Free Worksafe Incident Report Template
Worksafe Incident Report
I. Incident Overview
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Report Number: IR-2050-002
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Date of Report: May 19, 2050
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Time of Report: 2:00 PM
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Reported By: [Your Name]
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Position: Senior Safety Officer
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Incident Date: May 18, 2050
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Incident Time: 11:15 AM
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Location of Incident: Production Floor, Line 3
II. Description of Incident
Type of Incident: Near Miss
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At approximately 11:15 AM, a forklift driven by Mark Thompson nearly collided with a pallet of materials left in the walkway on the Production Floor, Line 3. The forklift operator managed to stop just in time, preventing potential injury and damage. The pallet had been left unattended by the loading crew, which created a hazardous obstruction in the designated walkway. Samantha Lee and Tom Hanks, who were working nearby, witnessed the incident.
III. People Involved
|
Role |
Name |
Position |
Contact Information |
|---|---|---|---|
|
Forklift Operator |
Mark Thompson |
Forklift Operator |
mark.thompson@example.com/(555) 321-9876 |
|
Loading Crew Member/Witness |
Sarah Johnson |
Loading Crew Member |
sarah.johnson@example.com/(555) 876-5432 |
|
Witness |
Tom Hanks |
Inventory Checker |
tom.hanks@example.com/(555) 987-6543 |
IV. Witness Statements
A. Witness 1
Name: Samantha Lee
Contact Information: samantha.lee@example.com / (555) 234-5678
Statement:
"I was stacking boxes nearby when I saw Mark's forklift coming down the aisle. It was going pretty fast, and then I noticed the pallet blocking his path. I thought they were going to collide, but Mark managed to stop just in time. It was a close call."
B. Witness 2
Name: Tom Hanks
Contact Information: tom.hanks@example.com / (555) 987-6543
Statement:
"I was doing inventory checks when I heard the forklift approaching. I saw the pallet in the walkway and thought, 'Uh oh, this isn't good.' Thankfully, Mark was able to stop in time. It could have been a serious accident if he hadn't reacted quickly."
IV. Injuries/Damage
A. Injuries
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No injuries were reported.
B. Damage
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No property or equipment damage occurred.
V. Immediate Actions Taken
The walkway was immediately cleared of the obstructing pallet. A brief safety meeting was held with the loading crew to emphasize the importance of keeping walkways clear and adhering to proper material storage protocols.
VI. Root Cause Analysis
A. Preliminary Findings
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The near miss was caused by the loading crew’s failure to follow established procedures for storing materials. The crew left the pallet in an area designated as a walkway, creating a significant safety hazard.
B. Follow-Up Actions
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A detailed review of the loading crew's procedures and adherence to safety protocols will be conducted. Additional training sessions will be scheduled to ensure all team members understand and follow the correct procedures.
VII. Corrective Actions
A. Short-Term Corrective Actions
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An immediate re-training session on material storage and walkway clearance has been conducted for the loading crew. Visual reminders and signs have been placed in critical areas to reinforce the importance of keeping walkways clear.
B. Long-Term Preventive Measures
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A new policy has been implemented requiring regular checks of all walkways to ensure they are free from obstructions. Monthly safety drills and inspections will be conducted to maintain high safety standards and compliance with protocols.
VIII. Conclusion and Recommendations
The near-miss incident was a result of non-compliance with material storage procedures. It is recommended that ongoing training and periodic audits be enforced to maintain safety standards. Enhanced communication between departments regarding the importance of workplace safety should also be promoted.
IX. Company Information
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Company Name: [Your Company Name]
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Company Address: [Your Company Address]
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Company Email: [Your Company Email]
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Company Phone Number: [Your Company Number]
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Company Website: [Your Company Website]
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Company Social Media: [Your Company Social Media]
