Attachment 17 PWS - DIA Region IV FSS TE-7 Eng_Form_3394_2021Aug.pdf

ENG FORM 3394, AUG 2021 PREVIOUS EDITIONS ARE OBSOLETE. Page of

U.S. Army Corps of Engineers (USACE)

MISHAP NOTIFICATION AND INVESTIGATION

For use of this form, see instructions in the attachments and USACE ER 385-1-99; the proponent agency is CESO.

Requirement Control Symbol

RCS-CESO-21-0001

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority 10 U.S.C. 7013, Secretary of the Army; 5 U.S.C. 7902, Safety Programs; Public Law 91-596, Occupational Safety and Health Act of 1970; DoD Instruction 6055.1, DoD Safety and Occupational Health Program; Army Regulations 385-10, Army Safety Program;

DoD Instruction 6055 .07, Mishap Notification, Investigation, Reporting, and Record Keeping; and E.O. 9397 (SSN), as amended.

Principal Purpose Information collected is to provide the USACE leaders, soldiers, families and civilians in injury, illness, and loss data to effectively manage its safety and occupational health program.

Routine Uses In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b) as follows: To the Department of Labor, the Federal Aviation Agency, the National Transportation Safety Board, and to Federal, State, and local agencies and applicable civilian organizations, such as the National Safety Council, for use in a combined effort of accident prevention. In some cases, data must also be disclosed to an employee's representative under the provisions of 29 CFR

1960.29. Records will be made available consistent with applicable laws and regulations. Information will be withheld from the public only if authorized by 5 U.S.C. Section 552 (Freedom of Information Act (FOIA), 5 U.S.C. 552a (Privacy Act)), or other statutory or regulatory authority.

Disclosure Failure to provide all the required information on the report may result in the rejection of report submission.

1. WHO IS REPORTING MISHAP

a. Name: b. Phone number:

c. Email address: d. Signature:

e. Report type:

1. Near Miss Report. (No injury/illness, or property damage. Complete all fields with underlined text.) Date:

2. Initial Accident Report. (For accident notification within 24 hrs, Complete all fields with underlined text.) Date:

3. Final Accident Report. (For reporting findings from accident investigation, complete full form.) Date:

f. Mishap Type. (Check all that apply)

Fatality Injury/Illness Property Damage Near Miss

g. Were any of the following items associated with the mishap ? (If yes, check all that apply)Yes No

Electrical and/or Hazardous Energy Working at Heights Diving

Load Handling Equipment or Rigging

Occupational Health Exposure

2. WHO WAS INVOLVED IN THIS MISHAP?

a. Name:

b. Personnel Classification: c. Time employee began work:

d. Gender: e. Date of birth (for Government personnel only): f. Age:

g. Date hired: h. Primary language:

i. Is individual a supervisor? Yes No j. Duty status at time of mishap: k. Years experience in job:

l. What was individual doing when mishap occurred? (Select activity from the drop downs below.)

1. General activities: 2. Vehicle/Equipment/Vessel:

3. Sports/Recreation: 4. Other not listed:

m. Did individual utilize all OSHA/EM 385-1-1 required Personal Protective Equipment (PPE) for activity? Yes No N/A

If no, identify missing PPE:

n. Was a Personal Flotation Device used? Yes No N/A o. Was a seat belt used? Yes No N/A

ENG FORM 3394, AUG 2021 Page of

p. Government personnel only:

4. Center/Division/Lab: 5. District:

1. Prime Contractor name:

q. Contractor personnel only:

2. Contract number: 3. Contract type: 4. Funding type:

Other not listed:

r. If mishap occurred on a contractor site, provide the following:

1. Employer/Contractor name:

3. Grade:2. Rank:

2. Individual's occupation/trade:

1. Job series:

h. If treatment was given away from the work-site, where was it given? (For Government Personnel Only)

j. Estimated days away from work: k. Estimated days of restricted/transferred duty:

Was OSHA notified? If yes, how many nights? Yes Noi. Was employee hospitalized as an in-patient? Yes No

Country:Zip:State: City:

Address:

Treatment facility name:

g. Was employee treated in an emergency room ? Yes No N/Af. Was treatment given away from work site? Yes No

Source of injury/illness: Cause of injury/illness:

Primary body part affected:

c. Identify body part(s) affected by injury/illness:

b. Type of Injury/Illness:a. Severity of injury/illness?

Secondary body part affected:

d. Identify cause and source of injury/illness:

If yes, provide name of physician or health care professional provider?

e. Was employee treated by a physician or health care professional provider? Yes No

Note: OSHA requires reporting all work-related fatalities within 8 hours and in-patient hospitalizations, amputations and loss of an eye within 24 hours to OSHA.

3. WHAT TYPE OF INJURY/ILLNESS OCCURRED?

4. WHAT HAPPENED?

a. What was the primary activity occurring at the time of the mishap?

