Attachment 4 SVAAPP Form.pdf

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TAM SVAAPP, 1 OCT 2019

U.S. ARMY CORPS OF ENGINEERS

Transatlantic Middle East District (TAM)

SITE VISIT ABBREVIATED ACCIDENT PREVENTION PLAN (SVAAPP)

FOR SITE VISITS ONLY

Purpose: This SVAAPP is ONLY TO BE USED FOR SITE SURVEY/VISITS and must be accepted by the TAM Safety Office prior to survey/visit. No type of physical work shall be allowed/conducted with this form. If physical work is required the TAM Safety Office must be notified because the task will require a Limited Scope Abbreviated Accident Prevention Plan (AAPP) or a full Accident Prevention Plan (APP) per the EM 385-1-1, Appendix A.

Process: With the assistance of the CEHNC PM, coordination shall be made with the installation prior to conducting the site survey. Coordination with the PM is also required if photographs and/or video recordings are determined necessary/required.

Responsibility: The Prime Contractor shall ensure ALL members (including subcontractors) of the site survey team are briefed on and comply with the provisions within this SVAAPP and the applicable EM 385-1-1 safety requirements prior to survey/visit beginning. After the brief the Team Lead shall ensure each Team Member signs the Survey Team Statement on the last page of this document.

Note: TAM personnel, contractors, and all subcontractors must comply with all Occupational Safety and Health Administration (OSHA) laws, EM 385-1-1, and all state and local mandates. This SVAAPP is not intended to define full compliance with OSHA or other safety laws, codes, or regulations. Compliance with these requirements is to maintain a safe work environment for the contractor or subcontractor employees remains the Contractor’s responsibility.

1. Contractor Information a. Date Prepared:

b. Contract Number: c. Task Order Number:

d. Contractor’s Name: e. Contractor’s Address:

f. Project Site Location: g. Date of Site Visit:

h. Prepared by: i. Telephone Number:

j. Signature: k. E-mail Address:

2. TAM Information

a. Project Manager (PM) Name: b. Telephone Number:

3. Purpose of Site Visit (Examples: Field survey, records search/review, site investigation, inspection)

Detailed Description:

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TAM SVAAPP, 01 OCT 2019

4. Personnel Responsibilities

a. Team Leader (TL) is responsible for ensuring all the information/requirements contained in this

SVAAPP and any other applicable topics are correct and effectively communicated to all involved team members prior to the commencement of the activity. The TL is responsible for submitting the signed SVAAPP to the TAM PM after survey/visit is completed for recordkeeping purposes.

i. TL Name: ii. TL Telephone Number:

b. Safety Officer/Designated Representative (SO/DR) will assist the TL in the instruction/briefing and oversight of the requirements of this SVAAPP during all activities.

i. SO/DR Name: ii. SO Telephone Number:

c. Will activities stop if site conditions change or hazards arise that are not addressed on this SVAAPP? Yes: ☐ No: ☐

d. Team Members (TMs) will all read or be briefed on the contents of this SVAAPP during the tailgate meeting (required)? Yes: ☐ No: ☐

e. Will all TMs sign the Survey Statement at the end of this document prior to the actual site visit commencing (required)? Yes: ☐ No: ☐

5. Emergency Response.

Note: Prior to site survey, arrangements shall be made for first aid and emergency medical treatment.

a. What method/s will be utilized to summon emergency services (cell phone, two-way radio, land line, etc.)? Cellular telephone or landline telephone

Emergency POC Phone # Emergency POC Phone # Medical Facility Fire Department Military Police Local Police

b. What means of transport will be readily available to transport injured or ill personnel (e.g., POV, Company Vehicle, etc.)?

c. When emergency medical services are not accessible within 5 minutes of work location and there are 2 or more workers at the location, at least one employee (preferably two) on each shift shall be qualified to administer first aid and CPR. Provide name/s of CPR trained individuals below if survey team is larger than two people.

