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Description of Incident/ Near Miss: escribe fully the incident/ near miss e ts. Tell exactly what happened <br /> and how it happened so that someone could recreate the incident or near miss. Use extra paper if you need. <br /> I <br /> Weather(Fog,rain,ice,sunshine,windy,extreme temperatures-report in degrees F or C) <br /> i <br /> Motor Vehicle Accident(MVA) -You may also have to fill out an Professional Driver? <br /> insurance form-Call Corporate Contracts Dept. 425 372-1600 ❑ Yes ❑ No <br /> Total Years Driving: Company Vehicle? ❑ Yes ❑ No I Operation Type: Accident Situation: <br /> _.._....._................................................................._..__._........_,....................._............................._._..........-.............................................................L..................._.........._........._....._._._•...._.............................................................._........................._L..._-___.._..__.._..__...._...............__....__._........._._.......... <br /> Truck Transportation: j Years with Carrier: i Vehicle Type: Equipment#: <br /> Accident Location(street,city,state): <br /> ......................._....-..........._..............................................................................-........................................................._................................................................._.._............................._......._.............................................. <br /> ..._..........._.-........... <br /> No.of Vehicles Towed I No.of Fatalities: <br /> Hazardous Material?F-1Yes El No Reportable? El Yes [I No I No.of Injuries: <br /> 1 <br /> Spill/Leak/Product Quality <br /> Product 1 Product 2j I i Product 3 <br /> I <br /> uantit uantit <br /> Name 1 Quantity I Name 1 4 Y I Name Q y <br /> Agency Notifications <br /> �i Estimated Cost of Incident $ <br /> Third Party Incidents <br /> Name of Address ; Telephone <br /> -� Owner <br /> j _..._................_........................._.................--........._..........—.._....—_._...._..........-.............._.............................................._:..............................................................................................................._.........................................................................._........................_._............__..._......................_........._........_................... <br /> Description of Damage: <br /> _...-----........._...... -----...—-- ... ....._......................------ --.-._..............-......._.............._.............................................._............_................_....._............._........_....._._.................._.............,.............---._.._—_.-.T-._.._..................._..... <br /> ....__._...--..... <br /> Witness Name I Address j Telephone <br /> —_..--..........I.._.__.....I._............__. ........._._..._._............__...._._..................__.....__._....--...._.. -_ --- -.._.__......- .._........---...... <br /> Witness Name Address _......._...._........__._.....____._..._.........___._._. Telephone I <br /> # Root Cause and Contributing Factors: Conclusion (Describe in Detail Why Incident/Near Miss Occurred) <br /> t <br /> 2 <br /> 3 — -................._......._........_.._._...._..._._................_........-........-...._....._.................---.....................................................-- ... ..._......._......__......_..__..._._._....._............... <br /> 41 <br /> Root Cause(s) Analysis(RCA) - Use proactively to avoid Incidents and Near Misses. <br /> .rl ♦Assign correct staff with level of experience and knowledge. ♦Drive defensively. <br /> ♦Provide correct resources and motivation. ♦Follow decontamination procedures. <br /> ♦Provide a mentor for the assignment. ♦Follow lockout/tagout procedures. <br /> ♦Perform a hazard assessment. ♦Prequalify and communicate with the contractor. <br /> ♦Develop and communicate a job safety analysis. ♦Perform SAFE Reviews <br /> ♦Design excavations with a competent person with Corp.H&S ♦Use Stop Work Authority when necessary <br /> support. <br /> # RCA# ( Solution(s):How to Prevent Incident/Near Miss From Reoccurring Person Responsible Due Closure <br /> Date Date <br /> I <br /> _.-.-....-.._-.._._-._.____._......................_.._.__..____..-___._._...-..__...-..�_...._...___. <br /> Investigation Team Members <br /> Name I Job Title Date <br /> ----........_.... <br /> _ <br /> Results of Solution Verification and Validation -after implementing solutions to make sure they work. <br /> Reviewed B <br /> Name I Job Title 1 Date <br /> I PG&E SECOR Intemational Incorporated <br /> SECOR Project No.050T.50234.00.0003 PG&E French Camp HASPB.doc <br /> i <br /> 30 <br />