Stamp Report

8/16/2019 Stamp Report

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T!()e o" *ontents

1. A(str!ct.'. Introdction+Liter!tre Re,ie.

-STAMP.

-STPA.

. Methodo)o%/+A&&ro!ch

-*!se Descri&tion.

-S!"et/ *onstr!ints.

-*ontro) Actions

-STPA !n!)/sis

-Reco00end!tions+S!"et/ "nction


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Abstract

The tr!dition!) !&&ro!ch to In-P)!nt Ro!d s!"et/ h!s (een th!t the indi,id!)

dri,er+o&er!tor is "))/ res&onsi()e "or hen !n !ccident or "!t!)it/ occrs.

*onter0e!sres !re 0ost)/ !i0ed !t 0ode))in% !nd ch!n%in% the (eh!,ior o" the dri,er

to !d!&t to the In-&)!nt ro!d s/ste0. ence there is ! need "or ! ne c!s!)it/ 0ode)

!nd h!2!rd !n!)/sis techni3e hich c!n incor&or!te the co0&)e4 d/n!0ic ro!d s!"et/

s/ste0. This techni3e sho)d (e !()e to in,o),e !)) the socio-technic!) s/ste0s "or the

In-P)!nt ro!d s/ste05 e!ch 0e0(er in this s/ste0 sho)d (e 0!de res&onsi()e !nd

!ccont!()e "or the ro!d s!"et/. The techni3e sho)d (e !()e to !d!&t to the ch!n%es in

In-P)!nt Ro!d s!"et/ o,er the ti0e !nd !)so 0ode) the co0&)e4 re)!tionshi&s (eteen the

co0&onents o" the In-P)!nt s/ste0.

S/ste0 Theoretic Accident Mode))in% Process 6STAMP75 ! c!s!)it/ 0ode) th!t tre!ts

s!"et/ !s contro) &ro()e0 r!ther th!n ! "!i)re &ro()e0. In STAMP5 !ccidents !re ,ieed

!s the res)t o" in!de3!te en"orce0ent o" constr!ints on s/ste0 (eh!,ior. The re!son(ehind the in!de3!te en"orce0ent 0!/ in,o),e c)!ssic co0&onent "!i)res5 (t it 0!/

!)so res)t "ro0 ns!"e inter!ctions !0on% co0&onents o&er!tin% !s desi%ned or "ro0

erroneos contro) !ctions (/ so"t!re or h0!ns. STAMP considers the socio-technic!)or%!ni2!tion o" the s/ste0 "or the i0&)e0ent!tion o" s!"et/ constr!ints5 hence !ssi%nin%

res&onsi(i)it/ to e!ch 0e0(er the s/ste0.

S/ste0 Theoretic Process An!)/sis 6STPA7 is ! ne !nd &oer") too) "or h!2!rd

identi8c!tion techni3e hich is (!sed on STAMP. STPA inc)des (oth co0&onent "!i)re

!ccidents !nd co0&onent inter!ction !ccidents5 it c!n &otenti!))/ 8nd 0ore c!ses o"

h!2!rds th!n the other 0ethods. ence !"ore0entioned &ro&erties o" the STAMP !ndSTPA 0eet the re3ire0ents o" the In-P)!nt Ro!d S!"et/ s/ste0.

This &!&er e,!)!tes the In-P)!nt ro!d s!"et/ s/ste0 sin% ro!d "!t!)it/ d!t! o" TATA

STEEL "or the /e!r '99:-11.This &!&er &resents !ssess0ent !nd s%%estion "or

i0&ro,in% the s!"et/ o" the in-&)!nt ro!d sers.


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Introduction/Literature Review

STAMP 6S/ste0 Theoretic Accident Mode))in% Process7 is 0!in)/ (!sed on to conce&ts

s/ste0 theor/ !nd s/ste0 thin


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Gener!) "or0 o" ! 0ode) o" sociotechnic!) contro).


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Process Models

Process 0ode)s !re !n i0&ort!nt &!rt in contro) theor/. This 0ode) is sed to deter0ine

h!t contro) !ctions !re needed5 !nd it is &d!ted thro%h "eed(!c


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Accidents in STAMP c!n (e nderstood (/ identi"/in% the s!"et/ constr!ints th!t ere

,io)!ted !nd deter0inin% h/ the contro)s ere in!de3!te in en"orcin% the0.

S/ste0 Theoretic Process An!)/sis 6STPA7

STPA 6S/ste0 Theoretic Process An!)/sis7 is ! h!2!rd !n!)/sis techni3e (i)t on STAMP.

