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Injury and Illness <br /> Prevention Program 2.22 <br /> PART 3: INCIDENT INVESTIGATION FINDINGS AND REPORT QUALITY REVIEW <br /> I Date Investigation Started (mm/dd/yyyy): <br /> Factors, Root Causes, and Solution (FRCS): Complete FRCS form and answer all 7 factor questions. If answering NO to Factors <br /> 1 —4 identify root cause(s)and explain why Qls)occurred. If answering YES to Factors 5—7 circle the root cause(s). Transfer <br /> the solutions guidance that addresses each root cause from the FRCS form to this form.Attach your completed FRCS <br /> Worksheet. If Factors 1-7 do not apply to the incident,write "External Cause" in the Factor column below and leave the <br /> remaining fields blank. Do not include individuals' names. <br /> DESCRIPTION OF UNDESIRABLE BEHAVIOR/CONDITION <br /> 11 <br /> 12 <br /> FACTOR(S)AND SOLUTION(S): HOW TO REDUCE POSSIBILITY OF INCIDENT RECURRING <br /> Selection of factors and solutions reflects the analysis of investigation team and is not meant to be a legally binding conclusion <br /> as to the Root Cause and/or solution. <br /> Behavior/ Root Solution(s) Person Completion Completion <br /> Condition Cause (Must Match Root Cause) Responsible Target Date Actual Date <br /> for <br /> Completion <br /> QUALITY REVIEW Correct root cause(s)identified? Do root cause(s)and solution(s)match?Are solution(s)feasible/maintainable? <br /> Name: Job Title: <br /> PART 4: Date Solutions were Implemented &Validated (Were Solutions Effective?) <br /> performed) <br /> Verifier/Validator Name and Job Details of I &V <br /> Date ` Solution Title ` ( p ) <br /> I <br /> *JOB TASK-Select the most appropriate one(primary job associated with incident-related work activity, avoid "Other" if possible) <br /> 1. CAMP 7. O&M 12. Trucking <br /> 2. Construction 8. Other Soil Work (e.g. 13. Waste Management <br /> 3. Drilling Compaction) 14. Work Area Preparation <br /> 4. Driving 9. Sampling 15. Other <br /> 5. Excavation/Trenching 10. Site Walk/ Inspection <br /> 6. Gauging 11. Subsurface Clearance <br /> 1/2019 Corporate Health and Safety Management Program I ROUX <br />