Other, not listed:

b. What happened? Provide a detailed description of the mishap. (Do not include any personally identifiable information (name, etc.).)

Note: Provide supporting photos, charts, diagrams, etc. with this report.

c. What other organizations or agencies have been notified about this mishap?

b. USACE Office/Program/Project name:

a. List all property/material involved in the mishap. (Include damaged and undamaged property.)

i. Type of item:

Item A Item B Item C

ii. Name of item(s):

iv. Ownership of item:

v. Dollar cost of damage:

a. Date the mishap occurred: b. Time mishap occurred:

c. What day did mishap occur on? d. What period of day did mishap occur?

a. Did the mishap occur on a military Base/Post? Yes No

c. Select the location type most closely associated with the mishap:

d. Identify exact location where mishap occurred:

e. Latitude: f. Longitude:

Other not listed:

Other not listed:

iii. Collision type:

Country:Zip:State: City:

Address:

5. WHAT TYPE OF PROPERTY/MATERIAL WAS INVOLVED?

6. WHEN DID THE MISHAP OCCUR?

7. WHERE DID THE MISHAP OCCUR?

8. WHY DID THE MISHAP OCCUR? (Recommend completing this section for Near Misses.)

A. Performance Causal Factors

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

If yes, select the error that contributed most to the mishap:

1. Did a problem with resources contribute to this mishap occurring?

1. Did a problem with performance contribute to this mishap occurring? Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If yes, select the error that contributed most to the mishap:

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

B. Support Causal Factors

C. Standards/Policy/Planning Causal Factors

If yes, select the error that contributed most to the mishap:

1. Did an organizational standard/policy/or plan contribute to this mishap occurring?

2. Was a written Activity Hazard Analysis (AHA) or equivalent completed and accepted by Government Designated Authority (GDA) for task(s) being performed at time of mishap? (If yes, attach a copy to this report)

If yes, was the AHA available and used by worker?

3. Was a written work plan (critical lift plan, fall protection plan, etc.) required, completed and accepted by the GDA for task(s) being performed at time of mishap?

If yes, was the plan available and used by worker?

4. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

If yes, select the error that contributed most to the mishap:

1. Did any leader/supervisory mistake/task error contribute to this mishap occurring?

If yes, select the error that contributed most to the mishap:

1. Did any individual mistakes/task errors contribute to this mishap occurring?

4. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

3. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

If yes, select the error that contributed most to the mishap:

1. Did any material failure contribute to this mishap occurring?

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

1. Did a problem with training contribute to this mishap occurring?

If yes, select the error that contributed most to the mishap:

If yes, select type of training: Classroom On the jobCertification/License

Other, describe:

What was date of most recent training?

2. Which failure is most closely associated with the material failure/malfunction?

If yes, select the error that contributed most to the mishap:

1. Did any physical environment contribute to this mishap occurring?

2. Was individual trained to perform the activity/task?

3. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

2. Did the safety climate/culture contribute to the mishap?

3. Did challenges with teamwork contribute to the mishap?

D. Training Causal Factors

E. Leader/Supervisor Causal Factors

F. Individual Causal Factors

G. Physical Environment Causal Factors

H. Material Causal Factors

I. Environmental Causal Factors

If yes, select the factor that contributed most to the mishap:

1. Did any environmental condition contribute to this mishap occurring?

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

2. Describe action(s) taken, anticipated or recommended to eliminate hazard:

If yes, describe:

1. Did the design of the facility/building contribute to the mishap?

J. Facility/Building Design

b. Who is responsible for the corrective action plan?

a. Have all corrective action(s) to prevent mishap recurrence been completed?

c. What date will/have all corrective action(s) be/been completed by:

d. Additional information:

2. Describe action(s) taken, anticipated or recommended to eliminate hazard(s):

If yes, describe the hazard(s):

1. Did a hazard(s) contribute to the mishap?

K. Existing Hazard

9. Corrective Action plan

10. Additional Information

Yes No

ENG FORM 3394, AUG 2021

PREVIOUS EDITIONS ARE OBSOLETE.

Page of

ENG FORM 3394, AUG 2021

Page of U.S. Army Corps of Engineers (USACE)

MISHAP NOTIFICATION AND INVESTIGATION

For use of this form, see instructions in the attachments and USACE ER 385-1-99; the proponent agency is CESO.

