AAAA FORKLIFT INVESTIGATION CHECKLIST

• AAAA FORKLIFT INVESTIGATION CHECKLIST

• Investigation conducted on

  Date

• Lead Investigator

• Location
  Address

• Other members of the Investigation Team

FORKLIFT IDENTIFICATION

• Forklift Identification Number

• Name of Forklift Operator

INCIDENT DESCRIPTION

• Date / Time of Incident

  Date

• Incident Type

  Incident

  Near Miss

  Hazard

• Location on site where incident occured

• Describe What Happened

• Immediate Actions Taken

• Was there damage to the forklifts?

  Yes

  No

• Describe damage to Forklift

• Add Photo (if applicable)

  Media

• Were people injured in the incident?

  Yes

  No

• What was the person doing?

  Pedestrian (walking in area)

  Pedestrian (performing work in area)

  Truck Driver

  Forklift Operator (operating the forklift involved in incident)

  Forklift Operator (operating other forklift)

• Was there other damage?

  Yes

  No

• Was there damage to other objects?

  Select Building Bollard Pallet (empty) Cylinders Pallet (with cylinders) Truck (being used to transport cylinders) Other vehicles Forklift

  • Building
  • Bollard
  • Pallet (empty)
  • Cylinders
  • Pallet (with cylinders)
  • Truck (being used to transport cylinders)
  • Other vehicles
  • Forklift

• Describe damage to other building, vehicle, equipment etc.

• Add photo (if applicable).

  Media

• Forklift operator's description of incident.

• Witness's description of incident (if applicable).

OPERATOR INFORMATION

• Was the operator trained for the activity being performed.

  Yes

  No

• Number of years the forklift operator has held a forklift licence?

• Forklift licence number.

• Date licence expires.

  Date

• Number of years the forklift operator has been handling BOC products?

• Number of Years since last eye test.

• Number of years since last hearing test.

• What activities was the forklift operator performing in the four hours prior to the forklift incident?

• How many hours of continuous forklift operations had the operator undertaken prior to the incident?

FORKLIFT INFORMATION

• What is the make of the forklift

  Toyota

  Other than Toyota

• What is the year of manufacture (as per plate)?

  Select 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 Pre 2008

  • 2017
  • 2016
  • 2015
  • 2014
  • 2013
  • 2012
  • 2011
  • 2010
  • 2009
  • 2008
  • Pre 2008

• What is the mast configuration?

  Single stage

  2 Stage

  3 Stage

• What was the date of the last service?

  Date

• What was the forklift hours at the time of the incidents?

• Who owns the forklift?

  Forklift owned by BOC

  Forklift leased by BOC

• What was the date / time of the last pre-start check?

  Date

• Were there any defects noted in the pre-start check?

• Was an attachment being used at the time of the incident?

  NO

  Crane Jib

  Drum lifter

  Tyne Extensions

  Other

• What was recorded on the "load chart" regarding the attachments?

• Was the forklift fitted with a camera?

  No camera fitted

  Camera, forward facing fitted

  Camera, rear facing fitted

  Camera, forward and rear facing fitted

• Was the forklift fitted with "collective intelligence"?

  Yes

  No

• What was the activated message regarding the incident?

LOCATION INFORMATION

• Describe incident location

  Select Roadway Intersection Sort Dock Filling Bay Cylinder Storage Area Test shop Loading Zone Maintenance Work Other

  • Roadway
  • Intersection
  • Sort Dock
  • Filling Bay
  • Cylinder Storage Area
  • Test shop
  • Loading Zone
  • Maintenance Work
  • Other

• Were other activities being performed in the incident location, or near the incident location? This includes activities that were not part of the incident.

  Select Forklifts loading Forklift travelling Forklift handling pallets Other vehicles Maintenance Pedestrians walking Pedestrians working Pallets placed outside storage location Objects handled by forklifts Other objects Other activities

  • Forklifts loading
  • Forklift travelling
  • Forklift handling pallets
  • Other vehicles
  • Maintenance
  • Pedestrians walking
  • Pedestrians working
  • Pallets placed outside storage location
  • Objects handled by forklifts
  • Other objects
  • Other activities

• Road Surface / Conditions

  Select Dry Wet Concrete Bitumen Rough Smooth Other surface

  • Dry
  • Wet
  • Concrete
  • Bitumen
  • Rough
  • Smooth
  • Other surface

• Road Marking / Traffic Controls

  Select Roadway, no line marking Roadway, line marking Stop sign Give way sign No signs Pedestrian Crossing

  • Roadway, no line marking
  • Roadway, line marking
  • Stop sign
  • Give way sign
  • No signs
  • Pedestrian Crossing

• Light conditions

  Select Dark - Yard and Forklift lights Dark - Forklift lights Sunny Cloudy Glare Sun - in operators face Sun - behind operator

  • Dark - Yard and Forklift lights
  • Dark - Forklift lights
  • Sunny
  • Cloudy
  • Glare
  • Sun - in operators face
  • Sun - behind operator

• Intersection

  Select 3 Way 'T' 4 Way 'X' Defined / Marked Open / No Marking Other Clear View Blind Intersection Not Applicable

  • 3 Way 'T'
  • 4 Way 'X'
  • Defined / Marked
  • Open / No Marking
  • Other
  • Clear View
  • Blind Intersection
  • Not Applicable

OTHER INFORMATION

• Was the operator performing other activities at the time of the incident?

