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

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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

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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.

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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:

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