Identi"/in% the &otenti!))/ ns!"e contro) !ctions "or the s&eci8c s/ste0 (ein% considered

is the 8rst ste& in STPA. These ns!"e contro) !ctions !re sed to cre!te s!"et/

re3ire0ents !nd constr!ints on the (eh!,ior o" (oth the s/ste0 !nd its co0&onents.

Addition!) !n!)/sis c!n then (e &er"or0ed to identi"/ the det!i)ed scen!rios )e!din% to

the ,io)!tion o" the s!"et/ constr!ints. As in !n/ h!2!rd !n!)/sis5 these scen!rios !re

then sed to contro) or 0iti%!te the h!2!rds in the s/ste0 desi%n.

Accordin% to STPA5 ns!"e contro) !ctions occr hen1. A re3ired contro) !ction is not &ro,ided 6i.e. contro) !ctions !re in!de3!te)/

e4ected7.

'. An incorrect or ns!"e contro) !ction is &ro,ided 6i.e. contro))er isses

in!de3!te contro) !ctions7.. There is in!de3!te "eed(!c< "or the contro) !ction !nd ths5 ! &otenti!))/

correct contro) !ction is &ro,ided !t the ron% ti0e 6e.%. too )!te7 or it is sto&&ed

too e!r)/.


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Methodology/Approach.

The In-P)!nt ro!d "!t!)it/ d!t! consists o" 1' ro!d !ccidents th!t h!,e occrred drin%

the /e!r '99:-11.*ASE1C

D!teC '99:

F!t!)it/C S!ihid Ans!ri '@B: Mo(i)e *r!ne O&er!tor ;: /e!rs E P-GROT PLAN-ENA=LING Ne!r LD1 *!nteen '@+9?+'99:

Shi"t-=

Descri&tion o" "!t!)it/CFor e0&t/ Gondo)! !%ons !tt!ched ith Loco @ !s (ein% &shed "ro0 RM to

LD1-**. At the crossin% o" the r!i)ro!d ne!r LD1 *!nteen5 hen the 1st !%on 6O&&.

to the en%ine7 0o,ed @:H o" the ro!d5 ! : ton Mo(i)e *r!ne 6)e"t h!nd dri,e7 co0in%

"ro0 E!st P)!nt dro& %!te !nd 0o,in% to!rds SMS hit the re!r &ortion o" the %ondo)!

(/ the ri%ht side o" its c!(in5 here Mr.S!hid Ans!ri !s sittin% in the 0e!nti0e Sri.S!hid

Ans!ri sst!ined injr/. The "ront &ortion o" the %ondo)! !s thron ot o" the tr!c


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Safety Constraint for better Visibility

1. ehic)es 0!r


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Gener!) Ro)es Res&onsi(i)ities o" the &ersonne) in,o),ed in contro) strctre

1. The M!n!%er is res&onsi()e "or the d!/ to d!/ &rodction !nd o&er!tions o" the &)!nt.

e i0&)e0ents or


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STPA !n!)/sis

1. A required control action is not provided (i.e. control actions are inadequately

executed)

-Dri,er ti0e+or< sched)e not &ro,ided (/ the 0!n!%er to e)i0in!te dri,er "!ti%eness.-Orders issed (/ the *hie" S!"et/ re%!rdin% the s!"et/ constr!ints !re not !de3!te)/

e4ected (/ the S!"et/ M!n!%ers.

2. An incorrect or unsafe control action is provided (i.e. controller issues inadequate

trol actions).

ron%+in!&&ro&ri!te sched)es !re &ro,ided to the s&er,isor.

!. "nadequate feed#ac$ for the control action

-There !re no "eed(!c< ch!nne)s re)!tin% to the e>ecti,eness o" the sched)e str!te%i2ed

(/ the 0!n!%er i0&)e0ent!tion s%%ested or ordered (/ the chie" s!"et/.

Reco00end!tions+s!"et/ "nctions.

