{"entity":{"name":"Acme Supplies SRL","registration":"BE0123456789","site":"Brussels warehouse"},"rca_id":"ACM-RCA-2026-006","related_incident_reference":"ACM-INC-2026-014 — forklift near-miss at rack column B-07","date_of_analysis":"2026-04-10","facilitator":{"name":"Marie Laurent","role":"Head of Operations (and certified ISO 45001 internal auditor)"},"team_members":[{"name":"Marc Dewinter","role":"Warehouse Operations Manager"},{"name":"Youssef El Amrani","role":"Forklift operator (incident witness)"},{"name":"Filip Vandenberghe","role":"Warehouse picker (incident witness)"},{"name":"Sophie Martens","role":"HSE coordinator"},{"name":"Jean-Michel Petit","role":"In-house maintenance technician"}],"problem_statement":"On 2026-04-05 at 13:42, a Linde H30T forklift clipped the front-right upright of rack column B-07 in the Brussels warehouse while exiting loading bay 2 at walking pace. The upright deformed between 15–25 cm from the floor. No injury and no falling load, but aisle B was blocked for approximately 30 minutes and one upright must be replaced (cost EUR 480 + labour). The event was reportable internally as a medium-severity near-miss (ACM-INC-2026-014).","chronology":[{"timestamp":"2026-03-10","event":"Layout change on aisle B completed; rack protectors on bay-side columns (B-01 to B-12) removed to access floor markings and not reinstalled."},{"timestamp":"2026-04-02","event":"Dock-side lighting replaced on aisle B; higher colour temperature (6500 K vs. 4000 K)."},{"timestamp":"2026-04-05 13:40","event":"Morning wave ending; two forklifts simultaneously exiting loading bays 1 and 2."},{"timestamp":"2026-04-05 13:42","event":"Forklift FL-LINDE-2021-03 clipped rack column B-07; impact at ~5 km/h."},{"timestamp":"2026-04-05 13:45","event":"Aisle B cordoned; Marc Dewinter notified; down-stacking of rack column B-07 commenced."},{"timestamp":"2026-04-05 14:15","event":"Aisle B reopened; rack column B-07 tagged out of service (RT-2026-041)."}],"analysis_method":"5_whys","five_whys":[{"level_1_why":"Why did the forklift clip the rack column? Because the operator's margin to the column was smaller than usual when exiting the bay and the upright was in the arc of the rear swing.","level_2_why":"Why was the margin smaller than usual? Because the rack protectors — which also act as a visual cue of the column's outer edge — were missing, so the apparent safe envelope was larger than the actual safe envelope.","level_3_why":"Why were the rack protectors missing? Because they were removed during the 2026-03 layout change and not reinstalled before the aisle was put back into service.","level_4_why":"Why were they not reinstalled? Because the layout-change checklist (ACM-WH-LC-001) does not list 'rack protectors reinstated' as a required sign-off step, so it was missed.","level_5_why":"Why does the checklist not list it? Because the checklist predates the 2022 rack retrofit when protectors were installed, and it has not been updated since."},{"level_1_why":"Why was the operator's peripheral perception reduced at that moment? Because aisle B had just been relit with a cooler colour temperature (6500 K) that produces glare at low sun angles, and mild glare was reported at the time.","level_2_why":"Why was a cooler colour temperature chosen without reassessing glare? Because facilities replaced the bulb on like-for-like lumens without checking the warehouse lighting standard (ACM-FAC-STD-LIGHT-004).","level_3_why":"Why was the standard not checked? Because the standard is not referenced in the Facilities work-order template used by the contractor."}],"root_causes":["Layout-change checklist ACM-WH-LC-001 does not require rack protectors to be reinstated before aisle re-opening; procedural gap.","Facilities work-order template does not reference the warehouse lighting standard, allowing bulb swaps that introduce glare at low sun angles.","No scheduled SEMA-style rack inspection in Q1 2026 that would have otherwise caught the missing protectors."],"corrective_actions":[{"action":"Add 'rack protectors reinstated' as a mandatory sign-off step in layout-change checklist ACM-WH-LC-001.","owner":"Marie Laurent","due_date":"2026-04-15","verification_method":"Revised checklist issued and acknowledged by warehouse supervisors; next layout change audited."},{"action":"Reinstall rack protectors on all loading-bay side columns (B-01 to B-12, A-01 to A-10).","owner":"Marc Dewinter","due_date":"2026-04-17","verification_method":"Physical walk-down with photo evidence filed in CMMS."},{"action":"Commission SEMA-approved rack inspection (Van Rompaey Racking BVBA) for the full racking installation.","owner":"Marc Dewinter","due_date":"2026-04-19","verification_method":"Inspection certificate filed; any findings tracked to closure."},{"action":"Add reference to the warehouse lighting standard in the Facilities work-order template.","owner":"Facilities team (with HSE sign-off)","due_date":"2026-04-22","verification_method":"Updated template in DMS; next lighting work order audited."},{"action":"Swap bay-2 lighting back to 4000 K fixtures consistent with the warehouse lighting standard.","owner":"Facilities team","due_date":"2026-04-25","verification_method":"Replacement WO closed; operator feedback confirmed."}],"preventive_actions":[{"action":"Schedule annual SEMA-style rack inspection and add it to the maintenance master schedule (CMMS).","owner":"Marc Dewinter","due_date":"2026-04-30","verification_method":"Recurring task visible in CMMS; first annual instance scheduled for 2026 Q4."},{"action":"Annual review of all warehouse checklists against current equipment layout (scope creep catch).","owner":"Marie Laurent","due_date":"2026-06-30","verification_method":"Review report filed; outputs actioned or declined with rationale."}],"lessons_learned":"Checklists outlive the equipment they were designed for unless they are part of a scheduled review. A layout change is a trigger to audit every checklist that touches the changed area — not just the one currently in use. The Facilities/HSE interface is a recurring weak point: like-for-like spec replacements must reference the authoritative standard, otherwise minor vendor substitutions (bulb colour temperature, belt type, etc.) can degrade the original engineering decision without anyone noticing.","approval":{"name":"Marie Laurent","title":"Head of Operations","date":"2026-04-11"}}