EOSH Impacts for the Tilt Down Pole Replacement at DJB RTR in Elyria OH.pdf

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Pre-Construction/Installation Environmental and Occupational Safety and Health Checklist

INSTRUCTIONS FOR COMPLETING FAA FORM 3900-18

FAA Form 3900-18 (03/15) Electronic Version (PDF) Page i of iii

Section A. Purpose. FAA Form 3900-18, Pre-Construction/Installation Environmental and Occupational Safety and Health (EOSH) Checklist, must be used to review construction, installation and non-routine maintenance activities involving construction prior to commencement of work that potentially has EOSH impacts on NAS operations and employees. The organization that directly manages the construction project is responsible for completing the checklist. They must coordinate with the appropriate District Office prior to commencement of work. Construction must not be initiated prior to completion and review of the checklist. This form must be used at the pre-construction meeting and similar meetings. Emphasis should be placed on using this checklist as a tool to assess as well as reassess hazards as the work progresses.

Responsibilities: Responsibility for completing the checklist may vary depending on the work being performed.

a. The District Office Manager will be responsible for District Office projects.

b. The Project Engineer for Engineering Services projects.

c. The Facilities Maintenance Program (FMP) Manager for FMP projects.

d. For turnkey projects managed by Headquarters organizations, the Headquarters program office will be responsible for completing the checklist.

Section B. Work Summary Information. The individual/organization initiating the checklist will complete this portion of the checklist.

1. District Office: Name of the District Office.

2. Work Location: City, State, Airport, building, room within building.

3. Facility: Facility type, associated runway, facility LOC ID.

4. Work Description: Provide a concise statement as to the nature of the work to be accomplished. Example: Asbestos abatement of the control room attic.

5. Project Number/JCN: Provide the Project Number and or Job Control Number (JCN).

6. Planned Start Date: Provide the expected start date of the work.

7. Expected Completion Date: Provide the expected completion date of the work.

8. Contractor Contact: Provide the name and telephone number for a contractor representative who has the authority to make decisions and implement stop work/change orders. If the work is being accomplished by an FAA employee(s) or FAA contract employee(s), provide the name, organization, and telephone number of the on-site lead.

9. Project/Design Representative: Provide the name for the designer of the work (e.g., Engineering Services project engineer, District Office engineer, Headquarters program manager for turnkey projects).

10. COR/Specialist: Provide the name, organization, and telephone number of the on-site lead (e.g., Contracting Officer’s Representative, Resident Engineer).

11. District Office EOSH Contact: Provide the name and telephone number of the person responsible for the occupational safety and health/environmental program for the District Office (e.g., SECM, District Office EOSH Professional).

12. Facility Representative: Provide the name and telephone number for an ATO representative at the facility who has the authority to make decisions for facility management.

Section C. Evaluation: The District Office Manager or designee may evaluate whether the remainder of the checklist needs to be completed. If necessary, the District Office Manager or designee will be provided any additional information regarding the project that will facilitate their determination on whether the remainder of the checklist should be completed.

If there is an impact (yes), forward the checklist to the organization directing the construction project for completion of the remainder of the checklist. If there is no impact, provide a justification, sign and date the form, and then proceed to Section I, Distribution List, for distribution only. The designee may be the COR, SSC Manager, or other party.

Section D. Facility Procedures: The individuals/organization performing the work, and their contractors, along with the facility POC, must review all applicable facility specific procedures and plans. The intent of this section is to review applicable facility procedures and plans for the project and that it may be necessary to supplement this form.

1. Asbestos Contingency Plan: Determine the responsibilities of the personnel performing the work in the event of an incident requiring implementation of the asbestos contingency plan.

2. Hazard Communication: The personnel performing the work must be made familiar with the facility Hazard Communication program. Information such as safety data sheets (SDS) must be shared between the facility and the personnel performing the work.

3. Lockout/Tagout (LOTO): The work must be performed in accordance with the facility LOTO program. Determine if the facility LOTO procedures require equipment to be locked out/tagged out by an FAA technician, or if the personnel performing the work will be allowed to LOTO the equipment.

