CRITICAL INCIDENT REPORT

Date: September 16, 2053	Position: Safety Manager
Report Prepared by: [Your Name]	Contact Information: [Your Company Number]

Incident Details

Date and Time of Incident: September 15, 2023, at 10:30 AM	Incident Report Number: CIR2023-001
Location: Warehouse 3, Loading Dock	Shift/Work Period: Day Shift

Incident Description

At approximately 10:30 AM on September 15, 2053, an incident occurred at Warehouse 3's loading dock. An employee, Jane Alvarez, was operating a forklift to load pallets onto a truck when the forklift's brakes failed. As a result, the forklift collided with a stack of pallets, causing a domino effect, and several pallets fell onto the truck's loading area.

 

Response and Actions Taken

Upon witnessing the incident, fellow employees rushed to the scene and immediately contacted the on-site medical team. Jane Alvarez was examined for injuries, and it was determined that she sustained minor bruising but was otherwise unharmed. Emergency services were not required.

 

The forklift was removed from the area, and the loading dock was temporarily closed to assess the damage and ensure safety. The maintenance team was called to inspect and repair the forklift's braking system.

 

Witnesses and Statements

●     Witness Name: James Holland

●     Contact Information: jamesholland@email.com / (555) 555-5556

●     Statement: "I saw the forklift lose control and hit the pallets. It happened so suddenly; I rushed over to help Jane."

 

●     Witness Name: Sarah Williams

●     Contact Information: sarah.williams@email.com / (555) 555-5557

●     Statement: "I called the medical team right away. Jane was shaken up but seemed okay after the incident."

 

Photos or Documentation

[Attach photos of the forklift, the damaged pallets, and the incident scene.]

 

Impact Assessment

●     Injuries: Jane Alvarez sustained minor bruising but did not require medical attention beyond initial examination.

●     Property Damage: Several pallets were damaged, and the forklift's braking system requires repair.

●     Disruptions to Operations: The loading dock was closed for 2 hours for assessment and repair, causing minor delays in outbound shipments.

 

Follow-up Actions

●     Investigation: The safety team will conduct a thorough investigation into the cause of the brake failure and recommend preventive measures.

●     Policy/Procedure Changes: A review of forklift maintenance and inspection procedures will be conducted to prevent similar incidents.

●     Training: All forklift operators will undergo refresher training on equipment safety.

Responsible Parties

●     Responsible Party 1: Maintenance Department

●     Responsible Party 2: Safety Department

 

Recommendations

●     Implement more frequent and rigorous forklift maintenance checks.

●     Consider replacing older forklifts with newer models for increased safety.

●     Conduct regular safety drills to ensure employees are familiar with emergency procedures.

 

Signatures and Approval

 

Report Prepared by:                                                Supervisor's Approval:

_______________________                                               _______________________          

[Your Name]                                                                              Jim Allen

September 16, 2053                                                          September 16, 2053

 

 

 

 

HR Department:

________________________

[HR Signature]

September 16, 2053

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