A nonconformance usually  means a failure to follow or comply with some sort of standard.  I am not quite sure how an accident like this constitutes a systems failure.  It looks more like an accident and for that you follow your organisations accident reporting and investigation policy. HSG48 which gives background to human errors and how to classify the various types of human error, the difference between errors and violations etc.

When it comes to your report I was always told to; introduce the report(what are you  going to say), substance of the report( say what you want to say) and finally a summary and conclusion (i.e. explain what you have just said). You don’t need to mention legislation as it’s not relevant to the accident and it’s causes. Do not get into the blame game; leave that to managers and HR. Focus on the root causes not the immediate causes- so why was the FLT driver not maintaining proper awareness while reversing? Was it a lack of training or supervision?  Were they distracted? On the phone? Does the driver have issues with their vision? Is  the yard a mess with lots of blind spots and dead ends where you end up reversing a lot of time?

It would be a non-conformance if the system says not to do what the driver did, or it says to do something that the driver didn't do but which would have prevented the incident.

In our system you don't need to do it more than once for it to be a non-conformance if it's found (taht is, it doesn't need to be a continuing error).

When is this forum going to get a functioning spell checker?

Hi Anet

From the way you have posed your question it rather sounds as if you have been dragged in after others have led the investigation and have been given a brief to now finalise the report on an investigation that might have been far from satisfactory for e.g. reasons such as those that AK has hinted at.

It does rather sound as if you are now to be the henchman to identify the operator's "unsafe act" as "the cause" without much in depth investigation to look for the multiple possible "unsafe condition" that may have contributed to this accident. 

Many years ago, I got the job of developing and delivering training on incident investigation for an organisation. 

At each course I asked each of my delegates to write down the basics of an incident that they were personally familiar with and one of those one day was (surprise, surprise) a fork truck incident. 

At first sight this appeared to have been the result of unsafe acts by both the operator and another person who SHOULD have been acting as a banksman but was doing something else.

....and that was exactly how the organisation had initially seen it - they were about to discipline both these people before deciding that they really ought to dig a bit deeper and that's when all the skeletons came tumbling out.

Now I didn't know about all these skeletons when I asked two parallel case study groups to do a "5 WHYs" analyis of this incident.

SOOOO many unsafe CONDITIONS, which if any had been dealt with would have made the unsafe ACTS on the day largely irrelevant. ONE of them was the reason why the banksman was doing something else.

Is it too late to say STOP and revisit the investigation?

For something to be a "major non-conformance" - in management system auditing terms - there has to be either a complete gap or breakdown in the control measures, or a series of smaller issues that have not been addressed.

Either way, it would not be the fault of a single operator (such as a forklift driver).

So what exactly is meant here by calling it a "major non-conformance" rather than, as it seems, an accident?

An accident should be investigated in exactly the way described by AK above.

Google (other search engines available) HSG245, you will find a template in there to get you started. I know it varies from companies in terms of what is an NCR, Accident etc.

I would class this as an Incident, however thats just how my system works.

I created a single document for all investigation types (you will find this makes life easier) and if you can, recommend you do the same!

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