1. Name: Telephone number:

2. Name: Telephone number:

Not applicable (Survey will be completed by one individual): ☐ Note: If task involves access to a remote or restricted area, the Two Person or Buddy System will be used. The two persons must maintain contact by line of sight and orally at all times. Emergency communication (Cell phone, radios, etc.) must be readily available at all times.

d. A map delineating the best route to the nearest medical facility shall be prepared and readily available onsite for TMs to access? Yes ☐ N o ☐

e. Briefly Describe Emergency Response Procedures:

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6. General Description of Survey Activities (Check all that apply) Walk-through ☐ Drive-through ☐ Off Road ☐ Off Paths/Trails ☐

On/Near Roadway ☐ Over on Water ☐ Fly Over ☐ Fence Line ☐

Crawlspace ☐ Basement ☐ Attic ☐ Roof near edges ☐

Warehouse ☐ Hospital ☐ Clinic ☐ Office Building ☐

Equipment Room ☐ Control Tower ☐ Mechanical Room ☐ Penthouse ☐

Mezzanine ☐ Pits and Sumps ☐ Catwalks ☐ ☐

7. Types of Hazards to consider (Check all that apply) Eye ☐ Head ☐ Foot ☐ Slips/Trips/Falls ☐

Heat Stress ☐ Cold Stress ☐

Electrical ☐ High Traffic Area ☐

Work from height ☐ Water ☐

Climbing ☐ Fall From Heights ☐

Vehicle ☐ Heavy Equipment ☐

Material Handling ☐ Lifting ☐

Environment ☐ Insects ☐ Snakes ☐ Biological ☐

Flammable Mat. ☐ Toxic Materials ☐ Chemicals ☐ Fire ☐

Electrical Tools ☐ Hand Tools ☐ Excavations ☐ Mechanical ☐

Confined Space ☐ Squatting/Bending ☐ Hand/Finger ☐ Near Energized Equipment

Note: All checked hazards shall be addressed in Section 8 below

8. Hazard Evaluation (Risk Management)

a. Hazards b. Controls c. Risk Level

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d. Overall Risk Level (After all controls are implemented)

Extremely High ☐ High ☐ Medium ☐ Low ☐ Note: Only LOW Risk Site Surveys are permitted to use this SVAAPP. If Risk is above LOW then the TAM Safety Office must be notified and the work will require an AAPP or an APP per the EM 385-1-1, Appendix A.

9. Personnel Protective Equipment (PPE).

a. Employees shall wear clothing suitable for the weather and work conditions. Check the minimum

PPE that will be utilized:

i. Short/long sleeve shirt ☐ ii. Long pants ☐

iii. Leather or other protective boots Open-toed shoes are prohibited ☐

iv. Hard Hat In areas with potential hazard of head injury

v. Safety glasses with side shields When eye hazards exist. ☐

vi. Hearing protection When noise hazards are known or expected ☐

vii. Click here to enter text. ☐ viii. Click here to enter text. ☐

10. Mishap Reporting

a. Will the Prime Contractor report all mishaps per the requirements of EM 385-1-1 Section 01.D to the Contracting Officer/Contracting Officer Representative OR as soon as possible but not more than 24 hours afterwards? Yes ☐ N o ☐

11. Contractor Additional Comments:

12. TAM Safety Office

a. Name: b. Date Reviewed:

c. Accepted: Yes: ☐ No: ☐

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13. TAM Additional Comments:

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U.S. ARMY CORPS OF ENGINEERS

Transatlantic Middle East District (TAM)

SVAAPP Team Statement Note: This statement is the record to be maintained in the government/Contractor’s on-site files through the entire life of the task order or project. The statement should only be completed prior to the actual visit taking place.

1. Team members will sign this statement:

a. Prior to the start of the site visit b. When a change is made to this document.

2. I have read, or have read to me, and understand the specific safety and environmental requirements, and will abide by the contents contained in this SVAAPP. I have been briefed and trained in, and am familiar with, my requirements to safely conduct the site visit.

Print Name Office Signature Date

3. Team Leader/Safety Officer presenting briefing:

Attach any additional information