1. M!n!%er sho)d str!te%i2e ! sched)e so th!t &ro&er rest inter,!)s !re &ro,ided to

dri,er to e)i0in!te dri,er "!ti%e. e sho)d see th!t the sched)e is i0&)e0ented

(/ contr!ctor+s&er,isor. Monitor *o))ect the "eed(!c< o" the dri,ers !nd re&ort it

to the S!"et/ M!n!%er. *ontr!ctor+S&er,isor sho)d i0&)e0ent the sched)e5 i"

there is !n/ dic)t/ in i0&)e0entin%. It sho)d (e i00edi!te)/ re&orted to the

M!n!%er.'. R!ndo0 chececti,e "eed(!c< ch!nne)s sho)d (e &ro,ided re%!rdin% i0&)e0ent!tion o" these

constr!ints. F!ci)it/ sho)d (e cre!ted sch th!t !n/ or


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;. A ti0e constr!ined re,ie sho)d (e s(0itted to chie" s!"et/ (/ the e4&ert te!0

re%!rdin% the Fe!si(i)it/ o" inst!))!tion !d,!nced !cti,e s/ste0 or !/ side horn !t

!)) n0!nned )e,e) crossin% sho)d (e chec


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*ontro) Actions

1. S!"et/ M!n!%er s!"et/ ocer sho)d condct s!"et/ dri)) !nd tests !nd %et "eed(!c<"ro0 the )oco0oti,e o&er!tor !nd cre re%!rdin% 0e!sres re3ired "or s!"e o&er!tion'. The M!int!iners +S&er,isors o" the tr!c< sho)d ensre th!t !n/ 0!inten!nce or<sho)d not (e done ne!r tr!cecti,e "eed(!c< in the i0&)e0ent!tion o" s!"et/ constr!int.

Reco00end!tions +s!"et/ "nctions.

1. *hie" s!"et/ sho)d order !)) the de&!rt0ent S!"et/ M!n!%er to !dit the 0ini00

s!"e hori2ont!) dist!nce o" tr!c< )ines in the &)!nt necess!r/ !ction sho)d (e t!


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1;

*ASE

D!teC '99@

*!s!)it/+F!t!)it/C Mn! N!0t!5 :;?;'5 9 Ye!rs5 e)&er En%ineerin% Projects GROT PLAN 1.B MTPA RM==N5 ne!r the

&ro&osed e4tension o"F)4 *rshin% =i)din% 6soth side79+9;+'99@5 9C;:C99 PM

Descri&tion o" F!t!)it/C Mr. Mn! N!0t!5 or


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'. K!rter)/ !ssess0ent on dri,er ,ision !nd he!rin% (/ condctin% tests.


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*ontro) Actions.

1. *hie" s!"et/ &!sses orders to s!"et/ 0!n!%ers thro%hot the &)!nt corres&ondin%de&!rt0ents to i0&)e0ent rn o,er &rotection in h/dr!5 cr!ne etc..'. S!"et/ 0!n!) o" !)) he!,/ ,ehic)es sho)d (e e0(edded5 t!%ht tested in tr!inin%o" the dri,er+he)&er (e"ore recritin%. *hie" s!"et/ orders tr!inin% institte.

. R!ndo0 chececti,e tr!inin% 0ethods to the dri,ers +he)&ers (e"ore his+her certi8c!tion.- F!ecti,e co00nic!tion (eteen the s!"et/ 0!n!%ers !nd the chie" s!"et/ )e!dsto 0is)e!din% st!nd!rds o" s!"et/ "or recritin% e0&)o/ees .

S!"et/ "nction+Reco00end!tions.

1. *hie" s!"et/ &!sses orders to s!"et/ 0!n!%ers thro%hot the &)!nt corres&ondin%de&!rt0ents to i0&)e0ent rn o,er &rotection in %ennie5 h/dr! etc. Feed(!c< on the

i0&)e0ent!tion o" rn o,er &rotection sho)d (e &ro,ide to the chie" s!"et/.I0&)e0ent!tion o" this constr!int sho)d (e ti0e constr!ined.'. E>ecti,e !nd &r!ctic!) tests sho)d (e condcted (/ the tr!inin% institte drin% thetr!inin% !nd e,!)!tion o" the dri,er he)&er. This crric)0 sho)d (e 0!de in!ccord!nce to the %ener!) s!"et/ st!nd!rds ith the in&ts "ro0 s!"et/ 0!n!%ers !crossthe de&!rt0ents.. An e>ecti,e s/ste0 to cr( "!


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1@


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1B

*ASE ;

D!teC '99@

*!s!)it/+F!t!)it/C S!r(es!r Moh!nt!5'' /e!rs5s+o Tri)och!n Moh!nt! 6FATAL7 M+s IR* Lo%istics Ltd.

S


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STPA !n!)/sis

1. A required control action is not provided (i.e. control actions are inadequatelyexecuted). - In!de3!te+Ine>ecti,e i0&)e0ent!tion o" the si%n (o!rds (/ the de&!rt0ents .

