Document text
Lessons Learned
INC-2026-0142 · Reach truck near miss at aisle C-14 · Harborline Distribution LLC
Incident date 22 Oct 2026
Type Near miss with a first-aid injury
Potential severity 16 — Critical
Review held 18 Nov 2026, with operators, pickers, supervisors, maintenance and EHS
Prepared by Rachel Kim, EHS Manager
Action status as of 16 Nov 2026
1. Summary
A reversing reach truck stopped about 3 ft (1 m) from a picker crossing the main aisle at the end of aisle C-14. The picker fell over a pallet in the walkway and needed first aid for a grazed hand. The investigation found that the truck's blue warning light had failed two days earlier and the defect was recorded but never reached maintenance. 9 actions were agreed; 5 are done and 2 are overdue.
2. Timeline
Date / time Event
20 Oct, 22:10 Blue light marked "fail" on RT-07 pre-use checklist; sheet filed, no work order
22 Oct, 06:52 Near miss at the end of aisle C-14; picker falls and grazes his hand
22 Oct, 07:05 RT-07 tagged out; site manager informed
22 Oct, 07:40 Work order WO-58213 raised
22 Oct, 11:40 Second witness statement received
23 Oct Blue light replaced; lights checked on all 12 reach trucks
27 Oct Root cause analysis session (5 whys, fishbone, risk matrix)
5 Nov SOP WH-07 revision 3 issued with defect-escalation step
18 Nov Lessons learned review
3. What went well
The operator stopped in time and the reverse alarm worked.
First aid was given within 6 minutes by a trained first aider.
The truck was tagged out within 13 minutes and the area was cleared.
Both witness statements were received the same day, before memories faded.
4. What did not go well
A failed safety item was recorded on paper and nobody acted on it for two days.
Pickers routinely cross at an unmarked point because it is the short way to the break room.
Put-away and picking share the main aisle at the busiest time of the shift.
Two similar near misses earlier in 2026 were filed separately and never linked.
5. Root cause
The pre-use inspection procedure (SOP WH-07) has no defect-escalation step and no owner, so defects found on trucks do not reach maintenance and trucks stay in service with failed safety equipment.
Contributing factors confirmed in the fishbone analysis:
People: Picker took a shortcut across the main aisle instead of the marked route
People: Operator reversing at shift change under time pressure to finish put-away
Methods: Pre-use checklist has no defect-escalation step
Methods: Put-away and picking both run in the main aisle at 06:45-07:10
Methods: SOP WH-07 has no owner or review date
Machines: Rear blue warning light failed on RT-07
Materials: Empty pallet left in pedestrian walkway at C-14
Measurement: No check of mirror alignment in the weekly safety walk
Measurement: Near misses at aisle ends not tracked as a trend
Environment: Pedestrian crossing paint worn at the end of C-14
Environment: Background noise high at shift change (dock doors, chargers)
6. Actions, owners and due dates
ID Action Owner Due Status
CA-01 Replace the rear blue warning light on RT-07 and check the lights on all 12 reach trucks Kevin O'Hara 23 Oct 2026 Done
CA-02 Realign and lock the convex mirrors at every aisle end in zone C Kevin O'Hara 30 Oct 2026 Done
CA-03 Add a defect-escalation step to SOP WH-07: any "fail" item = truck tagged out and work order raised in the same shift Rachel Kim 6 Nov 2026 Done
CA-04 Move the pre-use checklist to a digital form that raises a work order automatically Daniel Foster 30 Nov 2026 In progress
CA-05 Repaint the main-aisle pedestrian crossings and add "Stop - look" floor signs at zone C aisle ends Kevin O'Hara 13 Nov 2026 In progress, 3 days overdue
CA-06 Stagger shift change: no put-away in the main aisle from 06:45 to 07:10 Daniel Foster 9 Nov 2026 Done
CA-07 Toolbox talk on pedestrian routes and blind spots for all three shifts, with sign-off sheet Sophie Martin 6 Nov 2026 In progress, 10 days overdue
CA-08 Give every warehouse SOP a named owner and a review date Rachel Kim 15 Dec 2026 Not started
CA-09 Add a walkway check (no pallets in pedestrian routes) to the start-of-shift 5S round Dana Whitfield 2 Nov 2026 Done
7. What we are changing in our procedures
SOP WH-07 rev. 3: any "fail" on the pre-use check means the truck is tagged out and a work order is raised in the same shift.
Shift handover: no put-away in the main aisle from 06:45 to 07:10.
Start-of-shift 5S round now includes a walkway check.
Weekly safety walk now includes mirror alignment at every aisle end.
Every near miss gets a location code so repeats at the same spot are visible.
8. Who receives this
Name / group Why How
Luis Ortega and Marcus Bell Directly involved Close-out note + this document
Priya Nair and Tom Kowalski Witnesses Close-out note
All reach truck operators and pickers Same aisles, same risk Toolbox talk + noticeboard
Kevin O'Hara (maintenance) Owns CA-01, CA-02, CA-05 This document
Site leadership team Approves procedure changes This document
9. Sign-off
Role Name Signature Date
Prepared by (EHS) Rachel Kim
Site Operations Manager Daniel Foster
Maintenance Lead Kevin O'Hara
Close-out note to everyone involved
To Everyone involved in incident INC-2026-0142
From Rachel Kim, EHS Manager
Date 18 Nov 2026
Subject Near miss at aisle C-14 — what we found and what is changing
Thank you to everyone who gave a statement or took part in the review.
On 22 October a reversing reach truck stopped about 3 ft from a colleague at the end of aisle C-14. Nobody was seriously hurt. The main cause was not a person: a failed warning light was written down on the pre-use check, but our procedure had no step to get it to maintenance.
What changes now: a "fail" on the pre-use check takes the truck out of service until it is fixed; no put-away in the main aisle during shift change; walkways are checked at the start of every shift; please use the marked crossing at C-12.
5 of 9 actions are done. The rest have owners and due dates, and we will tell you when they are closed.
If you see something like this again, report it the same shift — a near miss reported today is an injury prevented tomorrow.
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