Attachment 5 - Form 4.pdf

AFRL Form 4 26 OCT 2022 Page 1 of 5 Prescribing Directive: AFI 91-202_AFMCSUP_AFMCGM2021-01_AFRLGM2022-01

SAFETY PLANNING FORM

Section 1: Programmatic Information

1. Work Unit Title

2. Work Unit Type

Section 2: Technical Details

Note: activity refers to only the activity that will occur as part of the work unit

7. What are the deliverables for this activity?

(Check all that apply)

□ Hardware (specify in notes)

□ Software (specify in notes)

□ Data Only

□ No deliverables

□ Unknown at this time

8. Will any government owned equipment be used for this activity?

□ Yes

□ No, exclusively contactor owned equipment will be used

□ Unknown at this time

9. Who will perform this activity?

(Check all that apply)

□ Government (military or civilian)

□ Contractor

□ Other (specify in notes)

□ Unknown at this time

10. Where will this activity occur?

(Check all that apply)

□ Government owned facilities (specify base and/or building name if applicable)

□ Contractor owned facilities

□ Military owned ranges

□ Other National Airspace

□ OCONUS

□ Other (specify in notes)

□ Unknown at this time

3. Work Unit Manager and Office Symbol

4. Work Unit No.

5. Total Work Unit Cost (Initial Estimate)

6. Work Unit summary:

11. Will this activity occur indoor or outdoor?

(Check all that apply)

□ Indoor (lab)

□ Outdoor (field)

□ Outdoor in an outdoor lab (field)

□ Unknown at this time

12. Will this activity regularly utilize an existing AFRL lab?

□ Yes (specify lab(s) in notes)

□ No

□ Unknown at this time

Attachment 5 FA2385-25-S-9761 14 July 2025

AFRL Form 4 26 OCT 2022 Page 2 of 5

13. Will AFRL be the lead testing organization for all efforts executed as part of this activity?

□ Yes

□ No (specify lead(s) in notes)

□ Unknown at this time

14. Is this an extension of a previous program or work unit?

□ Yes (specify in notes)

□ No

15. Will this work unit have a follow on effort not covered under this work unit/Form 4?

□ Yes (briefly describe scope of effort of phases in notes)

□ No

□ Unknown at this time

16. Will this activity fall under approved Standard Operating Procedure(s) (SOP(s))?

□ Yes (specify SOP(s) in notes)

□ No

□ Unknown at this time

17. Will this activity involve developing, testing, or operating any space system?

□ Yes

□ No

□ Unknown at this time

18. Will any part of this activity include launching into orbit or occur in space?

□ Yes

□ No

□ Unknown at this time

19. Will this activity include any flight?

If yes, please complete the Flight Activity Information Worksheet.

□ Yes

□ No

□ Unknown at this time

19a. Will this activity NOT include flying but WILL include taxiing an aircraft (manned or unmanned)? If yes, please complete the Flight Activity Information Worksheet.

□ Yes

□ No

□ Unknown at this time

20. Will this activity include flight inside an enclosed facility? (Outdoor netted facility, indoor flight testing, etc.) If yes, please complete the Flight Activity Information Worksheet.

□ Yes

□ No

□ Unknown at this time

21. Will this activity use directed energy devices? This includes, but is not limited to, microwaves or lasers.

□ Yes

□ No

□ Unknown at this time

22. Will this activity involve explosives of any size or type? This includes, but is not limited to, ammunitions, munitions, or energetic materials.

□ Yes

□ No

□ Unknown at this time

23. Will this activity involve electromagnetic radiation? This includes, but is not limited to, radio waves, gamma rays, and X-rays.

□ Yes

□ No

□ Unknown at this time

24. Will this activity involve a munitions system?

□ Yes

□ No

□ Unknown at this time

25. Will this activity use any other kind of hazardous material not already specified in questions 21-24?

□ Yes (specify in notes)

□ No

□ Unknown at this time

AFRL Form 4 26 OCT 2022 Page 3 of 5

26. Will this activity require a human subject determination?

If yes or unknown, please complete Worksheet for Assessing Applicability of Human Subjects Research, found in AFRLI 61-103 Vol 2.

