Attachment J-0200000-05(b) Form Contractor Significant Incident Report.pdf

Contractor Significant Incident Report (CSIR-1) Page 1 of 4 Report Date: Contracting Activity/ROICC Office

1. Accident Classification:

Injury Illness Fatality Property Damage Procedural Issues Environmental

Involving:

Hazardous Materials Electrical Equip/Motor Vehicle/ Diving Falls Material Handling Confined Space Crane/Rigging Trenching/Entrapment Fire Other Waterfront Operations Demolition/Renovation

2. Personal Data:

A. Name (Last, First, M.) B. Age C. Sex D. Social Security Number

E. Job Description/Title F. Employed By G. Supervisor s Name

3. Witness Data (Attach Witness Summary Statements to Report):

A. Name (Last, First, M.) B. Age C. Sex

D. Job Description/Title E. Employed By

4. General Information:

A. Date of Accident B. Time of Accident C. Exact Location of Accident D. Type of Construction Equipment (Month/Day/Year) (Make, Model, Serial Number, Vin #)

E. Contract Number/Title F. Construction Activity SIC G. Hazardous Material Spill/Release

H. Type of Contract I. Contractor’s Name/Address/Phone Number

Construction (1) Prime:

A/E Service

RAC

CLEAN (2) Sub:

JOC

OTHER_______

J. Safety Manager’s Name Phone # K. Insurance Carrier

L. Work Activity at Time of Accident M. Personal Protective Equipment?

(1) Available & Used (2) Not Required

(3) Available & not used (4) Not Related to mishap

(5) Wrong PPE for job

(6) List Type(s) used:

5. Injury/Illness/Fatality Information:

A. Severity of Illness/Injury B. Estimated Days Lost C. Estimated Days Hospitalized D. Estimated Days Restricted Duty

E. List Body Part(s) Affected F. Nature of Illness/Injury G. Type and Source of Injury/Illness

(1) Type: (2) Source:

6. A. Accident Description (Describe in your own words) (Use additional paper if necessary)

B. Who provided first aid and/or cleanup of mishap site?

C. Any blood borne pathogen exposure by other than EMT’s? If so who?

D. Was site secured and witness interviews taken immediately?

E. List OSHA and EM 385-1-1 standards/requirements that were violated?

7. Causal Factors (Explain yes answers on a supplementary sheet) YES NO

Design - Was design of facility, workplace, or equipment a factor?

Inspection/Maintenance - Were inspection & maintenance procedures a factor?

Persons Physical Condition - In your opinion, was the physical condition of the person a factor?

Operating Procedures - Were operating procedures a factor?

Job Practices - Were any job safety/health practices not followed when the accident occurred?

Human Factors - Did any human factors such as size or strength of person etc., contribute to the accident?

YES NO

Environmental Factors - Did heat, cold, dust, sun, glare, etc., contribute to the accident?

Chemical & Physical Agent Factors - Did exposure to chemical agents, such as dust, fumes, mists, vapors or physical agents such as noise, radiation, etc., contribute to the accident?

Office Factors - Did office setting such as lifting office furniture, carrying, stopping, etc., contribute to the accident?

Support Factors - Were inappropriate tools/resources provided to properly perform the activity task?

Personal Protective Equipment - Did the improper selection use, or maintenance of personal protective equipment contribute to the accident?

Drugs/Alcohol - In your opinion, were drugs or alcohol a factor?

Activity Hazard Analysis - Was the lack of an adequate (IAW EM 385-1-1 Sec 01.A.09) Activity Hazard Analysis a contributing factor?

- Was it site specific and address the type of work/operations performed when the mishap occurred?

Management - Did the lack of adequate supervision contribute to the accident?

- Was inadequate information provided at pre-con meeting?

8. Training:

A. Was/were person(s) trained to perform activity/task?

B. Type of training?

C. Date of most recent formal training? / / D. List topics discussed

9. Fully Explain What Allowed or Caused The Accident, Include Direct and Indirect Causes:

A. Direct Cause

B. Indirect Cause

C. Action(s) taken to prevent re occurrences or provide on-going corrective actions.

D. Corrective Action Dates

(1) Beginning (Mo/Da/Yr) / / (2) Anticipated Completion Date (Mo/Da/Yr) / /

10. OSHA

A. Date OSHA was notified / / C. Date of OSHA Citation / /

B. Date OSHA Investigated / / D. $ Amount of Penalties:

11. Report Preparer

Print Name & Title of Supervisor Completing Report

Signature: _____________________________________ Date (Mo/Da/Yr) _________________

12. Management Review (Contracting Officer)

A. Accepted B. Amendments Required C. Comments (include program improvements required for your Command. NAVFACHQ Construction Safety Program and EM 385-1-1)

D. Print Name & Title of Official Completing Report

Signature: ________________________________ Date: (Mo/Da/Yr) _________________

13. Safety And Occupational Health Officer Review

A. Concur B. Non Concur C. Additional Actions/Comments

D. Print Name & title of Safety Personnel Reviewing

Signature: ____________________________ Date (Mo/Da/Yr) _____________________