FAA Form 3900-18 (03/15) Electronic Version (PDF) Page ii of iii

4. Work Permits: Applicable FAA facility, District Office, or Service Area work permits must be submitted by the individuals/organization performing the work, signed and posted at the work site. General note: All work permits should be included in this document (e.g., asbestos, lead, hot work, welding, cutting, brazing).

5. Emergency Plans: Describe the responsibilities, including the points of contact, in the event of an incident that requires implementation of the facility Occupant Emergency Plan or Fire Prevention Plan

6. Impacts to Fire Protection Systems (e.g., fire alarm, fire suppression, smoke control, fire rated doors): Identify the Fire Alarm and Suppression System and instructions to avoid unintentional impact to it. If the work involves intentional impact to the Fire Alarm and Suppression System, determine what coordination has to be done to ensure no disruption of the NAS. Determine what interim life safety measures (i.e., egress pathways, occupant emergency notification & fire alarm impairments) will be required during the project.

7. Confined Space Entry: Describe the facility procedures used in and around confined spaces. In addition, describe specific procedures for permit-required confined space in and around where the work will take place.

8. Work at Heights: Describe procedures for working at elevated surfaces (e.g., catwalks, towers, roofs) that may require fall protection procedures or equipment. Review rescue procedures and ensure awareness of responsibilities.

9. Restricted Areas due to EOSH Concerns: Describe those areas of the facility that have restricted access due to safety and health hazards (e.g., asbestos regulated areas, radiation, noise).

10. First Aid/Bloodborne Pathogens: Describe the facility procedures for dealing with emergency first aid situations and other trauma situations.

11. Other: The personnel performing the work should be made familiar with other facility programs, procedures, and requirements.

Section E. Activity Hazard: The individuals/organization performing the work, and their contractors, along with the facility POC, must identify potential EOSH hazards that may be encountered during the accomplishment of the work. Determine the possibility of causing disruption of NAS operations.

1. Asbestos: Determine if known or assumed asbestos containing material will be impacted by this work.

2. Chemical, Gases, Fumes, Vapors, Mist, Dust, Radiation: Determine if any products or methods will be used that may cause odors or vapors (from chemicals volatizing or biological agents), fumes (from welding or burning), excessive dust (e.g., sanding, grinding), or radiation (e.g., heat sources, light sources such as lasers, ionizing radiation sources such as X-ray equipment).

3. Use and Storage of Hazardous Materials: Determine if substances that exist at the facility may be impacted and what substances may be brought into the facility, which may have an impact on the facility and/or occupants.

4. Waste Management: Determine if work activities will generate wastes (e.g., construction waste, hazardous waste) and what procedures will be used for waste management (e.g., accumulation area, training).

5. Impact on HVAC System: Determine whether the environmental control elements of the facility may be impacted by the accomplishment of the work.

6. Equipment Removal/Installations: Determine if work activities will cause disturbance of excessive dust (e.g., disturbance of equipment which has been in place for a long time).

7. Fire Protection: Determine if work activities will impact fire protection systems and procedures at the facility (e.g., blocking egress, removing fire stopping, impacting fire rated barriers).

8. Impact to Integrity of Fire Alarm/Suppression System: Identify impacts to the fire alarm and suppression system. If the work involves intentional impact to the fire alarm and suppression system, determine what coordination has to be done to ensure no disruption of the NAS. Determine what interim life safety measures will be required during the project.

9. Lead Exposure: Determine if activities will expose FAA employees to lead dust, lead fumes, or other exposure to lead from known or assumed lead-containing material during the construction project.

10. Electrical Safety: Determine if work activities will expose FAA employees to electrical safety hazards (e.g., open electrical panel doors, exposed energized conductors, energized work).

11. Excessive Noise Exposure: Determine if work activities will expose FAA employees to excessive noise.

12. Walking Working Surfaces: Determine if work activities will expose FAA employees to tripping, slip and fall hazards (e.g., open panels in a raised floor, uneven floors, raised or loose carpeting, stairs, wet floors, etc.).