  Select Handling paperwork Mobile phone ringing Two way radio call Other noise event Looking at other activity Looking at other people NO Other activities / distractions

  • Handling paperwork
  • Mobile phone ringing
  • Two way radio call
  • Other noise event
  • Looking at other activity
  • Looking at other people
  • NO Other activities / distractions

• If the incident occurred at an intersection, did the operator sound the horn when entering the intersection?

  Yes

  No

  N/A

INCIDENT DEFINITION

• Incident Type

  Select Struck Object Dropped Load Mechanical Failure Refuelling Accessing Forklift Pain Whilst Operating Other

  • Struck Object
  • Dropped Load
  • Mechanical Failure
  • Refuelling
  • Accessing Forklift
  • Pain Whilst Operating
  • Other

• Direction of Travel

  Forward

  Reverse

  Not Moving

• Direction of Turning

  Turning Left

  Turning Right

  Not Turning

• Forklift Struck Object

  Select NO Object Struck Sort Dock Filling Bays Cylinder Storage Yard Truck - Loading Truck - Not Loading Building Bollard Forklift Other Person Ground / Concrete Hole / Grate Other

  • NO Object Struck
  • Sort Dock
  • Filling Bays
  • Cylinder Storage Yard
  • Truck - Loading
  • Truck - Not Loading
  • Building
  • Bollard
  • Forklift Other
  • Person
  • Ground / Concrete
  • Hole / Grate
  • Other

• Forklift Struck Object - Object / Material Struck

  Select NO Object Struck Cylinders Pallet - Cylinders Pallet - Empty Dry Ice Box Pack Lead / Manifold Strap / Ratchet

  • NO Object Struck
  • Cylinders
  • Pallet - Cylinders
  • Pallet - Empty
  • Dry Ice Box
  • Pack
  • Lead / Manifold
  • Strap / Ratchet

• Forklift Struck Object - Material Carried at Time of Strike ( The highest cylinders in the pallet)

  Select NO Load Empty Pallet G3 Cylinders G & G2 Cylinders S Cylinders F Cylinders E Cylinders D Cylinders C Cylinders 4 Pack 9 Pack 15 Pack Other Gas / Liquid Packages Dry Ice Box Other Materials

  • NO Load
  • Empty Pallet
  • G3 Cylinders
  • G & G2 Cylinders
  • S Cylinders
  • F Cylinders
  • E Cylinders
  • D Cylinders
  • C Cylinders
  • 4 Pack
  • 9 Pack
  • 15 Pack
  • Other Gas / Liquid Packages
  • Dry Ice Box
  • Other Materials

• Forklift Dropped Object

  Select NO Load Dropped Truck - Loading Sort Dock Filling Bay Cylinder Storage Yard Maintenance Other

  • NO Load Dropped
  • Truck - Loading
  • Sort Dock
  • Filling Bay
  • Cylinder Storage Yard
  • Maintenance
  • Other

• Forklift Dropped Object - Material Dropped

  Select NO Load Dropped Pallet - Empty (Queensland Pallet) Pallet - Cylinders (Queensland Pallet) Pallet - Empty (National Pallet) Pallet - Cylinders (National Pallet) 4 Pack 9 Pack 15 Pack Dry Ice Box Liquid Packages Maintenance Materials Other Objects Timber Pallet

  • NO Load Dropped
  • Pallet - Empty (Queensland Pallet)
  • Pallet - Cylinders (Queensland Pallet)
  • Pallet - Empty (National Pallet)
  • Pallet - Cylinders (National Pallet)
  • 4 Pack
  • 9 Pack
  • 15 Pack
  • Dry Ice Box
  • Liquid Packages
  • Maintenance Materials
  • Other Objects
  • Timber Pallet

• Forklift Dropped Object - Loading / Unloading

  Select Not Applicable Dropped Pallet / Pack / Ice box - Opposite side of truck Dropped Pallet / Pack / Ice box - Same side of truck Caught on truck Caught on strap / ratchet Caught on other Other loading / unloading dropped load

  • Not Applicable
  • Dropped Pallet / Pack / Ice box - Opposite side of truck
  • Dropped Pallet / Pack / Ice box - Same side of truck
  • Caught on truck
  • Caught on strap / ratchet
  • Caught on other
  • Other loading / unloading dropped load

• Forklift Dropped Object - Vehicle

  Select VCH Truck SDS Truck Flat Bed Truck - With Combing Rail Flat Bed Truck - Without Combing Rail Shipping Container - Without Combing Rail Shipping Container - With Combing Rail

