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3 <br /> Praftssronal Dnver? ❑ Yes ❑ No <br /> Total Years Driving Company Vehicle? ❑ Yes ❑ No Operation Type. Accident Situation <br /> :E <br /> Transportation Years with Carrier Vehicle Type Equipment# <br /> :cadent Location(street city,state) <br /> f Hazardous Material?❑ Yes ❑ No Recordable? ❑ Yes ❑ No No of Vehicles Towed No of Injuries No of Fatalities <br /> Product Name Quantity Peruct 2 Name 3 Qu aty <br /> cy Notifications <br /> Now of Owner Address Te bane <br /> Pescnption of Damage <br /> Witness Name Address 'Telephone <br /> Witness Name Address Telephone <br /> # Root Caliseand Contributing Factoi.s: conellision (Describe if) Detail Why Incident Neat-Aliss Oucurred) <br /> 3 <br /> ,4 <br /> Root CatiNe(s) Analysis(RCA): <br /> I Lack of skill or knowledge 5 Correct way takes more time and/or requires more effort <br /> 2 Lack of or inadequate operational procedures or work standards 6 Short-cutting standard procedures is positively reinforced or tolerated <br /> 3 Inadequate communication of expectations regarding procedures or work standards 7 Person thinks there is no personal benefit to always doing the job according <br /> to standards <br /> r <br /> Inadegnate tools or equipment S Uncontrollable <br /> RCA# Closu <br /> # Solution(s) How to Prevent Incident/Near Miss From Reoccurring Person Responsible Due Date re <br /> Date <br /> Name Job Title Date <br /> Job Title Date <br /> Fust Line Supervisor <br /> Other(name) <br /> SECOR Interrtatcona[Incorporated 17 HASP-geoprobe <br /> Y� <br />