13. Work above Equipment/People: Determine if work activities will expose FAA employees to objects dropped from above.

14. Water Quality/Sanitation: Determine if work activities may cut off or contaminate the facility’s potable water system.

15. Cranes/Rigging/Hoisting: Determine if work activities will expose FAA employees to hazards associated with rigging, hoisting and cranes.

FAA Form 3900-18 (03/15) Electronic Version (PDF) Page iii of iii

16. Lighting: Determine if work activities will create insufficient lighting for FAA employees.

17. Machinery and Mechanized Equipment: Determine if work activities may expose FAA employees to hazards such as being struck by, caught in, or injured by machinery and mechanized equipment.

18. Excavation: Determine if work activities performed near facilities may cause catastrophic failure of a NAS facility.

19. Other: Other work activities that may impact NAS operations and employees.

Section F. Site Safety and Health – Controls. Ensure that measures and controls to address applicable site safety and health risks (e.g., through discussions, available site safety plans, or other applicable documents) have been identified. If a hazard has been identified in Section E, Activity Hazard, briefly describe the controls to be used.

1. Identify issues/hazards in Section E, Activity Hazard.

2. “Description of Controls” – The purpose of this column is to very briefly describe the controls in place for addressing each hazard.

Section G. Site Walk-Through: Following review of all applicable facility procedures, activity hazards and applicable control measures, the personnel performing the work must participate in a walk-through of the area of the facility where the work will be accomplished, led by a facility representative. The purpose of the walk-through is to allow the personnel performing the work to be introduced to the facility and the potential hazards as referenced in Sections E and F. It also allows the personnel performing the work to become familiar with the facility with respect to the work being done and awareness of the method of implementation of the various emergency plans. If the project is located at a staffed Air Traffic facility, inclusion of the Air Traffic Manager is warranted. The time, date, and personnel present for the walk-through must be recorded in Section G.

Section H. Review Information. This form must be reviewed by those individuals identified below, as appropriate, during design of the project, during pre-bid conferences, prior to the beginning of work (preferably at or prior to the pre-construction conference) and periodically throughout the completion of the project.

1. Originator: This is the individual/organization responsible for initiating the work (e.g., project engineer, senior engineer, technical support office) or the organization directly managing the day-to-day activities in the construction project.

2. Contractor/Installation Crew Lead/Specialist: These are the individuals performing the work who have the authority to make decisions and implement stop work/change orders. If the work is being accomplished by an FAA employee or an FAA contract employee, the employee should sign the form and provide a routing symbol and platform title.

3. District Office Manager or designee: This person must be the District Office Manager or designee. The designee may be the COR, SSC Manager, or other party.

Section I. Distribution List: This form must be forwarded to the following as applicable:

1. District Office Manager.

2. Safety and Environmental Compliance Manager (SECM) or District Office EOSH Professional.

3. Engineering Services EOSH Coordinator.

4. Engineering Services Manager.

5. Engineering Services Project Engineer.

6. Contracting Officer’s Representative.

7. Facility Air Traffic Manager.

FAA Form 3900-18 (03/15) Electronic Version (PDF) Page 1 of 5

Section A. Purpose

This checklist is intended to review construction, installation and non-routine maintenance activities, prior to commencement, that potentially have occupational safety and health related impacts on NAS operations and employees. This tool must be used, as appropriate, during critical phases of the work (e.g., the pre-construction meeting, prior to commencement of work, etc.). Emphasis should be placed on using this checklist as a tool to assess as well as reassess hazards as the work progresses. This form is required to be completed as per FAA Order JO 3900.57A.

Section B. Work Summary Information

The purpose of this section is to provide a brief description of the construction project and/or specific maintenance tasks, and identify key personnel responsible for project completion. Fill in the requested site-specific information. Indicate if this work will occur in or adjacent to an occupied space (e.g., equipment room, ATCT cab, etc.). Note: Provide further explanation of activities on additional sheets if necessary.

