CR
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Environment · Health · Safety
CONFIDENTIAL · EHS RECORD
Workplace Incident Investigation Report

Forklift
Collision —
Bay 3.

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OSHA Recordability / Severity Classification
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Incident No.
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Date / Time
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Location
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Investigator
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01
Executive Summary
For: Safety / EHS Manager
Action: Corrective-action planning

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Injuries
1
Minor · First aid only
Lost-Time Days
0
Modified duty same shift
Property Damage
$3.4k
Rack upright + clip
Lane Downtime
11h
Bay 3 — Aisle C
Immediate Cause

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Snapshot — Factors at the Time of Contact

Factor
Finding
Operator
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Equipment
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Task
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Environment
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Witnesses
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Reportability & Notifications

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EHS Investigation · Page 2 of 5
02
Sequence of Events
Reconstructed from
dock cam + 3 witnesses

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Time to First Aid
6m
Within target
Time to Report
22m
EHS notified
Scene Secured
14:30
Lane barricaded
Evidence Sources
5
Cam · log · 3 stmts
Contributing Conditions

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Evidence Basis & Confidence

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EHS Investigation · Page 3 of 5
03
Root-Cause Analysis
Method: 5-Why +
contributing-factor weighting

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Contributing-Factor Weighting

Blocked rear sightline
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Staging outside footprint
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No spotter assigned
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Mid-task reassignment
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Handoff communication gap
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5-Why Chain

#
Question & Answer
1
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2
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3
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4
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5
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Barrier Analysis — Which Defenses Failed

Barrier
Status
Why it failed / was absent
Marked travel-path
Defeated
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Spotter for blind moves
Absent
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Staging-zone rule
Missing
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Operator training
Held
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Root Cause Statement

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04
Corrective Actions & Closure
Owner · Due date · Status
Verified by EHS
CA-1
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Done
CA-2
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In progress
CA-3
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In progress
CA-4
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Open

Corrective-Action Progress

CA-1 · Rack inspection
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CA-2 · Staging standard
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CA-3 · Spotter rule
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CA-4 · Toolbox talk
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Recommendations & Lessons Learned

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Effectiveness Verification

Control
Verification method & target
Engineering
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Administrative
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Training
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Recurrence
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Investigation Closure

Prepared by — EHS Manager
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Reviewed by — Plant Manager
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EHS Investigation · Page 5 of 5