□ Yes

□ No

□ Unknown at this time

27. Will this activity involve infectious agents and toxins, human-derived materials, or recombinant DNA?

□ Yes

□ No

□ Unknown at this time

28. Will this activity involve animals? □ Yes

□ No

□ Unknown at this time

29. Will this activity include radio frequency (RF) use for communication or transmitting information? This includes, but is not limited to, radios, radars, and datalinks. If yes, please work with the AFRL Frequency Managers (AFRL/ DOO) to determine requirements.

□ Yes

□ No

□ Unknown at this time

30. Explain/elaborate questions as necessary (to be filled out by Work Unit Manager). Specify which information is for which question, as applicable.

AFRL Form 4 26 OCT 2022 Page 4 of 5

Section 3: System Safety Feedback

31. System Safety feedback (to be filled out by System Safety Manager (SSM)). This can include requirements for safety reviews, contract requirements, Contract Data Requirement Lists (CDRLs), MIL-STD-882E requirements, other offices to contact, specific hazards to prioritize, timelines to consider, whether program has potential to be high test safety risk, etc.

32. Work unit meets all AFRL Form 4 exemption requirements per AFI 91-202 AFRL Supp paragraph 16.5.1.3.

Work unit is exempt if work unit:

does not have any hardware or software deliverables (see question 7) does not use government equipment, facilities, or employees (see questions 8-12) does not involve space operations (see questions 17-18) does not involve flight operations (see questions 19-20) does not involve weapons or munitions systems (see questions 21-24) does not involve human subject research (see question 26) does not involve infection agents, toxins, human derived materials, or recombinant DNA (see question 27) does not involve animal use (see question 28)

AFRL Form 4 26 OCT 2022 Page 5 of 5

33. Work Unit Manager – Name and Office Symbol

34. System Safety Manager – Name and Office Symbol

35. Other signatures as required by local guidance – Name and Office Symbol

36. Other signatures as required by local guidance – Name and Office Symbol

37. Environmental Coordinator – Name and Office Symbol

Environmental Impact Analysis (to be completed by Environmental Coordinator) CATEX A2.3.24 applies to this action. Study efforts that involve no commitment of resources other than personnel and funding allocations. Contractor must comply with all applicable local, state and federal environmental guidelines/regulations.

A separate AF Form 813, Request for Environmental Impact Analysis, is NOT required for this action.

CATEX A2.3.27 applies to this action. Normal or routine basic and applied scientific research confined to the laboratory and in compliance with all applicable safety, environmental, and natural resource conservation laws. All work with hazardous materials or radiation must occur in a licensed facility.

A separate AF Form 813 is NOT required for this action.

This action DOES NOT qualify for a CATEX A2.3.24 or CATEX A2.3.27.

A separate AF Form 813 IS required for this action.

Section 4: Signatures

Additional Signatures:

Attachment 1

AFRL/DO Instructions and Notes to Contracting Officer

Notes to the Contracting Officer

Contracting Officer: Please provide AFRL/DO with a summary of proposed flight test activities within 15 days of contract award (submit via email to afrl.do.workflow@us.af.mil).

This summary should include at a minimum program title, type of air vehicle, a brief overview of the flight test concept, proposed date of first flight test, Technical Point of Contact name and contact information and AFRL Program Manager name and contact information.

Contracting Officer: Please provide AFRL/DO with a copy of the awarded contract within 15 days of contract award (submit via email to afrl.do.workflow@us.af.mil).