1. District Office: 2. Work Location: 3. Facility:

4. Work Description:

5. Project Number/JCN: 6. Planned Start Date: 7. Expected Completion Date:

8. Contractor Contact Name: Phone:

9. Project/Design Representative Name: Phone:

10. COR/Specialist Name: Phone:

11. District Office EOSH Contact Name: Phone:

12. Facility Representative Name: Phone:

Section C. Evaluation

The purpose of this section is to allow the District Office Manager or designee to determine whether the remainder of the checklist needs to be completed. If there is a potential EOSH hazard, then no signature is required in Section C and subsequent sections of the form are to be completed by the organization managing the construction project or maintenance task. If there is no potential hazard, the District Office Manager or designee must sign below and provide an explanation, then proceed to Section I.

Yes

Is there a potential EOSH hazard?

(Explanation) No (if no, explain)

Name: (print)

(Title)

Signature:

(Date)

FAA Form 3900-18 (03/15) Electronic Version (PDF) Page 2 of 5

Section D. Facility Procedures

Review site-specific FAA procedures and considerations with the contractor/installer/specialist. For example, discuss when or how during the work, emergency plans will be required and/or used.

Facility Procedures Reviewed?

[Yes/No/N/A] Notes

1. Asbestos Contingency Plan

2. Hazard Communication (e.g. SDSs)

3. Lockout/Tagout

4. Work Permits (e.g., asbestos, lead, hot work)

5. Emergency Plans (e.g., Occupant Emergency Plan)

6. Impacts to Fire Protection Systems

7. Confined Space Entry

8. Work at Heights

9. Restricted Areas due to EOSH Concerns

10. First Aid/Bloodborne Pathogens

11. Other

NOTE: Think about your work and its potential hazards. Consider sensitive NAS operations and all facility personnel that may be impacted by your work. As an example, construction activities with potential for impacting asbestos materials in or near sensitive operations could result in incidents that may disrupt NAS operations.

Section E. Activity Hazard

Note: Provide further explanation of potential hazards, locations, etc. below and attach additional sheets if necessary.

Potential Hazardous Exposures and/or Activities Consider Sensitive NAS Operations

Potential for Exposure/Release

/ Incident

Description of Hazard

1. Asbestos (e.g., tiles & insulation)

2. Chemical, Gases, Fumes, Vapors, Mist, Dust, Radiation

a. Painting/Solvent/Adhesive/Sealant

b. Grinding/Sanding/Cutting/Welding/Soldering

c. Indoor Air Quality (e.g., biological agents, mold, odors, CO2)

3. Use and Storage of Hazardous Materials (e.g., flammables, compressed gas)

4. Waste Management

5. Impact on HVAC System

6. Equipment Removal/Installation (e.g., dust disturbance)

7. Fire Protection (e.g. blocked egress, fire barrier penetration)

FAA Form 3900-18 (03/15) Electronic Version (PDF) Page 3 of 5

Consider Sensitive NAS Operations

Potential for Exposure/Release

/ Incident

Description of Hazard

8. Impact to Integrity of Fire Alarm/Suppression System(s)

9. Lead Exposure (e.g., lead-based paint)

10. Electrical Safety

a. Work on Live Electrical Systems

b. Temporary Wiring

11. Excessive Noise Exposure

12. Walking/Working Surfaces (e.g., tripping hazards, work at heights)

13. Work above Equipment/People

14. Water Quality/Sanitation

15. Cranes/Rigging/Hoisting

16. Lighting

17. Machinery and Mechanized Equipment (e.g., operator training and certification and equipment certification)

18. Excavation

19. Other

Section F. Site Safety and Health – Controls

After reviewing the potential hazards in Section E, ensure that measures and controls to address applicable site safety and health risks (e.g., through discussions, available site safety plans, or other applicable documents) have been identified. If a hazard has been identified in Section E, briefly describe the controls to be used.

