Attachment J-0200000-05(j) Crane and Rigging Gear Accident Report.pdf
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- Solicitation number
- N4008027R1001
About this file
This document is a Crane and Rigging Gear Accident Report form template designed for submission to the Navy Crane Center at Naval Station Norfolk, Portsmouth, Virginia. The form serves as the official reporting mechanism for crane accidents and rigging gear accidents occurring at naval activities and must be submitted via fax to (757) 967-3808 or email to m_nfsh_ncc_accident@navy.mil.
The form captures comprehensive accident details including basic information (reporting activity, UIC, crane number, accident date and time), operational context (service category, crane type, manufacturer, SPS usage, complex lift designation), physical parameters (crane capacity, hook capacity, load weight, location, weather conditions), and injury/damage assessment (fatality status, property cost estimates, NAVSAFECEN reporting). The reporting party must identify the accident type (personal injury, overload, derail, load collision, crane collision, damaged equipment, dropped load, or other), cause of accident (improper operation, equipment failure, inadequate visibility, improper rigging, switch alignment issues, inadequate communication, track condition, procedural failure, or other), responsible party (crane walker, rigger, operator, maintenance, management/supervision, or other), and crane functions in operation at the time of incident (travel, hoist, rotate, luffing, telescoping).
The form requires attachment of a detailed situation description with probable cause, contributing factors, damage assessment, responsibility determination, and both immediate and long-term corrective and preventive actions. Electronic submissions are accepted without signatures provided that preparer, concurring personnel, and certifying official names are included. The accompanying instructions provide detailed guidance for completing each field and defining short-term versus long-term corrective actions.
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Text version
CRANE AND RIGGING GEAR ACCIDENT REPORT
Accident Category: Crane Accident Rigging Gear Accident
From:
UIC:
To: Navy Crane Center Bldg. 491 NNSY Portsmouth, VA 23709 Fax: 757-967-3808
Activity:
Report No:
Crane No:
Category:
Accident Date:
Time: hrs:
Category of Service: SPS GPS Crane Type:
Crane Manufacturer:
Was Crane/Rigging Gear Being Used in SPS: Yes No Was Crane/Rigging Gear Being Used in a Complex Lift/Critical
Non-Crane Rigging Operation: Yes No
Location:
Weather:
Crane Capacity:
Hook Capacity:
Weight of Load on hook:
Fatality or Permanent Disability? Yes No
Material/Property Cost Estimate:
Reported to NAVSAFECEN? Yes No
Accident Type:
Personal Injury Overload Derail Damaged Rigging Gear
Load Collision Two Blocked Dropped Load Damaged Crane
Crane Collision Damaged Load Other: Specify
Cause of Accident:
Improper Operation Equipment Failure Inadequate Visibility
Improper Rigging Switch Alignment inadequate Communication
Track Condition Procedural Failure Other: Specify
Chargeable to:
Crane Walker Rigger Operator
Maintenance Management/Supervision Other: Specify
Crane Function:
Travel Hoist Rotate Luffing Telescoping Other N/A
Is this accident indicative of a recurring problem? Yes No
If yes, list Accident Report Nos.:
ATTACH COMPLETE AND CONCISE SITUATION DESCRIPTION AND CORRECTIVE/PREVENTIVE ACTIONS TAKEN AS
ENCLOSURE (1). Include probable cause and contributing factors. Assess damages and define responsibility. For equipment malfunction or failure, include specific description of the component and the resulting effect or problem caused by the malfunction or failure. List immediate and long term corrective/preventive actions assigned and respective codes.
Preparer:
Phone:
E-mail:
Code:
Date:
Concurrences: (Include Code, Signature and Date)
Certifying Official (Crane Accident Only):
ATTACHMENT J-0200000-05
FORMS
CRANE AND RIGGING GEAR ACCIDENT REPORT INSTRUCTIONS
This form is designed for fax transmission without a cover page or by e-mail and, with enclosures and signatures shall be the official document. Electronic submission will be accepted without signatures but the names of the preparer, concurring personnel, and certifying official (for crane accidents only) shall be filled in. The e-mail address is m_nfsh_ncc_accident@navy.mil. The fax number is (757) 967-3808.
1. Accident Category: Indicate either crane accident or rigging gear accident.
2. From: The naval activity that is responsible for reporting the accident and UIC number.
3. Activity: The naval activity where the accident took place.
4. Report No.: The activity assigned accident number (e.g., 95-001).
5. Crane No.: The activity assigned crane number (e.g., PC-5), if applicable.
6. Category: Identify category of crane (i.e., 1, 2, 3, or 4), if applicable.
7. Accident Date: The date the accident occurred.
8. Time: The time (24 hour clock) the accident occurred (e.g., 1300).
9. Category of Service: Check the applicable service (SPS as defined by NAVSEA 0989 -030-7000).
10. Crane Type: The type of crane involved in the accident (e.g., mobile, bridge), if applicable.
11. Crane Manufacturer: The manufacturer of the crane (e.g., Dravo, Grove, P&H), if applicable.
12. SPS: Was the crane or rigging gear being used in an SPS lift?
13. Complex lift: Was the crane or rigging gear being used in a complex lift?
14. Location: The detailed location where the accident took place (e.g., building 213, dry dock 5).
15. Weather: The weather conditions at time of accident (e.g., wind, rain, cold).
16. Crane Capacity: The certified capacity of the crane (e.g., 120,000 pounds), if applicable.
17. Hook Capacity: The capacity of the hook involved in the accident at the max radius of the operation, if applicable.
18. Weight of Load on Hook: If applicable, the weight of the load on the hook.
19. Fatality or Permanent Disability?: Check yes or no.
20. Material/Property Cost Estimate: Estimate total cost of damage resulting from the accident.
21. Reported to NAVSAFECEN?: Self-explanatory.
22. Accident Type: Check all that apply.
23. Cause of Accident: Check all that apply.
24. Chargeable to: Check all that apply.
25. Crane Function: Check all functions in operation at time of accident. Check N/A if a rigging gear accident.
26. Is this a recurring problem?: Check yes or no. Identify any other similar accidents.
27. Situation Description/Corrective Actions: Self -explanatory.
28. Preparer: Self-explanatory.
29. Concurrences: Self-explanatory.
30. Certifying Official (Crane Accidents Only): Self -explanatory.
31. Brief Description: No more than one paragraph summarizing the resultant incident.
32. Background and Detailed Description: Provide the relevant background in a descriptive timeline of preconditions leading up to the event, as well as a detailed description of the event.
33. Corrective Actions: List all short term and long term corrective actions that are taken to prevent recurrence of the incident. Short Term Corrective Actions are those actions taken that will allow return to work in short time frame.
Long Term actions are more ‘programmatic’ in nature and typically include process revision, changes in training, ‘mistake proofing’, etc.
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