Contracting Officer: Please include the following clauses in the contract

252.228-7005 Mishap Reporting and Investigation Involving Aircraft, Missiles, and Space Launch Vehicles

252.247-7007 - Liability and insurance

Do NOT include 252.228-7001 Ground and Flight Risk. DO NOT include the GFRC since the aircraft will be Contractor-Owned. Instead, include the following language that requires following the DCMA 8210.1: Combined regulation/instruction: The Contractor shall be bound by the operating procedures contained in the combined regulation/instruction entitled “Contractor’s Flight and Ground Operations” (Air Force Instruction 10-220, Army Regulation 95-20, NAVAIR Instruction 3710.1 (Series), Coast Guard Instruction M13020.3, and Defense Contract Management Agency Instruction 8210.1) in effect on the date of contract award.

Contracting Officer: Please include the following text in the contract

Contractor Support for AFRL Research Test Review, Approval and Oversight: The contractor shall comply with Air Force Research Laboratory Instruction (AFRLI) 61-103, AFRL Research Test Review, Approval and Oversight, which establishes policy for how AFRL reviews, approves, and oversees research test activities. AFRLI 61-103 paragraph 1.2 defines “test” to include laboratory and field tests, experiments and demonstrations and that this guidance applies to all AFRL test activities that involve AFRL assets (full or part ownership) or AFRL personnel (government civilian, military, and support contractors), and tests executed by organizations under contract to AFRL where AFRL holds either mishap investigative responsibility or has more than a minimal risk of liability. Paragraph 1.2.3 further defines which tests are “ground tests” and paragraph 1.3 clarifies which activities are “out of scope” for this instruction. Paragraph 2.10 describes the roles and responsibilities of program managers, scientists and engineers conducting applicable government and contractor test activities.

Contractor Support to Program Test Planning and Design Reviews: The contractor shall support test planning meetings and (a) design review(s) during the course of the program. The review(s), the(ir) timing, and the topics to be covered will be determined jointly among the contractor, the AFRL PM, the PM’s division technical advisor (if desired), and AFRL/DO (as applicable). The contractor shall submit the review agenda to the government for review and approval at least 15 days prior to the desired review date. Review topics shall include at a minimum technical objectives and success criteria, test article description, vehicle modifications, safety systems, airworthiness of vehicle(s) and subsystems, preliminary test plans and schedules, and instrumentation system requirements. [Reference AFRLI 61-103 (Parent and Volume 1), AFRLI 61-601]

Contractor Test Plan and Support to the AFRL Technical Review Boards (TRBs) and Safety Review Boards (SRBs): The contractor shall develop a flight test plan and secure AFRL approval of it prior to flight testing, to include high-speed taxi tests. The contractor will submit the draft test plan (using contractor or AFRL-specified format) to the government for review and approval at least eight (8) weeks prior to testing and the final test plan at least six (6) weeks prior to testing. The contractor shall support safety and technical reviews, either through in-person attendance or participation via telecommunication means. The nature and scope of contractor support to the reviews will be made by the PM and government technical and safety review board chairs. The contractor shall complete any post-TRB or post-SRB actions generated by those reviews. [Reference AFRLI 61-103 (Parent and Volume

1), AFRLI 61-601]

Contractor Support to Air Force Mishap Investigations:

In accordance with AFI 91-204 and AFRLI 61-103 Vol 1, the Contractor shall cooperate with any safety investigation in the event of a mishap (defined as an unplanned event, or a series of events, that result in damage to DoD property, occupational illness to DoD military or civilian personnel, injury to DoD military personnel on- or off-duty, injury to on-duty civilian personnel; damage to public or private property or injury and illness to non-DoD personnel caused by DoD operations). If requested by the PCO, the contractor shall immediately secure the mishap scene and/or damaged property and applicable records until released by the investigating Safety Office. If the Government investigates the mishap, the contractor and subcontractors shall cooperate fully and assist the Government personnel until the investigation is completed. If requested by the cognizant contracting officer, the contracting officer’s representative, and/or the cognizant program manager, the contractor shall immediately secure the mishap scene/damaged property and impound pertinent maintenance and training records until released by the investigating safety office. This includes, but is not limited to, providing the government immediate access to all test data, test-related documents, and vehicle documentation including, but not limited to, video, pictures, witness statements, onboard recorded data, telemetered data, vehicle systems checks, and vehicle or system squawk sheets.

