Employee Name

INCIDENT / ACCIDENT / NEAR MISS REPORT

Incident Reference001-FZE-2014Date 22 /01 /2015

LocationNear Gate No-2Time of Incident5:45PM

Type of InjuryLost Time Injury|_| Yes |X| No

No. of Days Lost

Property Damage|X| Yes NoExtent of Damage: Minor.

Description of incidentA 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:ID Number:

Occupation:Nationality

Age & Date of Birth Experience

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

Contributory FactorsProtective Equipment not usedNoInattentionNo

Protective Equipment not availableNoFatigueNo

Instructions not followedNoDefective EquipmentxYes

Lack of CommunicationNoPoor Judgmentx Yes

Lack of TrainingNoPoor HousekeepingNo

Contributory Negligence by OthersNoShortcutsNo

Good Accesses and Egress |_|NoImproper body positionNo

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 Action PlanResponsible PersonTarget DateComl.Date

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

See examples

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.

Prepared By:Arun NairDate: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:

YesNoUnsure

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 1 of 4UG-FM-FZE-HSE-19 R: 04 D: 27-08-14