- Re)ct!nce o" the s&er,isor to i0&ose &en!)ties re%!rdin% ns!"e or< &r!ctices (/

the e0&)o/ees. 2. "nadequate feed#ac$ for the control action.

- Ine>ecti,e "eed(!c< "ro0 the orecti,eness o" si%n (o!rds

c!n )e!d to 0is)e!din%+ron% co00nic!tion re%!rdin% h!2!rdos e)e0ents s!"e

&r!ctices.

S!"et/ "nctions+Reco00end!tions.

1. Inst!))!tion o" si%n (o!rds cont!inin% in"or0!tion re%!rdin% the h!2!rdos e)e0ent s inth!t &!rtic)!r or


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'9

*ASE :

D!teC '99@

*!s!)it/+F!t!)it/C T!rn $0!r5 e)&er5 *SD 1B++'99@

'.1: !0 At M+s. T!t! R/erson P!r


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'1

. E4&erti2e co00ittee sho)d (e set& (/ chie" s!"et/ "or s!"e tr!nsit5 &!r


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*ASE ?

D!teC '99B

*!s!)it/+F!t!)it/C R.N!rr!sin0h! R!o5 G.No.?@15 ;: /e!rs E)ectrici!n Techn.

M+s. T!r!&ore *o. 9'+9@+'99B5 9C1:C99 PM SMS Poo) Iron S+Y!rd

Descri&tion o" F!t!)it/C A"ter !ttendin% 0!inten!nce o" e4c!,!tor' he was seenstanding by the dumper driver. A&ter some time one person saw him crushedlaying in the SMS 3 4 pooled iron stoc" yard. A dumper o& M/s. -arapore * !o.was )ust came out &rom the yard a&ter reversing. 6 FATAL7. !. Un)o!din% &oints !snot %ided (/ tr!ined &erson. (. This &erson do not h!,e !n/ jo( !t the &)!ce o"incidence. c. Persons entr/ restriction not there. d. More n!nted &ersons 0o,e0ent.

or


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B. Site )!/ots c!n (e desi%ned 6or 0odi8ed7 to incre!se ,isi(i)it/ "or dri,ers !nd&edestri!ns5 "or e4!0&)eC. =/ incre!sin% the !re! !))oed "or re,ersin%.19. =/ inst!))in% 84ed 0irrors in s0!))er !re!s.-Redcin% the d!n%ers c!sed (/ ()ind-s&otsC11. Most ,ehic)es !)re!d/ h!,e e4tern!) side-0onted !nd re!r-,ie 0irrors 8tted. These

need to (e


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'. An incorrect or unsafe control action is provided (i.e. controller issues inadequatecontrol actions).

-ron% +0is)e!din% r)es &ro,ided (/ the 0!n!%er re%!rdin% tres&!ssin% o" the orecti,e site )!/ot "or s!"e tr!nsit o" ,ehic)es (/ the !thorit/.


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. "nadequate feed#ac$ for the control action.

-In!de3!te o" "eed(!c< on the &er"or0!nce o" the si%n!)er (/ the dri,ers to the s!"et/0!n!%er c!n )e!d to 0ish!& i" the si%n!)er is ine>ecti,e +inc!&!()e.


1. A e)) tr!ined si%n!)er 6(!n


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*ASE @

D!teC '99B

*!s!)it/+F!t!)it/C Md.S)t!n A)i5 P. No. 1191'15 A%e :1 /e!rs Technici!n5 *o


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- I0&ro&er r)es+co00nic!tion to dri,ers re%!rdin% &rohi(ition o" to hee)ers in th!t&!rtic)!r !re!+ro!d.


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'B

'. "nadequate feed#ac$ for the control action.

-constr!ined ti0e "eed(!c


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*ASE B

D!teC '99

*!s!)it/+F!t!)it/C D0ni Td M+s.N.$0!r *o. Q RM

1;++'99

Descri&tion o" F!t!)it/C D0ni Td5 G.No-1B@ M+S N.$0!r *o. was &ound laying

on road with in)ury on Hand * 7ace. As reported by her colleague she too" the

bus !t P %!te %ot don "ro0 the (s ne!r LD %!s ho)der is)!nd it !&&e!r th!t she

might have hit by bus or other vehicle.

or


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. A)) the s!"et/ oci!)s *ondct !n edc!tion!) !d,ertisin% c!0&!i%n to encor!%e&edestri!ns to cross !t 0!r


