Manager Investigation Report for Motor Vehicle Accident

• Employee Name

• Conducted on

  Date

• Prepared by

Employee Information

• Department

• Title

• Date of hire

• Date of birth

• # months in current position

Incident Information

• Date & Time of incident

  Date

• Amount of time on duty prior to incident

• Equipment involved

  Select Forklift Triple Pallet Jack Double Jack Single Jack Other

  • Forklift
  • Triple Pallet Jack
  • Double Jack
  • Single Jack
  • Other

• Other

• Equipment #

• Date and time Supervisor was notified.

  Date

• Specific work method being performed at the time of the incident.

• How many employee perform this same task?

• Description of the incident and any injuries, illness or property damage.

• Have there been similar incidents or near misses prior to this? If yes, explain. If no, mark NA.

• Did an unsafe act contribute to this incident?

  Yes

  No

• If yes, select all that apply from the list below. If no, mark NA.

• Unsafe Acts

  Select Lack of training Lack of skill Distracted Failure to anticipate Operating without authority Disabled safety device Working on moving equipment Poor sanitation Operating at unsafe speed Unsafe lifting Failure to use available PPE Other NA

  • Lack of training
  • Lack of skill
  • Distracted
  • Failure to anticipate
  • Operating without authority
  • Disabled safety device
  • Working on moving equipment
  • Poor sanitation
  • Operating at unsafe speed
  • Unsafe lifting
  • Failure to use available PPE
  • Other
  • NA

• Other

Review of Training Records

• Was training required for this task?

  Yes

  No

• Was training required for this task?

  Yes

  No

• Was training documented?

  Yes

  No

• Describe any 'no' answers or mark NA

Unsafe Conditions

• Did unsafe conditions contribute to this incident?

  Yes

  No

• If yes, mark all that apply below. If no, mark NA.

• Unsafe Conditions

  Select Inadequate Guarding Unsafe equipment Improper lighting Unsafe position Weather conditions (rain, snow, etc.) Uneven surface Other NA

  • Inadequate Guarding
  • Unsafe equipment
  • Improper lighting
  • Unsafe position
  • Weather conditions (rain, snow, etc.)
  • Uneven surface
  • Other
  • NA

• Other

Motor Vehicle Incident Information

• Truck type

  Semi

  Straight

  Bobtail

  Other

• Trailer Length

  28

  36

  48

  53

  NA

• Combination vehicle type

  Single

  Double

  Triple

  NA

• Truck #

• Trailer #

• Driver type

  Single

  Single w/ helper

  Team

• Time between routes

• Nearest city & state

• Road name/ hwy number

• Amount of time since last 34 hour break

• Amount of time since last 10 hour break

• DriveCam event number

• DriveCam event history reviewed?

  Yes

  No

• Accident history reviewed

  Yes

  No

• Traffic violation reviewed?

  Yes

  No

  N/A

• Does this driver meet minimum retention standards?

  Yes

  No

• Accident on a public road

  Yes

  No

• Injuries?

  Select 1 2 3 4 5 No injuries

  • 1
  • 2
  • 3
  • 4
  • 5
  • No injuries

• Fatalities?

  Select 1 2 3 4 5 No Fatalities

  • 1
  • 2
  • 3
  • 4
  • 5
  • No Fatalities

• Towed Vehicles?

  Select 1 2 3 4 5 No Towed Vehicles

  • 1
  • 2
  • 3
  • 4
  • 5
  • No Towed Vehicles

• Hazardous Materials Released?

  Yes

  No

• Citation issued to company driver?

  Yes

  No

• DOT drug test required?

  Yes

  No

• DOT drug test completed?

  Yes

  No

• If DOT drug test not completed within 32 hours, please explain why.

• DOT alcohol test required?

  Yes

  No

• DOT alcohol test completed?

  Yes

  No

• If DOT alcohol test not completed within 8 hours, please explain why.

• Driving Conditions

  Select Interstate Highway Parking Lot/Private Property Two way-divided Two way- not divided Other

  • Interstate
  • Highway
  • Parking Lot/Private Property
  • Two way-divided
  • Two way- not divided
  • Other

• Other

• Surface Type

  Select Asphalt Concrete Dirt Gravel Sand Grass

  • Asphalt
  • Concrete
  • Dirt
  • Gravel
  • Sand
  • Grass

• Road Configuration

  Select Bridge Crest Curve Grade Intersection Level Underpass Ramp Other

  • Bridge
  • Crest
  • Curve
  • Grade
  • Intersection
  • Level
  • Underpass
  • Ramp
  • Other

• Other

• Traffic Control

  Select Flashing Traffic Signal No Passing Zone No Controls Officer Railway Crossing School Zone Stop Sign Traffic Signal Work Zone Other

  • Flashing Traffic Signal
  • No Passing Zone
  • No Controls
  • Officer
  • Railway Crossing
  • School Zone
  • Stop Sign
  • Traffic Signal
  • Work Zone
  • Other

• Other

• Company Vehicle Action

  Select Backing Changing Lanes Entering Traffic/Merging Leaving Traffic/Exiting U-Turn Passing Parked Slowing/Stopping Stopped at light or sign Straight Turning-Left Turning- Right Other

  • Backing
  • Changing Lanes
  • Entering Traffic/Merging
  • Leaving Traffic/Exiting
  • U-Turn
  • Passing
  • Parked
  • Slowing/Stopping
  • Stopped at light or sign
  • Straight
  • Turning-Left
  • Turning- Right
  • Other

• Other

• Company Vehicle Direction

  North

  South

  East

  West

• Other Vehicle Action

  Select Backing Changing Lanes Entering Traffic/Merging Leaving Traffic/Exiting U-Turn Passing Parked Slowing/Stopping Stopped at light or sign Straight Turning-Left Turning- Right Other

  • Backing
  • Changing Lanes
  • Entering Traffic/Merging
  • Leaving Traffic/Exiting
  • U-Turn
  • Passing
  • Parked
  • Slowing/Stopping
  • Stopped at light or sign
  • Straight
  • Turning-Left
  • Turning- Right
  • Other

• Other

• Event Type

  Select Animal Awning/Overhang Bridge Overpass Building Concrete Barrier/Median Customer Sign Fire Hydrant Found Damage Guardrail Jackknife Mailbox Overturned/Rolled Parked Vehicle Pedestrian Pole (utility, light, etc.) Railway Vehicle Tree Underpass Vehicle Other

  • Animal
  • Awning/Overhang
  • Bridge Overpass
  • Building
  • Concrete Barrier/Median
  • Customer Sign
  • Fire Hydrant
  • Found Damage
  • Guardrail
  • Jackknife
  • Mailbox
  • Overturned/Rolled
  • Parked Vehicle
  • Pedestrian
  • Pole (utility, light, etc.)
  • Railway Vehicle
  • Tree
  • Underpass
  • Vehicle
  • Other

• Other

5 Whys

• Why did the incident occur?

• Why #2

• Why #3

• Why #4

• Why #5

• Additional Questions (if needed)

Root Cause Analysis

• What is the root cause of the incident?

• List any contributing factors or mark NA

• List any interim protections or mark NA

• What are the corrective actions?

• Who is responsible for the corrective actions?

• Date Completed

  Date

Media

• Add media

  Media

• Add drawing

  Drawing

Executive Review

• Supervisor Signature

  Sign

• Department Manager Signature

  Sign

• Safety Manager Signature

  Sign

• VPO/President Signature

  Sign