Note: Provide further explanation of controls below and attach additional sheets if necessary.

Identified as a hazard in Section E? [Yes/No/N/A]

Description of Controls (e.g., addressed in Accident Prevention Plan or Site Safety

Plan)

1. Asbestos (e.g. tiles & insulation)

2. Chemical, Gases, Fumes, Vapors, Mist, Dust, Radiation

a. Painting/Solvent/Adhesive/Sealant

b. Grinding/Sanding/Cutting/Welding/Soldering

c. Indoor Air Quality (e.g., biological agents, mold, odors, CO2)

3. Use and Storage of Hazardous Materials (e.g., flammables, compressed gas)

4. Waste Management

5. Impact on HVAC System

FAA Form 3900-18 (03/15) Electronic Version (PDF) Page 4 of 5

Identified as a hazard in Section E? [Yes/No/N/A]

Description of Controls (e.g., addressed in Accident Prevention Plan or Site Safety

Plan)

6. Equipment Removal/Installation (e.g., dust disturbance)

17. Machinery and Mechanized Equipment (e.g., operator training and certification and equipment certification)

18. Excavation

19. Other

10. Electrical Safety

a. Work on Live Electrical Systems

b. Temporary Wiring

11. Excessive Noise Exposure

12. Walking/Working Surfaces (e.g., tripping hazards, work at heights)

13. Work Above Equipment/People

14. Water Quality/Sanitation

15. Cranes/Rigging/Hoisting

16. Lighting

7. Fire Protection (e.g., blocked egress, fire barrier penetration)

8. Impact to Integrity of Fire Alarm/Suppression System(s)

9. Lead Exposure (e.g., lead-based paint)

Section G. Site Walk-Through

Time/date of site walk-through with appropriate personnel (e.g., District Office representative, SSC Manager, SECM, Air Traffic Manager, Resident Engineer, COR, Contractor).

Site Walk Through:

(Date) (Time)

Appropriate Personnel:

(Name) (Organization)

FAA Form 3900-18 (03/15) Electronic Version (PDF) Page 5 of 5

Section H. Review Information

The appropriate FAA point-of-contact and the contractor/installation crew lead/specialist print and sign below to document discussion of the items on this form.

Completed By:

FAA Originator of Work (e.g., Project Engineer, Resident Engineer):

(Print or Type Name) (Signature ) (Title) (Date)

Contractor Name:

Reviewed By:

District Office Manager or Designee:

Section I. Distribution List

This form must be forwarded to the following as applicable:

Name/Routing Symbol

1. District Office Manager

2. SECM/District Office EOSH Professional

3. Engineering Services EOSH Coordinator

4. Engineering Services Manager

5. Engineering Services Project Engineer

6. Contracting Officer (if contractor resources perform the construction work)

7. Facility Air Traffic Manager

Reviewed 1:

Asbestos Contingency Plan? [Yes/No/N/A]: [ ]

1:

Asbestos Contingency Plan- Notes:

Reviewed 2:

Hazard Communication [Yes/No/N/A]: [ ]

Reviewed? 3:

Lockout/Tagout [Yes/No/N/A]: [ ]

3:

Lockout/Tagout- Notes:

Reviewed? 4:

Work Permits [Yes/No/N/A]: [ ]

4:

Work Permits- Notes:

5:

Emergency Plans- Notes:

Reviewed? 5:

Emergency Plans [Yes/No/N/A]: [ ]

Reviewed? 6:

Impacts to Fire Protection Systems [Yes/No/N/A]: [ ]

6:

Impacts to Fire Protection Systems- Notes:

Reviewed? 7:

Confined Space Entry [Yes/No/N/A]: [ ]

7:

Confined Space Entry- Notes:

8:

Work at Heights- Notes:

Reviewed? 10:

First Aid/Bloodborne Pathogens [Yes/No/N/A]: [ ]

10:

First Aid/Bloodborne Pathogens- Notes:

Reviewed? 11:

Other [Yes/No/N/A]: [ ]

11:

Other- Notes:

