SUPERVISOR'S VEHICULAR ACCIDENT REPORT ACCIDENT DESCRIPTION PLANT DATE OF ACCIDENT DATE OF REPORT NAME OF EMPLOYEE DRIVER CLOCK NO.

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1 SUPERVISOR'S VEHICULAR ACCIDENT REPORT ACCIDENT DESCRIPTION PLANT DATE OF ACCIDENT DATE OF REPORT NAME OF EMPLOYEE DRIVER CLOCK NO. SHIFT DESCRIPTION OF HOW COLLISION OCCURRED: MAKE DIAGRAM OF COLLISION IN SPACE BELOW: INDICATE POINTS OF COLLISION DIRECTION TO NORTH 1 SHOW YOUR VEH. AS 1 ARROW INDICATES DIRECTION OF TRAVEL DRIVER'S RECOMMENDATIONS TO PREVENT REOCCURRENCE: PAGE 1

2 SUPERVISOR'S VEHICULAR ACCIDENT REPORT INFORMATION PAGE NAME OF EMPLOYEE DRIVER CLOCK NO. SHIFT JOB TITLE LENGTH OF TIME DRIVING LENGTH OF EMPLOYMENT PAST ACCIDENT HISTORY OF DRIVER TIME EMPLOYEE STARTED WORK ON DATE OF COLLISION? WAS CO. DRIVER WEARING SEAT BELT? DEPARTMENT SUPERVISOR TIME OF COLLISION AM / PM EXACT LOCATION WHERE COLLISION OCCURRED TYPE OF CO. VEHICLE INVOLVED CO. VEH. I.D. NUMBER WITNESSES NAMES AND PHONE NUMBERS WAS CO. DRIVER INJURED? IF YES, EXTENT OF INJURY WHERE TREATED WAS CO. VEHICLE TOWED? IF YES, WHERE DAMAGED AND SEVERITY ESTIMATE AUTHORITIES CALLED? TYPE OF AUTHORITY (POLICE, SHERIFF, STATE TROOPER, F.D.) DID THEY FILL OUT A REPORT? RPT # WERE CITATIONS ISSUE? TO WHOM? NAME OF DRIVER(S) OF OTHER VEHICLE ADDRESS (STREET, CITY, STATE) PHONE NUMBER D.L. # FROM WHAT STATE NO. OF OTHER VEHICLES INVOLVED DESCRIPTION (LIC PLATE NO., MAKE, YEAR, COLOR) PASSENGERS? NO. WERE THEY INJURED? EXPLAIN OTHER PERSONS INJURED? TOTAL NO. OF INJURED NAMES OF INJURED PAGE 2