In accordance with AFI 91-204, paragraph 2.12, the contractor shall report mishaps involving injury or damage to USAF personnel or property. If an AFRL representative is not present during the mishap, the contractor shall notify the AFRL PM or AFRL/DO of the mishap as soon as practicable after the mishap has been debriefed at the test location, but not later than eight (8) hours immediately following the mishap. If the AFRL PM or AFRL/DO cannot be reached in person, the contractor shall execute the alternate notification procedures as specified on the AFRL Unexpected Event Worksheet. In the event of a mishap, the data and information collected must be protected in accordance with guidance provided by a cognizant government representative. It is recommended that the contractor have an established safety representative made known to the government through whom communication will occur and the data and information collected will be transmitted. [Reference AFRLI 61-103 Volume 1, AFI 91-204]

Contractor-Identified Lessons Learned: At the completion of the program the contractor shall provide lessons learned to the government using AFRL Form 20, Lessons Learned.

Insights gained during the formulation, conduct, and reporting of flight test activities to include system under test design and development shall be included. However, in the case of a lesson learned that is safety related, the contractor shall notify the government immediately. [Reference AFI 91-202 AFRL Supplement]

Flight Test Vehicle Airworthiness: The contractor shall provide sufficient technical documentation and detail of the vehicle and modifications, of operator experience, safety and mishap history of the air vehicle, and design/procedural safety precautions to support the government independent airworthiness assessment and associated issuance of a Civil/Public Air Operations (CAO or PAO) Letter or Military Flight Release (MFR) whichever is applicable. The contractor shall support government reviews conducted in the course of the airworthiness assessment process. The contractor shall support Continuing Airworthiness Maintenance and Operations (M&O) on-site inspections or remote interviews conducted by the government (as applicable) [Reference AFRLI 61-601; Airworthiness Bulletins (AWB) issued by the Air Force Airworthiness Office as current and applicable]

Liability and insurance: The Contractor shall be responsible for, and hold the Government harmless from, loss of or damage to non-government property. The Contractor shall be responsible for, and hold the Government harmless from, bodily injury and death of persons, resulting either in whole or in part from the negligence or fault of the Contractor, its officers, agents, or employees in the performance of work under this contract.

Blank Page

Signature: //SIGNED// in WU Mgmt App Date: 03/04/2024

Signature: //SIGNED// in WU Mgmt App Date: 02/22/2024

Review navigation performance needs. Evaluate sensing and communication options. Design a relative navigation system, implement automated refueling processes, and test in a laboratory environment. For the relative navigation system, develop an flight test instantiation of the system, conduct flight test, and evaluate relative navigation system against a truth system and against the navigation performance needs.

RDTE - Research, Development, Test, & Evaluation Work Unit

Signature: //SIGNED// in WU Mgmt App Date: 02/14/2024 QuestionTextOption30_1: 7. Explain Hardware: Sensors and communications hardware necessary to develop & demonstrate relative navigation system. Hardware required to implement refueling automation.

7. Explain Software: Software to calculate relative navigation information and implement refueling automation

10. Specify contractor and/or facility if known: Unknown at this time.

15. Briefly describe scope of effort of phases: Contracted boom automation development concludes with a laboratory demonstration. CRONUS is anticipating a future flight test demonstration of the boom automation technology.