Activity Hazard-potential for exposure/release/incident for question 1 [Yes/No/N/A]: [ ]

Activity Hazard-potential for exposure/release/incident for question 2 [Yes/No/N/A]: [ ]

Activity Hazard-potential for exposure/release/incident for question 2a:

[Yes/No/N/A]: [ ]

Activity Hazard-potential for exposure/release/incident for question 2b:

[Yes/No/N/A]: [ ]

Activity Hazard-potential for exposure/release/incident for question 2c:

[Yes/No/N/A]: [ ]

Activity Hazard-potential for exposure/release/incident for question 3 [Yes/No/N/A]: [ ]

Activity Hazard-potential for exposure/release/incident for question 4 [Yes/No/N/A]: [ ]

Activity Hazard-potential for exposure/release/incident for question 5 [Yes/No/N/A]: [ ]

Activity Hazard-potential for exposure/release/incident for question 6 [Yes/No/N/A]: [ ]

Activity Hazard-potential for exposure/release/incident for question 7 [Yes/No/N/A]: [ ]

Date of Site Walk Through:

Time of Site Walk Through:

Appropriate Personnel Name 1:

Appropriate Personnel Organization 1:

Appropriate Personnel Name 2:

Appropriate Personnel Name 3:

Appropriate Personnel Organization 2:

Appropriate Personnel Organization 3:

Title of FAA Orginator of Work (e:

g:

, Project Engineer, Resident Engineer):

Name of FAA Orginator of Work:

Name of Contractor:

Name of District Office Manager or Designee:

Title of Contractor:

Please state whether you are the District Manager or Designee, if you are the Designee please provide your title:

Reviewed? 8:

Work at Heights [Yes/No/N/A]: [ ]

Reviewed? 9:

Restricted Areas due to EOSH Concerns [Yes/No/N/A]: [ ]

9:

Restricted Areas due to EOSH Concerns- Notes:

Was question 6:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 7:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 8:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 9:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 10:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 10a:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 10b:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 11:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 12:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 13:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 14:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 15:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 16:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 17:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 18:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Was question 19:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Date of signature indicating form completion- FAA Orginator of Work:

Date of signature indicating form completion- Contractor:

Name and routing symbol of Engineering Services Project Engineer:

Name and routing symbol of Engineering Services Manager:

Name and routing symbol of Engineering Services EOSH Coordinator:

Name and routing symbol of SECM/District Office EOSH Professional:

Name and routing symbol of District Office Manager:

Name and routing symbol of Facility Air Traffic Manager:

Date of signature indicating form review:

Activity Hazard question 1- Description of Hazard:

Activity Hazard question 2- Description of Hazard:

Activity Hazard question 2a:

- Description of Hazard:

Activity Hazard question 2b:

- Description of Hazard:

Activity Hazard question 2c:

- Description of Hazard:

Activity Hazard question 3- Description of Hazard:

Activity Hazard question 4- Description of Hazard:

Activity Hazard question 5- Description of Hazard:

Activity Hazard question 6- Description of Hazard:

Activity Hazard question 7- Description of Hazard:

Site Safety and Health Controls question 6- Description of Controls:

Site Safety and Health Controls question 7- Description of Controls:

Site Safety and Health Controls question 8- Description of Controls:

Site Safety and Health Controls question 9- Description of Controls:

Site Safety and Health Controls question 10- Description of Controls:

Site Safety and Health Controls question 10a:

- Description of Controls:

Site Safety and Health Controls question 10b:

- Description of Controls:

Site Safety and Health Controls question 11- Description of Controls:

Site Safety and Health Controls question 12- Description of Controls:

Site Safety and Health Controls question 13- Description of Controls:

Site Safety and Health Controls question 14- Description of Controls:

Site Safety and Health Controls question 15- Description of Controls:

Site Safety and Health Controls question 16- Description of Controls:

Site Safety and Health Controls question 17- Description of Controls:

Site Safety and Health Controls question 18- Description of Controls:

