Laserfiche WebLink
Description of Incident Near Miss: (Describe fully the incident near miss events. 'rell what happened and how it <br /> Professional Driver? ❑ Yes ❑ No <br /> To�Ye. ing Company Vehicles ❑ Yes ❑ No Operation Type <br /> - — --- -- Accident Situation <br /> Truck Transportation Years with Camer E Vehicle Type <br /> - ��-- ---- mint# <br /> Accident Location(street,city,state) <br /> Hazardous Matenah El Yes - ❑ No I Recordable? El Yes El No No of Velucles Towed No of InJurres I No of Fatalities <br /> Quality 3 <br /> Product Name Quantity Product 2 ( Quantity Product 3 Quantity_ � Name Name <br /> Agency Notifications <br /> Third Party Incidents <br /> Name of Owner Address 'Fele hone <br /> Description of Damage <br /> -Witness Name --�- --- Address ------------ ----------- ---Telephone--------- - - <br /> Witness Name -- -- Address —� i Telephone <br /> Root <br /> 3 1 <br /> 5 <br /> Root Cause(s) Analysis(RCA): <br /> 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 the Job according to <br /> standards standards <br /> 4 Inadequate tools or equipment 8 Uncontrollable <br /> # i RCA# ! Solution(s) How to Prevent Incident/Near Miss From Reoccurring i Person Responsible i Due Date I CDa[e e <br /> I <br /> Name Job Title Date <br /> E I <br /> i i <br /> I <br /> Name Job Title ( Date <br /> - - First Line Supervisor <br /> Other(name) <br /> SECOR International Incorporated 23 Generic HASP 6-14-01 <br />