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�. Description of Incident I Near Miss: (Describe fully the incident/near miss events. Tell exactly what happened and <br /> how it ha ened so that someone could recreate the incident or near miss. Use extra paper if ou need. <br /> Weather(Fog,rain,ice,sunshine,windy,extreme temperatures-report in degrees F or C) <br /> V <br /> Motor Vehicie Accident(MVA)-You may also have to fill out an Professional Driver? <br /> ti.. <br /> insurance form-Call Corporate Contracts Dept. 425 372-1600 ❑Yes ❑ No <br /> Total Years Driving: Company Vehicle? ❑ Yes ❑ No ! Operation Type: ; Accident Situation: <br /> -- -- - - - - — ........................_ ---- <br /> Truck Transportation: Years with Carrier: I Vehicle Type: Equipment#: <br /> u <br /> Accident Location(street,city,state): <br /> -- - __ <br /> Hazardous Material?E] Yes El No Reportable? ElYes ElNo No.of Vehicles Towed No.of Injuries: No.of Fatalities: <br /> Spill/Leak/Product Quality <br /> Product <br /> Name Quantity Product 2 Name QuantName <br /> ity ; Product 3 ! Quantity 1 <br /> ---- <br /> Agency Notifications <br /> Estimated Cost of Incident $ <br /> �,. Third Party Incidents <br /> Name of I Address i Telephone <br /> Owner <br /> -- --- -_ -- --------_ _........... <br /> Description of Damage: <br /> 4. —.. --........-_.------ --_-_ ---- <br /> Witness Name i Address Telephone - <br /> Witness Name E Address Telephone <br /> # Root Cause and Contributing Factors: Conclusion Describe in Detail Why Incident 1 Near Miss Occurred) <br /> 2 , <br /> ....... ......... -- <br /> 3 <br /> �. Root Causes Analysis RCA -Use proactive) to avoid Incidents and Near Misses. <br /> 1)Deficiency in task related ability or knowledge 5)Proper execution requires increased time or effort. <br /> 2)Deficiency in Standard Operating Procedures or 6) Improper procedures and performance is accepted <br /> Job Safety Analysis and allowed. <br /> �,. 3)Deficiency in the transference of information concerning 7)Previous improper performance of a task did not result <br /> the Standard Operating Procedures or JSA steps. in adverse results. <br /> 4)Deficiency or lack of the proper tools or equipment 8)Beyond the control of the Supervisor/worker(s). <br /> # RCA# Solution(s): How to Prevent Incident 1 Near Miss From Reoccurring Person Responsible ! Due Date Closure <br /> Date <br /> _... . <br /> Investigation Team Members <br /> Name Job Title ! Date <br /> Results of Solution Verification and Validation-after implementing solutions to make sure they work. <br /> +.+ ..._................._....._ ....._.... _. .__ __.._......— - ......_... <br /> _ <br /> Reviewed B <br /> Name Job Title I Date <br /> Acknowledgment Signatures for Injuries/illnesses <br /> Title Signature Date <br /> STANTEC Consulting Corporation <br /> +r Attachment 3 <br />