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1

STPA !n!)/sis

1. A required control action is not provided (i.e. control actions are inadequatelyexecuted). -Desi%ners o" the (s st!tion i%norin% the "!ct th!tC the "!r side sto& is t/&ic!))/

&re"erred5 since it )oer ris< "or o(strcted ,ie cr!shes hen co0&!red to ne!r side (ssto&s. -In!de3!te i0&)e0ent!tion o"

(!sic !0enities ne!r the (s sto& sch )i%htin%5 she)ter5 ro!d 0!r


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*ASE

D!teC '919

*!s!)it/+F!t!)it/C =i

'?++'919

Descri&tion o" F!t!)it/C Shri =i

cleaning the truc" body on the rear side o& the truc". All o& a sudden'

another empty hauling truc" bearing registration number 8R $9% :;9<

reversed towards the loaded truc" and hit Shri %i"ash pradan. As ! res)t Shri

Pr!dh!n sst!ined serios he!d injr/ !nd "e)) on the %rond. I00edi!te)/ he !s

shi"ted to or )oc!) Sected co)dnt resce hi0se)".

S!"et/ *onstr!int

1.Re,ersin% !re!s sho)d (e &)!nned ot !nd c)e!r)/ 0!r


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@. The "o))oin% ste&s 0i%ht he)& to redce the ris< o" re,ersin% !ccidents. The "o))oin%!re e4!0&)es5 (t it is n)i


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'. An incorrect or unsafe control action is provided (i.e. controller issues inadequatecontrol actions).

-ron% +0is)e!din% r)es &ro,ided (/ the 0!n!%er re%!rdin% tres&!ssin% o" the orecti,e site )!/ot "or s!"e tr!nsit o" ,ehic)es (/ the !thorit/.


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-Ine>ecti,e o" "eed(!c< on the &er"or0!nce o" the si%n!)er (/ the dri,ers to the s!"et/0!n!%er c!n )e!d to 0ish!& i" the si%n!)er is ine>ecti,e +inc!&!()e.




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*ASE 19

D!teC '919

*!s!)it/+F!t!)it/C Mr. T!&!n =!nerjeeRo!d !ccident !t TGS or


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*ontro) Actions

1. ehic)e 0onitorin%+chececti,e s/ste0 to cr( "!


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B

*ASE 11

D!teC '911

*!s!)it/+F!t!)it/C MD AA AMAD5 1@9? En%%. Ser,ices

1?+9:+'911 A%e-:@ Ro!d Accident

Descri&tion o" F!t!)it/C At !(ot 19C99 AM Md. A2!2 Ah0!d o" En%%. Ser,ices de&t. !s inGener!) Shi"t dt/ !nd he !s %oin% "or rotine 0!inten!nce jo( !t G=).Fce. A"ter!ttendin% ! jo( !t sinter &)!nt 1 thro%h sinter &)!nt 1' ro!d on his (iennie his bi"e s"idded on road and ran over by >ennie &rontright wheel on trac" at ?iamond crossing. S!id Gennie !s co0in% "ro0 ARS*O%odon ne!r strctr!) sho& h!d to %o to!rds LD1.

or


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;9

*ASE 1'

D!teC '911

*!s!)it/+F!t!)it/C =inod Y!d!,511'5 9 Do2er he)&er est =o

$!r0n!))!h T!i)in%s D0& '1+19+'911 9'C1:C99 PM.

Descri&tion o" F!t!)it/C Sri =inod Y!d!,5 !%e !(ot 9 /e!r5 !n e0&)o/ee o" M+S G.S.At!) !s or

!2!rdos S/ste0 St!tesC 1.The !rnin% s/ste0 o" the ti&&er hi)e re,ersin% co)dntco00nic!te to the &erson (ehind e>ecti,e)/.

'. Dri,er re,ersed the ,ehic)e ithot !n/ %id!nce "ro0 ! he)&eror !n/ other &erson hi)e re,ersin%.

. Dri,er !nd !>ected &erson not t!


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;1

-Redcin% the d!n%ers c!sed (/ ()ind-s&otsC11. Most ,ehic)es !)re!d/ h!,e e4tern!) side-0onted !nd re!r-,ie 0irrors 8tted. Theseneed to (e


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-Ine>ecti,e "eed(!c< on the &er"or0!nce o" the si%n!)er (/ the dri,ers to the s!"et/0!n!%er c!n )e!d to 0ish!& i" the si%n!)er is ine>ecti,e +inc!&!()e.



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