Additional Information CRONUS A3R development includes 2 work areas both of which are included in this PACER BAA. (1) Relative Navigation (RelNav) calculates and communicates (as nececessary) the relative position between two aircraft to enable aerial refueling. The system may be located on the tanker, the receiver, or both. AFRL Automated Aerial Refueling (2000-2011) implemented a RelNav system which is no longer considered operationally feasible. CRONUS A3R is developing the replacement RelNav System and conducting both laboratory and flight testing. (2) Boom automation describes a process internal to an aerial refueling tanker. The aerial refueling industry has started developing boom automation, but it still requires an aerial refueling operator monitoring the system on the tanker. For an uncrewed tanker, the level of boom automation needs to increase. Under this contract, the offeror will be developing and demonstrating boom automation technology in a laboratory environment. In the future, the intent is to establish a CRADA to enable industry participants to demonstrate boom automation with the USAF.

Signature: //SIGNED// in WU Mgmt App Date: 03/17/2024

Deliverable required: Preliminary Hazard List, as described in attached CDRL (A001 - PHL CDRL), must be submitted upon hardware delivery. PHL template also attached.

Note to PM (for in house effort)/Note to Buyer (for contractor efforts): Work unit must complete an AFRL-led SRB as described in AFI 91-202, Mishap Prevention Program, AFRL Supplement, Chapter 16, before testing as part of this work unit may begin.

Note to buyer: Contractor must cooperate with any DAF investigation in the event of any reportable damage or injury, to include toxicology testing per DAFI 91-204 paragraph 2.14 and 2.6.4.3.4.

Note to buyer: Contractors must comply with applicable Federal, state, and local codes and standards, including safety and occupational health requirements. Contractor must immediately notify the contracting officer of any work-related mishap that involves, or appears that it may involve a fatality, total or partial permanent disability of any employee, inpatient hospitalization of any employee, or property damage over $2,000, regardless of whether such matters involve government or private personnel/property. The contracting officer should notify the contracting element safety office of reported contractor mishaps normally within 24 hours of occurrence. Additionally, the contractor should also notify the contracting officer of any illness or injury that is, or appears that it may be, an OSHA recordable illness/injury as defined by 29 CFR 1904 as soon as reasonably possible, but not later than on the first business day following the day on which the illness/injury occurred, regardless of whether such matters involve government or non-government personnel. Contractor is required to investigate all mishaps, illnesses, and injuries, report the results of such investigations, and cooperate with any government investigation of such matters, as requested by the contracting officer.

Note to buyer: Add clause 252.228-7005 to require contractor to participate in a mishap investigation.

For all directed energy devices: If a directed energy device is developed for this test, it must be for research purposes and cannot be used operationally. Email afrl.se.workflow@us.af.mil for any clarification required.

For tests with lasers: Note to PM (for in house effort)/Note to Buyer (for contractor efforts): If test uses government property or if government personnel are part of executing test, the team must receive approval from government Laser Safety Officer (LSO) before conducting laser testing. Email afrl.se.workflow@us.af.mil to initiate this process. Note that this process can take one month or longer. See AFMAN 13-212 Vol 1 for more information about laser use on Air Force ranges.

For testing using uncertified directed energy systems: Note to PM (for in house effort)/Note to Buyer (for contractor efforts):The team must receive a completed Test Hazard Assessment Review (THAR), as described in AFI 91-401, paragraph 7.4, from a HQ AFMC system safety engineering organization or by another organization possessing sufficient system safety engineering expertise as determined by the Directed Energy Safety Board (DESB), before testing uncertified directed energy systems. This requirement only applies when the directed energy device could cause a catastrophic risk to the MDS or injury. (Note to SSM: this rarely applies to lasers - exception is AHEL or other extremely powerful lasers that could cause loss of aircraft.)

For programs that include ordnance containing EIDs: See AFI 91-208 for HERO requirements. Note: AFI 91-208 applies to explosive operations of any kind in Air Force owned or leased facilities, United States-titled ammunition in contractor owned facilities, and civilian and military members of the Air Force. Applicability of 91-208 includes work units in the research and development or test phase.

For programs that use government equipment/facilities/people AND program includes ordnance containing EIDs: Work Unit must meet requirements of AFI 91-208, Hazards of Electromagnetic Radiation to Ordnance (HERO) Certification and Management.