This report form must be completed and signed by the employee and supervisor for all accidents and incidents at ABC Software Company.

Incident Report for ABC Software Company

This report form must be completed and signed by the employee and supervisor for all accidents and incidents at ABC Software Company. One copy is to be submitted to the branch manager and one copy is to be kept in the personnel records of all parties involved.

Branch manager name: ______Sonja Rohos________

Name of reporter: __________Your Name ______ Employee number: __11022011__

Department: ___Publications Development__________________________________________

Location of incident: __Shared company break room__ Date of incident: ____1/3/2015___


Incident type:

Fire _X__ Injury ____ Spill ____ Malfunction ____

Brief description of incident: __A fire broke out at the company break room on Tuesday,______ December 31st , 2014. Two employees from the programming department were hospitalized for difficulty breathing._____________________________________________________________


Is a separate report attached: YES ___X___ NO _______


I certify that all information contained in this report is truthful and accurate to the best of my knowledge.

Employee signature: _ ____Your name________

Supervisor signature: _____Isec Rowan___________

Date: ______7/20/2020____________



ABC Software Company Incident Report


TO: Sonja Rohos, Branch Manager

FROM: Your Name, Technical Writer

SUBJECT: Incident report for fire in shared company break room


Hello Ms. Rohos,

I am a technical writer in the Publication Developments Department for ABC Software Company, located in 1234 ABC Way, Redmond, WA. Yesterday afternoon (Tuesday, October 5th, 2011), a fire occurred at the company break room in the microwave oven. As I was present at the time and doused the fire, I am writing this incident report according to company policy concerning the incident mentioned above. I have filled the appropriate form and attached it with this report. Details follow.

On Tuesday, October 5th, 2011, I walked into the shared company break room at 2:34PM and found a fire going inside the microwave oven. The oven was still operating and had 14 minutes remaining in its timer. An open generic brand popcorn box lay on the counter next to the oven, with one bag missing from its contents. I immediately turned off the microwave oven with its ‘Stop’ button and used the fire extinguisher on the south wall next to the microwave to douse the flames in the oven. After the smoke cleared, I checked inside the microwave and saw there were charred remains of a popcorn bag and blackened pieces of the popcorn kernels. The bag itself had caught fire and exploded.

I do not know exactly how the fire started. However, after I put out the fire I checked the recommended microwave time for the popcorn. The microwave oven’s timer is suggested to be set for 2 minutes. Based on the time remaining (14 minutes), it is likely the operator set the time to 20 minutes and started the microwave. It seems the fire occurred after the bag was heated beyond its recommended time of 2 minutes.

Please note that when I entered the break room, the time was 2:34PM. After dousing the fire, I assessed the situation. Due to the smoke and charred smell pervading both the break room and the floor as well as the potential fire hazard of the damaged microwave, I called the emergency services at 2:38 PM. The firefighters arrived at 2:43 PM from the nearby fire station one block away. On my floor, Alan Martin and Dennis Alcott, both from the Programming Department, reported difficulty breathing. They were taken to General Hospital by ambulance at 3:00PM.

As I mentioned, there was no one present in the shared break room or in the vicinity. The fire occurred probably because there was no operator to turn off the microwave after the bag had been heated to its recommended time.

I inquired as to who was present at the break room several minutes prior to the fire. I found Bob Smith from the Accounting Department was outside smoking a cigarette. Bob Smith put the popcorn in the oven, as he frequently makes popcorn at his 2:25 PM break. He mentioned to me that he thought he had set the timer to 2 minutes for the popcorn.

The smoke and charred smell extended throughout the floor remained for several hours, forcing a halt in work. As mentioned above, two colleagues reported difficulty breathing and were hospitalized. I heard that they have been released after some medication and treatment for lung blockage. There may be some ventilation maintenance, filter unit repairs, and microwave replacement.

I believe this accident could have been prevented if the operator had remained in the break room while using the microwave. To forestall such incidents and ensure a safer workplace, I recommend that a new policy be instituted requiring the presence of the user of such electrical appliances in the shared company break room.


Your Name

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