Incident Investigation Report

On February 18, 2024, a significant safety incident occurred at Global Manufacturing Plant, located at 234 Industrial Park Rd, Heavy Industries City, HIC. At approximately 2:15 PM, a conveyor belt malfunction in the assembly section led to an unexpected stoppage, causing a pile-up of materials. This resulted in one employee, Michael Johnson, sustaining a minor arm injury while attempting to clear the blockage without following the standard shutdown procedures.

Immediate first aid was administered to Mr. Johnson, and he was subsequently taken to the nearest medical facility for further treatment. He was released the same day with a recommendation for minimal work use of the injured arm for one week. The assembly line was temporarily halted to ensure a safe environment for the initial investigation and to prevent further incidents.

The investigation team, comprising safety officers and engineering staff, conducted a thorough review of the incident. It was determined that the conveyor belt malfunction was due to a failed motor, which had not been flagged by the routine maintenance checks as it was still within its operational lifespan. Additionally, it was found that the immediate attempt to manually clear the jammed conveyor by Mr. Johnson was due to a lack of clarity in the emergency shutdown and blockage clearing procedures.

Following the findings, corrective actions have been implemented to prevent recurrence. These include an overhaul of the maintenance schedule to include more rigorous checks of critical machinery components, regardless of their projected lifespan. A review and update of the emergency and safety procedures were also conducted, emphasizing the importance of shutting down machinery before attempting to clear blockages. Furthermore, all staff in the affected section have undergone additional safety training to reinforce the proper response to equipment malfunctions and emergencies.

To address the procedural ambiguity, clear, step-by-step emergency shutdown and blockage clearing guidelines have been developed and communicated to all relevant personnel. Signage displaying these procedures has been installed at all machinery stations throughout the plant.

The incident and the outcomes of the investigation have been documented in the company’s safety management system. A review meeting is scheduled for six months post-incident to assess the effectiveness of the implemented changes and to determine if further adjustments are necessary.

This incident underscores the importance of clear safety procedures, proper training, and the need for vigilance in maintenance practices to ensure the safety and well-being of all employees at Global Manufacturing Plant.

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