In 2014, a Front End Loader (FEL) collided with a Forklift (FLT) that was being driven through a bulk product storage shed. Although there was no injuries sustained and only minor damage to the FLT, an investigation was undertaken to determine what went wrong and how the incident could be prevented from occurring again.
By way of background the FEL was being driven by an experienced operator who was performing a “floor blend” of various dry products which involved the FEL being driven back and forth into the product pile and the scooping up the products and blending them together. The operator would repeat this process multiple times, reversing in and out of the bay and the product pile until the products were adequately blended.
During a particularly busy period in the day, a contract, labour hire employee entered the bulk shed to get the FLT and assist with loading of customers outside.
The operator of the FLT proceeded to drive from the allocated parking space, past the bulk product storage bays. As he proceeded towards the exit door, he observed the FEL undertaking the floor blend however as he got closer, he realised the FEL was reversing out of the bay, and not going back in to continue the blending operation.
The FLT operator sounded the horn to alert the FEL operator to his presence. The FEL operator heard the horn, but could not see the FLT or operator due to significant blind spots from both the design of the storage walls and the size of the FEL versus the FLT. The FEL operator immediately applied the brakes however the FEL slid approximately 12 feet on the wet, slippery floor and collided with the diagonal front and right hand side of the FLT, pushing the FLT approximately 1 foot before stopping.
No injuries were sustained to either operator although the FLT did sustain minor structural damage to the load backrest, however due to the high potential of the incident; an investigation was commenced almost immediately.
What is PEEPO?
PEEPO is the acronym given to the process of Data Collection. For want of a better way to describe it, it provides a roadmap for the investigation team in terms of what they need to be exploring, who they need to talk to and others things to do throughout the investigation.
The collection of this data can be divided in to five main areas:
Conditions, actions or deficiencies in each of the five main areas may be identified as contributing factors to the incident.
Case Study PEEPO
For the incident involving the FEL colliding with the FLT, a comprehensive PEEPO was written which provided guidance for the investigation team. As the investigation progressed, some things were removed as they were determined to be non-contributory. Vice-versa there was also others that were added.
The PEEPO chart is one of your greatest assets when conducting an incident investigation. It will guide you through the process and keep you on track.
Take the time to work through it and develop it as comprehensively as possible to ensure you’ve explored all facets of the incident.
Interested in Knowing More?
Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Luke Dam (Chief Operations Officer)
Luke has worked in various industries over the years including pharmaceutical, retail, manufacturing, and transport including iconic brands like WesFarmers, Goodyear, CSL Limited, and Incitec Pivot Limited.
His work in OHS and learning and development has seen him deliver services to clients, both internal and external as well as managing service delivery teams around the world.
Luke holds a Graduate Certificate of Management (Learning) as well as a Diploma of Occupational Health and Safety, a Diploma of Training and Assessment Systems, a Certificate IV Workplace Training and Assessment, a Certificate III in Mine Emergency Response & Rescue and a Certificate II in Public Safety (SES Rescue).
Luke is extensively involved in a project to establish an association dedicated to confined space safety and to drive change in legislation to promote best-practice in this high-risk area. Luke is passionate about online OHS and incident investigation communities, moderating a number of large LinkedIn groups boasting over 11,000 members globally.