  • VCH Truck
  • SDS Truck
  • Flat Bed Truck - With Combing Rail
  • Flat Bed Truck - Without Combing Rail
  • Shipping Container - Without Combing Rail
  • Shipping Container - With Combing Rail

• Mechanical Failure

  Select NO Mechanical Failure Engine Oil Leaks Hydraulic Hose / Ram Failure Wheel / Tyre Failure Steering Failure Lift Chain / Mast Failure Coolant Failure Other Mechanical Failures

  • NO Mechanical Failure
  • Engine Oil Leaks
  • Hydraulic Hose / Ram Failure
  • Wheel / Tyre Failure
  • Steering Failure
  • Lift Chain / Mast Failure
  • Coolant Failure
  • Other Mechanical Failures

• Filling Bay Incidents

  Select NOT at Filling Bay Tow-Away - Cylinders - Filling lead connected Tow-Away - Cylinders - Caught on manifold / lead Tow-Away - Pack - Filling lead connected Tow-Away - Pack - Caught on manifold / lead Tow-Away - Liquid Package - Filling lead connected Tow-Away - Liquid Package - Caught on lead Tow-Away - Other Other

  • NOT at Filling Bay
  • Tow-Away - Cylinders - Filling lead connected
  • Tow-Away - Cylinders - Caught on manifold / lead
  • Tow-Away - Pack - Filling lead connected
  • Tow-Away - Pack - Caught on manifold / lead
  • Tow-Away - Liquid Package - Filling lead connected
  • Tow-Away - Liquid Package - Caught on lead
  • Tow-Away - Other
  • Other

CONCLUSION

• What was identified as the "Root Cause"?

  Unsafe BEHAVIOUR

  Unsafe CONDITIONS

• What conclusions were identified part of the investigation?

ACTIONS

• Action 1 - Recommendation

• Action 1 - Relates To:

  Unsafe BEHAVIOUR

  Unsafe CONDITIONS

• Action 1 - Person Responsible

• Action 1 - Due date

  Date

• Action 2 - Recommendation

• Action 2 - Relates To:

  Unsafe BEHAVIOUR

  Unsafe CONDITIONS

• Action 2 - Person Responsible

• Action 2 - Due date

  Date

• Action 3 - Recommendation

• Action Relates To:

  Unsafe BEHAVIOUR

  Unsafe CONDITIONS

• Action 3 - Person Responsible

• Action 3 - Due Date

  Date

LESSON FROM LOSSES

• Could is incident occur in other locations on this site?

  Yes

  No

• Could this incident occur on other sites?

  Yes

  No

• Do other sites need to be advised of the incident?

  Yes

  No

SYNERGI CATEGORIES

Immediate Cause

• Behaviour

  Select Failure to follow safe system of work Improper loading / unloading Inadequate assessment of hazard or risk Operating at improper speed Operating equipment without authority Using defective equipment Using equipment improperly Improper lifting operation Other Not Applicable

  • Failure to follow safe system of work
  • Improper loading / unloading
  • Inadequate assessment of hazard or risk
  • Operating at improper speed
  • Operating equipment without authority
  • Using defective equipment
  • Using equipment improperly
  • Improper lifting operation
  • Other
  • Not Applicable

• Conditions

  Select Communication Competence and training Emergency preparedness and response Engineering and design failure Identification and evaluation of aspects, impacts and risk Operational management processes, planning and control Preventative maintenance and inspections NO SYSTEM FAILURE IDENTIFIED

  • Communication
  • Competence and training
  • Emergency preparedness and response
  • Engineering and design failure
  • Identification and evaluation of aspects, impacts and risk
  • Operational management processes, planning and control
  • Preventative maintenance and inspections
  • NO SYSTEM FAILURE IDENTIFIED

Root Cause

• Behaviour

  Select Inadequate education and training Inadequate engineering Inadequate equipment and tools Inadequate maintenance Other Not Applicable

  • Inadequate education and training
  • Inadequate engineering
  • Inadequate equipment and tools
  • Inadequate maintenance
  • Other
  • Not Applicable

Relevant Controls

• Relevant Controls

  Select Communication Competence and training Emergency preparedness and response Engineering and design failure Identification and evaluation of aspects, impacts and risk Operational management processes, planning and control Preventative maintenance and inspections NO SYSTEM FAILURE IDENTIFIED

  • Communication
  • Competence and training
  • Emergency preparedness and response
  • Engineering and design failure
  • Identification and evaluation of aspects, impacts and risk
  • Operational management processes, planning and control
  • Preventative maintenance and inspections
  • NO SYSTEM FAILURE IDENTIFIED

INVESTIGATOR

• Investigator

• Add signature

  Sign

• Sponsor, Reviewer, Approver

INSTRUCTIONS

• When complete, email completed form to the Zone Manager
  Synergi: Update Synergi with the information provided in the form including actions.
  Investigation to be reviewed and approved by Sponsor.

THE END