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`, u <br /> Description oflucident I Near I%I iss: (Describe fidly the incident/near miss events. Tell NvIi-M hapl)ened and hovir it happened.) <br /> MotorProfessional Driver? ❑ Yes ❑ No <br /> Total Years Driving: Company Vehicle? ❑ Yes ❑ No Operation Type: Accident Situation: <br /> Truck Transportation: Years with Carrier I 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 /> Spill/Leak/1'roduct Quality <br /> Produ <br /> Product Name Quantity ct 2 Product 3Nam Q.-fily C i Name Q�ury <br /> Agency Notifications <br /> Cost ol'Incident <br /> Third Party Incidents <br /> Name of Owner 7 Address Telephone <br /> Description of Damage: <br /> Witness Name Address Telephone <br /> Witness Name Address Telephone <br /> (Describe# Root Cause and Contributing Factors: Conclusion <br /> 1 <br /> 2 <br /> 3 <br /> 4 <br /> Rool 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 in 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 thejob according <br /> to standards <br /> 4.Inadequate tools or equipment 8.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 /> 77 <br /> Results cil'Solution Nlerification and Validation <br /> ORCMUMMEWE <br /> Name Job Title Date <br /> First Line Supervisor <br /> Other(name). <br /> SECOR International Incorporated 16 - HASP-drilling <br />