Document text
Incident Report
Harborline Distribution LLC · Riverside Distribution Center, Building B
Report number INC-2026-0142
Report status Final — investigation opened
Investigation lead Rachel Kim, EHS Manager
1. Type of incident
Tick every type that applies.
Type Details
Injury ☒ First aid only — graze to left palm
Near miss ☒ Vehicle–pedestrian, no contact
Property damage ☐
Security ☐
IT outage ☐
Other ☐
2. When and where
Date of incident 22 Oct 2026 (Thursday)
Time 06:52
Exact location Main aisle at the end of aisle C-14, zone C
Equipment involved Reach truck RT-07
Shift / activity Night shift, last 10 minutes before handover; put-away and picking
3. Reported by
Name Dana Whitfield
Role Night Shift Supervisor
Contact dana.whitfield@harborline.example · (555) 010-4417
Reported on 22 Oct 2026, 07:02
4. What happened
Facts only: what was seen, in order. No opinions and no blame — causes are analysed in the root cause analysis.
At 06:52 reach truck RT-07, operated by Marcus Bell, was reversing out of aisle C-14 into the main aisle with a pallet raised about 1 ft (0.3 m).
Luis Ortega, order picker, was walking across the main aisle toward the break room at the end of C-14. This point is not a marked crossing; the nearest marked crossing is at C-12.
Marcus saw Luis when the truck was about 3 ft (1 m) away and stopped. The truck did not touch Luis.
Luis stepped back, caught his heel on an empty pallet lying in the walkway and fell, landing on his left hand.
The truck's reverse alarm sounded. The rear blue warning light was not on. The convex mirror at the end of C-14 was pointing at the racking, not the aisle.
5. People affected and first aid
Name Role Injury / effect First aid given (by whom) Further treatment
Luis Ortega Order Picker Graze to left palm Cleaned and dressed by Angela Brooks, 06:58 None needed; returned to work 07:30
Marcus Bell Reach Truck Operator No injury; shaken Not needed; stood down for 30 min None
6. Witnesses
Each witness fills in a statement in their own words. Statements are attached in Appendix A.
Statement Name Role Contact Received
W-01 Priya Nair Inventory Clerk priya.nair@harborline.example 22 Oct 2026, 09:14
W-02 Tom Kowalski Loader, day shift (555) 010-2290 22 Oct 2026, 11:40
7. Immediate actions taken
Time Action By
06:53 Truck stopped; main aisle at C-14 closed with cones Dana Whitfield
06:58 First aid given to the picker Angela Brooks
07:05 RT-07 tagged out of service; keys to supervisor Dana Whitfield
07:20 Empty pallet removed; walkway at C-14 cleared Tom Kowalski
07:40 Work order WO-58213 raised for blue light and mirror Dana Whitfield
8. Photos and attachments
Ref Description Taken by / source
P-01 Worn pedestrian crossing paint at end of C-14 Dana Whitfield
P-02 Empty pallet in walkway (before removal) Dana Whitfield
P-03 RT-07 rear blue light, not lit Kevin O'Hara
P-04 Convex mirror at C-14 pointing at racking Kevin O'Hara
V-01 CCTV camera 7, 06:50–06:55 (kept for 90 days) Site security
9. Severity classification
Rate the worst credible outcome, not only what happened. Score = severity × likelihood (each 1–5).
Actual outcome First aid only
Potential severity (1–5) 4 — Major: serious injury if the truck had struck the picker
Likelihood of recurrence (1–5) 4 — Likely: same aisle end, every shift change
Score and level 16 — Critical
Low: 1–4 Medium: 5–9 High: 10–15 Critical: 16–25
10. Notifications
Record who was told, how and when. Check what your local regulator requires for this type of incident and record the decision here.
Notified How When By
Daniel Foster, Site Operations Manager Phone 22 Oct 2026, 07:05 Dana Whitfield
Rachel Kim, EHS Manager Email + this report 22 Oct 2026, 07:30 Dana Whitfield
Kevin O'Hara, Maintenance Lead Work order WO-58213 22 Oct 2026, 07:40 Dana Whitfield
Regulator — requirement checked Decision recorded in site log 22 Oct 2026, 10:00 Rachel Kim
11. Sign-off
Role Name Signature Date
Reported by Dana Whitfield
Supervisor / manager Daniel Foster
EHS / investigation lead Rachel Kim
Appendix A. Witness statements
One statement per witness, in their own words. Do not edit a statement; add questions and answers below it.
Statement W-01
Name Priya Nair
Role Inventory Clerk
Contact priya.nair@harborline.example
Where were you? At the cycle-count desk next to aisle C-13, about 20 ft (6 m) away.
What did you see? (your own words) I heard the reversing beeper and looked up. Luis was walking across from C-14 toward the break room with a tote. The truck came out backwards and stopped very close to him. He jumped back and fell over a pallet on the floor. I did not see a blue light on the floor behind the truck.
Time you saw it About 06:50, just before handover
Who else was nearby? Marcus on the truck; Tom coming in from the dock
Photos attached None
May we contact you with questions? Yes
Statement W-02
Name Tom Kowalski
Role Loader, day shift
Contact (555) 010-2290
Where were you? Walking in from dock door 4 toward the main aisle.
What did you see? (your own words) I saw the truck stop and Luis on the floor holding his hand. There was an empty pallet in the walkway at the end of C-14. Several people were crossing there because it is the short way to the break room.
Time you saw it 06:52 or a minute after
Who else was nearby? Priya, Marcus, two pickers from zone D (names not known)
Photos attached Photo of the pallet (sent to Dana)
May we contact you with questions? Yes
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