident

    5:45PM

    Type of Injury
    Lost Time Injury
    No. of Days Lost

    Yes

    Property Damage

    Yes No

    No
    Extent of Damage: Minor.

    Description of incident
    A Water drain pipe ( PVC ) was broken during the material offloading. The incident occurred during
    the offloading of steel material with larger length(12 mtr). Reportedly the incident was occurred
    because of a fork lift tire slip and it is noticed that the traction is very poor because of the worn out
    tires.
    People Particular
    First and Last Names:
    Occupation:
    Age & Date of Birth

    ID Number:
    Nationality
    Experience

    Primary Cause
    Poor traction because of worn out tires.
    Lack of protection to downpipe

    Page 1 of 4

    UG-FM-FZE-HSE-19 R: 04 D: 27-08-14

    Contributory Factors
    Protective Equipment not used

    No

    Inattention

    No

    Protective Equipment not available

    No

    Fatigue

    No

    Instructions not followed

    No

    Defective Equipment

    xYes

    Lack of Communication

    No

    Poor Judgment

    Lack of Training

    No

    Poor Housekeeping

    No

    No

    Shortcuts

    No

    Improper body position

    No

    x Yes

    Contributory Negligence
    by Others
    Good
    Accesses and Egress

    No

    Action Taken
    It is advised to change the fork lift tires.
    Repair the downpipe
    Install protection

    Recommendation to Prevent a Recurrence of a Similar Accident in Future

    Responsible
    Person
    I have warned about similar incidents to racking. Facility
    Fork Lift accidents can happen. Facilities and Management
    especially storage racking and down pipes need
    adequate protection.
    See examples
    Action Plan

    Page 2 of 4

    Target
    Date

    Coml.
    Date

    UG-FM-FZE-HSE-19 R: 04 D: 27-08-14

    See YouTube video of racking accident caused by


    forklift
    https://www.youtube.com/watch?v=5OqsPL22_Uw
    This incident should demonstrate the potential risk
    to racking if struck by a vehicle or forklift.

    Page 3 of 4

    UG-FM-FZE-HSE-19 R: 04 D: 27-08-14

    Prepared By:

    Arun Nair

    Date:

    26 Jan 2015

    Review by Department (Division) Head


    I am in agreement with the findings of the incident / accident/ near miss report and concur with the
    steps taken or to be taken to prevent a recurrence of a similar incident in the future:
    Yes

    No

    Unsure

    If not in full agreement with the steps taken or to be taken to prevent a recurrence of a similar
    incident, as indicate by the incident / accident/ near miss report, specify the steps or additional
    steps that you deem necessary to prevent a recurrence of a similar incident:
    Name:

    Position:

    Date:

    Signature:

    Page 4 of 4

    UG-FM-FZE-HSE-19 R: 04 D: 27-08-14

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