3 SUPERVISOR'S VEHICULAR ACCIDENT REPORT ACCIDENT PROFILE NAME OF EMPLOYEE DRIVER DATE OF ACC. SHIFT POTENTIAL CAUSES SAFETY MANAGEMENT DRIVING TASK z NEED FOR MORE SAFETY CONTROL z FOLLOWING TOO CLOSELY z LACK OF SUPERVISION z INATTENTION OR DROWSINESS z UNFAMILIAR WITH ROUTE TO BE TRAVELED z MISJUDGING SPEED OR ONCOMING TRAFFIC z MISJUDGING SPEED AND CLOSENESS OF VEHICLES DRIVER QUALIFICATIONS z WANDERING OVER LANE DIVIDERS z AGGRESSIVE OR WRIECKLESS ATTITUDE z FAILURE TO ANTICIPATE LANE MERGERS z LACK OF SKILL z FAILURE TO SIGNAL z HEALTH PROBLEMS z PERSONAL PROBLEMS z ALCOHOL PROBLEMS z DRUG IMPAIRMENT zillness OR FATIGUE z ADVERSE EMOTIONAL STATE znot FAMILIAR WITH PROPER SPEED CONTROL z NOT FAMILIAR WITH PROPER GEAR RATIO z UNAWARE OF CONDITIONS WHICH CAUSE JACKKNIFING z UNAWARE OF INFLUENCE OF TOP HEAVY CARGO VEHICLE MAINTENANCE z LACK OF PREVENTIVE MAINTENANCE z INADEQUATE MAINTENANCE z MECHANICAL DEFECT z INADEQUATE INSPECTIONS z FAILURE TO CHECK BRAKE ADJUSTMENT z FAILURE TO REPLACE BADLY WORN PARTS z FAILURE TO INSPECT TIRE CONDITION z FAILURE TO REPLACE WORN OR DAMAGED TIRES z FAILURE TO TORQUE WHEEL NUTS PROPERLY z FAILURE TO GREASE STEERING JOINTS REGULARLY z FAILURE TO REPLACE WORN OUT STEERING JOINTS z FAILURE TO CHECK POWER STEERING FLUID LEVEL z FAILURE TO PERIODICALLY INSPECT SPRINGS z FAILURE TO CHECK U-BOLTS z MISJUDGING TIME FOR VEHICLE TO CLEAR INTERSECTION z FAILURE TO OBEY TRAFFIC CONTROL DEVICE z POOR MIRROR ADJUSTMENT z FAILURE TO USE MIRRORS z FAILURE TO SCAN SPACE TO THE SIDES z FAILURE TO BLOCK AREA TO THE RIGHT z FAILURE TO USE TURN SIGNALS zturning FROM WRONG LANE z FAILURE TO GIVE RIGHT-OF-WAY TO PASSING TRAFFIC z ASSUMING OTHER DRIVER WILL SEE AND AVOID z ADVERSE CONDITIONS z UNABLE TO JUDGE SAFE SPEED FOR ROAD VISIBILITY/CONDITIONS z AGGRESSIVE BRAKING ON SLIPPERY ROAD z FAILURE TO ANTICIPATE OBJECTS ON ROAD/BAD ROAD SURFACE z FAILURE TO USE HEADLIGHTS AND RUNNING LIGHTS z SUDDEN STOPPING IN TRAVEL LANE z PARKING IN TRAVEL LANE WITHOUT USE OF EMERGENCY EQUIPMENT z EXCESSIVE SPEED FOR CURVE z INATTENTIVE TO PEDESTRIAN TRAFFIC z FAILURE TO ANTICIPATE A PEDESTRIAN ERROR z RUNNING ON TO CURVE z OVERUSE OF BRAKES ON DOWNGRADE z OVERUSE OF TRAILER ONLY BRAKES z FAILURE TO RESPOND TO SYMPTOMS DURING DRIVING z FAILURE TO START UP SLOWLY z FAILURE TO CHECK ALL AROUND VEHICLE FOR CLEARANCE z FAILURE TO BEGIN BACKING UP IMMEDIATELY CARGO/PASSENGERS AFTER CHECKING AROUND VEHICLE z CARGO NOT PROPERLY SECURED z FAILURE TO SECURE VEHICLE AFTER PARKING z OVERLOADING VEHICLE z FAILURE TO ENSURE CLEARANCE z LIQUID/GAS CARGO LEAK PRE-TRIP INSPECTION z DRIVER UNINFORMED OF NATURE OF SEALED CARGO z FAILURE TO CHECK BRAKE ADJUSTMENT z PERMITTING PASSENGERS TO STAND FORWARD OF LINE z PERMITTING PASSENGERS TO MOVE TO OR FROM SEAT WHILE UNDERWAY z IMPROPER COUPLING z DAMAGED HITCH z PINTLE HOOK NOT LATCHED z PERMITTING PASSENGERS TO TALK TO DRIVER WHILE UNDERWAY z SAFETY CHAINS NOT USED RECOMMENDED ACTION TO PREVENT REOCCURRENCE SUPERVISOR'S RECOMMENDATIONS: PAGE 3

4 ACCIDENT REVIEW BOARD RECOMMENDATIONS: SUPERVISOR'S VEHICULAR ACCIDENT REPORT CONCLUSION NAME OF EMPLOYEE DRIVER DATE OF ACC. SHIFT AFTER REVIEWING THE CIRCUMSTANCES SURROUNDING THE ACCIDENT, IT IS DETERMINED THAT THE ACCIDENT BE CLASSIFIED AS: z PREVENTABLEz NON-PREVENTABLE z UNABLE TO DETERMINE EXPLANATION OF DECISION/CLASSIFICATION: IF DISCIPLINARY STEPS WERE TAKEN, DESCRIBE THESE: DESCRIBE FINAL STEPS RECOMMENDED: PLANT MANAGER'S RESPONSE TO RECOMMENDATIONS: DESCRIBE WHAT HAS BEEN DONE TO DATE: SUPERVISOR SIGNATURE SAFETY COORDINATOR SIGNATURE PLANT MANAGER'S COMMENTS PLANT MANAGER'S SIGNATURE DATE FOLLOW UP COMMENTS: PAGE 4

5 DATE OF FOLLOW UP FOLLOW UP DONE BY PAGE 5