Requirement Control Symbol RCS-CESO-21-0001

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority 10 U.S.C. 7013, Secretary of the Army; 5 U.S.C. 7902, Safety Programs; Public Law 91-596, Occupational Safety and Health Act of 1970; DoD Instruction 6055.1, DoD Safety and Occupational Health Program; Army Regulations 385-10, Army Safety Program;

DoD Instruction 6055 .07, Mishap Notification, Investigation, Reporting, and Record Keeping; and E.O. 9397 (SSN), as amended.Principal Purpose Information collected is to provide the USACE leaders, soldiers, families and civilians in injury, illness, and loss data to effectively manage its safety and occupational health program.Routine Uses In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b) as follows: To the Department of Labor, the Federal Aviation Agency, the National Transportation Safety Board, and to Federal, State, and local agencies and applicable civilian organizations, such as the National Safety Council, for use in a combined effort of accident prevention. In some cases, data must also be disclosed to an employee's representative under the provisions of 29 CFR

1960.29. Records will be made available consistent with applicable laws and regulations. Information will be withheld from the public only if authorized by 5 U.S.C. Section 552 (Freedom of Information Act (FOIA), 5 U.S.C. 552a (Privacy Act)), or other statutory or regulatory authority.Disclosure Failure to provide all the required information on the report may result in the rejection of report submission.

1. WHO IS REPORTING MISHAP

e. Report type:

f. Mishap Type. (Check all that apply)

g. Were any of the following items associated with the mishap ? (If yes, check all that apply)

2. WHO WAS INVOLVED IN THIS MISHAP?

i. Is individual a supervisor?

l. What was individual doing when mishap occurred? (Select activity from the drop downs below.)

m. Did individual utilize all OSHA/EM 385-1-1 required Personal Protective Equipment (PPE) for activity?

n. Was a Personal Flotation Device used?

o. Was a seat belt used?

p. Government personnel only:

q. Contractor personnel only:

r. If mishap occurred on a contractor site, provide the following:

h. If treatment was given away from the work-site, where was it given? (For Government Personnel Only) Was OSHA notified?

i. Was employee hospitalized as an in-patient?

g. Was employee treated in an emergency room ?

f. Was treatment given away from work site?

c. Identify body part(s) affected by injury/illness:

d. Identify cause and source of injury/illness:

e. Was employee treated by a physician or health care professional provider?

Note: OSHA requires reporting all work-related fatalities within 8 hours and in-patient hospitalizations, amputations and loss of an eye within 24 hours to OSHA.

3. WHAT TYPE OF INJURY/ILLNESS OCCURRED?

4. WHAT HAPPENED?

Note: Provide supporting photos, charts, diagrams, etc. with this report.

a. List all property/material involved in the mishap. (Include damaged and undamaged property.)

i. Type of item:

Item A Item B Item C

ii. Name of item(s):

iv. Ownership of item:

v. Dollar cost of damage:

a. Did the mishap occur on a military Base/Post?

Other not listed:

Other not listed:

iii. Collision type:

5. WHAT TYPE OF PROPERTY/MATERIAL WAS INVOLVED?

6. WHEN DID THE MISHAP OCCUR?

7. WHERE DID THE MISHAP OCCUR?

8. WHY DID THE MISHAP OCCUR? (Recommend completing this section for Near Misses.)

A. Performance Causal Factors

1. Did a problem with resources contribute to this mishap occurring?

1. Did a problem with performance contribute to this mishap occurring?

B. Support Causal Factors C. Standards/Policy/Planning Causal Factors

1. Did an organizational standard/policy/or plan contribute to this mishap occurring?

2. Was a written Activity Hazard Analysis (AHA) or equivalent completed and accepted by Government Designated Authority (GDA) for task(s) being performed at time of mishap? (If yes, attach a copy to this report) If yes, was the AHA available and used by worker?

3. Was a written work plan (critical lift plan, fall protection plan, etc.) required, completed and accepted by the GDA for task(s) being performed at time of mishap?

If yes, was the plan available and used by worker?

1. Did any leader/supervisory mistake/task error contribute to this mishap occurring?

1. Did any individual mistakes/task errors contribute to this mishap occurring?

1. Did any material failure contribute to this mishap occurring?

1. Did a problem with training contribute to this mishap occurring?

If yes, select type of training:

1. Did any physical environment contribute to this mishap occurring?

2. Was individual trained to perform the activity/task?

2. Did the safety climate/culture contribute to the mishap?

3. Did challenges with teamwork contribute to the mishap?

D. Training Causal Factors E. Leader/Supervisor Causal Factors F. Individual Causal Factors G. Physical Environment Causal Factors H. Material Causal Factors I. Environmental Causal Factors

1. Did any environmental condition contribute to this mishap occurring?

1. Did the design of the facility/building contribute to the mishap?

J. Facility/Building Design

a. Have all corrective action(s) to prevent mishap recurrence been completed?

1. Did a hazard(s) contribute to the mishap?

K. Existing Hazard

9. Corrective Action plan

10. Additional Information 1.0 darwin.chen@usace.army.mil 2021-06-28 Forms Design Team Darwin Chen 2021-07-30

MISHAP NOTIFICATION AND INVESTIGATION

MISHAP NOTIFICATION AND INVESTIGATION