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Description of Incident/Near Nliss: (Describe fully the incident/near miss events. Tell what happened and ho%1 it <br /> Motor Professional Drive? ❑ Yes ❑ No <br /> Total Years Driving: Company Vehicle? ❑ Yes ❑ No Operation Type: Accident Situation: <br /> Truck Transportation: Years with Carrier: Vehicle Type: Equipment#: <br /> Accident Location(street,city,state): <br /> Hazardous Material?❑ Yes ❑ No Recordable? ❑ Yes ❑ No No.of Vehicles Towed No.of Injuries: No.of Fatalities: <br /> Quality <br /> Product Name Quantity PNamec[2 NamQuaadty Product 3 d4' <br /> Agency Notifications <br /> Cost $ <br /> identsThird Party Inc <br /> Name of Owner Address Telephone <br /> Description of Damage: <br /> Witness Name Address Telephone <br /> Witness Name Address Telephone <br /> Root Cause and Contributing Factors: Conclusion(Describe Detail Why Incident Near Miss Occurred) <br /> 1 <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> Root Cause(s)Analysis(RCA)- <br /> 1.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 7.Person thinks there is no personal benefit to always doing thejob according to <br /> standards standards <br /> 4.Inadequate tools or equipment 8.Uncontrollable <br /> # RCA# Solution(s):How to Prevent Incident/Near Miss From Reoccurring Person Responsible Due Date Closure <br /> Date <br /> Investigation Team Members <br /> Name Job Title Date <br /> Results of Solution Verification and Validation <br /> Name ' Job Tide Date <br /> First Line Supervisor <br /> _.............. Other(name) <br /> SECOR International Incorporated 27 Generic HASP <br />