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06/04/2008 09:33 FAX 8777958400 INCIDENT REPORT DESK 121 004 <br /> 06l04t2008 06:42 2094770116 C #1589 PAGE 03/04 <br /> F�cit # Pbrolae No. ( ) / Date of Loss / / PaLe# 3 <br /> (10)Coutrib+uting Factors: Conclodom me aribe in Detail Why Loss/Near Loss Occurred)Be sure to ask WHY 5 times <br /> (or as many times as necessary)in order to probe enough to mach the root cause(s). There maybe more than one* <br /> root cause for each questionable item so be Inquisitive throughout the endre observation process. Remember to stick <br /> to the facts. Your comments should begirt with the following phrase:'The employee said the Loss/Near Loss occurred <br /> because..."For example: <br /> ➢ `The employee stated that they do not usually walk around the vehicle prior to backing up:therefore,they did <br /> not see the pole behind the vehicle.` <br /> In addition,number each conclusion 2Wrately in order to WE Joentify what Root Cause a2plies to which conclusion <br /> 1 <br /> 3 — <br /> i <br /> (11)Root Causes)Analysis(RCA}: <br /> 9.Lack of skill or knowledge 5.Correct way takes more time and/or requires more effari <br /> 2.Lack of or inadequate operatioml procedures or work standard® 6.Shon-cutting standard procedures is posidvaly reinforced or tolerated <br /> 3.Inadequate Communication of expectation regarding procedures or work 7.Person thinim there Is no personal benefit 20 always doing the Job according to <br /> Standards Standards <br /> 4.Inade uate tools orequipment B.Uncontrollable <br /> Solution(s):Haw to Prevent Loss ear Loss From e4CCurring C°^'p1 e <br /> The employee and manger should agree on a feasible solutions)that Daze f Dote <br /> z RCA can be maintained for the longterm.Additionally the person responsible Parson our ! varmad <br /> No. N0, must agree on the solutions and the due date.This will help ensure the Resp iw Data f a <br /> ( } I validated <br /> dug date will give the person responsible a reasonab]a amount of time to <br /> r im lement the solution. l , <br /> 1 I , <br /> i <br /> , <br /> , <br /> I ' <br /> (12►6rve'stigation Team Members .lob rale Date <br /> N <br /> Business Gor>sultalac <br /> Stals Mara sr <br /> HES Specialist(For all injury cases) <br /> _ I <br /> Chevrakrroduct Coampsny lvlazketing Rev.Sept 2005 <br /> CSI-LI-NLI1 <br />