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INC-2026-0098

MEDIUMClosed

Reported by Alex Brown — Fitter

26 December 2025 at 02:00 amWorkshop Bay 2Near MissPressure/HydraulicsDay Shift

Incident Description

Tyre inflation cage door latch found to be defective during pre-use check. If tyre had been inflated, door could have opened under pressure. Cage taken out of service.

Immediate Actions Taken

  • 1Cage locked out and tagged
  • 2Replacement latch ordered
  • 3All inflation cages inspected

Likelihood x Consequence Matrix

InsignificantMinorModerateMajorCatastrophic
Almost Certain
Likely
Possible
Unlikely
Rare

Likelihood

3 / 5 — Possible

Consequence

3 / 5 — Moderate

Risk Score

9/25

Failed / Breached Controls

Procedural Compliance

Standard procedure not fully followed

MEDIUM
Effectiveness
30%

Controls That Held

PPE Usage

All personnel wearing correct PPE

Effectiveness
100%

Supervision

Supervisor was present in the area

Effectiveness
75%

Priority Questions

  • What were the direct and contributing causes of this incident?
  • Were all relevant procedures followed by personnel involved?
  • Was there adequate supervision at the time of the incident?

Follow-Up Questions

  • Were there any similar incidents in the past that could have predicted this?
  • Were all personnel adequately trained for the task being performed?
  • Were environmental conditions a contributing factor?

Systemic Questions

  • Does this incident indicate a gap in the current risk management framework?
  • Are there systemic issues with procedure adherence in this area?
  • Would additional engineering controls reduce the likelihood of recurrence?
01:45 am

Pre-start meeting completed

02:00 am

Incident occurred

02:05 am

Incident reported to supervisor

02:10 am

Area secured and barricaded

02:20 am

HSE team notified and on-scene

02:45 am

Initial investigation commenced

03:00 am

Report filed in SafetyScribe AI

Incident Details

Date & Time

26 December 2025 at 02:00 am

Location

Workshop Bay 2

Type & Category

Near Miss

Pressure/Hydraulics

Severity
Medium
Status
Closed
Shift

Day Shift

Reported By

Alex Brown — Fitter

  • Fitter — Alex Brown
Indoor workshop
Tyre Inflation Cage

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