Fire or Explosion Failed to yield right of way Hazardous environment (gases, spills, etc.) Failed to use safety equipment High/low temperature exposure Failed to yield right of way Horseplay Following too closely Icy or slippery conditions Fog or smoke Improper body mechanics Glare Improper loading Holes/ruts in road Improper placement Icy/snowy road conditions Improper position for task Inadequate lighting (roadway) Improper safety equipment Inclement weather Inadequate lighting Improper backing Inadequate ventilation Improper lane change Inadequate warning system Improper parking Operating equipment without authority Improper passing Operating at improper speed Improper turning Pinch point (gears, pulleys, belts, etc.) Improper or over-loaded Projecting hazard Improper use of lights Removing safety devices Improper use of mirrors Safety devices inoperable Improper use of turn signal Service equipment in operation Loose road surface materials/gravel Under the influence of drugs/alcohol Misjudged clearance Using defective equipment/tools Obstructed view (signs, trees, etc.) Using equipment/tools improperly Parked/stopped vehicle Other (explain in detail below) Road construction Standing water Under the influence of drugs or alcohol Unsafe speed for conditions Worn or smooth tires Other (explain in detail below) Provide details for all contributing factors checked above: Section Four: Root Causes (Check all applicable causal factors that, if corrected, would prevent recurrence of the same or similar injury/illness, accident, or near miss.) Personal Factors Job Factors Provide details for all the root causes checked above:
Fire or Explosion Hazardous environment (gases, spills, etc.) High/low temperature exposure Horseplay Icy or slippery conditions Improper body mechanics Improper loading Improper placement Improper position for task Improper safety equipment Inadequate lighting Inadequate ventilation Inadequate warning system Operating equipment without authority Operating at improper speed Pinch point (gears, pulleys, belts, etc.) Projecting hazard Removing safety devices Safety devices inoperable Service equipment in operation Under the influence of drugs/alcohol Using defective equipment/tools Using equipment/tools improperly Other (explain in detail below) Failed to yield right of way Failed to use safety equipment Failed to yield right of way Following too closely Fog or smoke Glare Holes/ruts in road Icy/snowy road conditions Inadequate lighting (roadway) Inclement weather Improper backing Improper lane change Improper parking Improper passing Improper turning Improper or over-loaded Improper use of lights Improper use of mirrors Improper use of turn signal Loose road surface materials/gravel Misjudged clearance Obstructed view (signs, trees, etc.) Parked/stopped vehicle Road construction Standing water Under the influence of drugs or alcohol Unsafe speed for conditions Worn or smooth tires Other (explain in detail below) Provide details for all contributing factors checked above: Section Four: Root Causes (Check all applicable causal factors that, if corrected, would prevent recurrence of the same or similar injury/illness, accident, or near miss.) Personal Factors Job Factors Provide details for all the root causes checked above:
Accident%20Investigation%20Report%20Fill-in.docx