Site Safety and Health Controls question 19- Description of Controls:

1 District Office: ZOB

2 Work Location: Elyria, OH

3 Facility: DJB RTR

4 Work Description: Replace Tilt-Down Pole

5 Project Number/JCN: 1604986

6 Planned Start Date:

7 Expected Completion Date:

8 Contractor Contact Name:

Phone Number of Contractor:

9 Project Design Representative Name: Sary Sancen

Phone Number of Project or Design Representative: 847-294-7100

Phone Number of COR or Specialist:

11 District Office EOSH Contact Name:

Phone Number of District Office EOSH Contact:

12 Facility Representative Name:

Phone Number of Facility Representative:

Is there potential EOSH hazard?-Yes: Off

Is there potential EOSH hazard-No: Off

If there is no potential EOSH hazard then provide an explanation:

Name of District Office Manager or designee:

Title of District Office Manager or designee:

Date of evaluation by District Office Manager or designee:

10 COR or Specialist Name:

Name and routing symbol of Contracting Officer:

2:

Hazard Communication (e:

g:

SDSs)- Notes:

Activity Hazard-potential for exposure/release/incident for question 8 [Yes/No/N/A]: [ ]

Activity Hazard question 8- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 9 [Yes/No/N/A]: [ ]

Activity Hazard question 9- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 10 [Yes/No/N/A]: [ ]

Activity Hazard question 10- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 10a:

[Yes/No/N/A]: [ ]

Activity Hazard question 10a:

- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 10b:

[Yes/No/N/A]: [ ]

Activity Hazard question 10b:

- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 11 [Yes/No/N/A]: [ ]

Activity Hazard question 11- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 12 [Yes/No/N/A]: [ ]

Activity Hazard question 12- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 13 [Yes/No/N/A]: [ ]

Activity Hazard question 13- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 14 [Yes/No/N/A]: [ ]

Activity Hazard question 14- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 15 [Yes/No/N/A]: [ ]

Activity Hazard question 15- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 16 [Yes/No/N/A]: [ ]

Activity Hazard question 16- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 17 [Yes/No/N/A]: [ ]

Activity Hazard question 17- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 18 [Yes/No/N/A]: [ ]

Activity Hazard question 18- Description of Hazard:

Activity Hazard-potential for exposure/release/incident for question 19 [Yes/No/N/A]: [ ]

Activity Hazard question 19- Description of Hazard:

Was question 1 identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Site Safety and Health Controls question 1- Description of Controls:

Was question 2 identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Site Safety and Health Controls question 2- Description of Controls:

Was question 2a:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Site Safety and Health Controls question 2a:

- Description of Controls:

Was question 2b:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Site Safety and Health Controls question 2b:

- Description of Controls:

Was question 2c:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Site Safety and Health Controls question 2c:

- Description of Controls:

Was question 3:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Site Safety and Health Controls question 3- Description of Controls:

Was question 4:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Site Safety and Health Controls question 4- Description of Controls:

Was question 5:

identified as a hazard in Section E? [Yes/No/N/A]: [ ]

Site Safety and Health Controls question 5- Description of Controls:

ATTACHMENT

EOSH IMPACTS

Project:

Tilt-Down Pole Replacement at DJB RTR in Elyria, OH

Engineer / Routing Code: Sary Sancen / AJW-2C15C Manager/Routing Code: Chris Keil / AJW-2C15C SECM (District): Garry Gavin / ZOB NISC (District): John Guty / ZOB EOSH Coordinator: Stephen Diblik / AJW-2C15H

EOSH IMPACTS

1. Compressed Gases:

Compressed gases may be utilized during the welding process of this project. Workmen in charge of the oxygen or fuel-gas supply equipment, including generators and oxygen or fuel-gas distributions shall be instructed and judged as being competent by their employers for this work before being left in charge. Rules and regulations covering the operation and maintenance of oxygen or fuel-gas supply equipment shall be readily available. All welding activities should conform to the Engineering Services SOP for Welding and Compressed Gas.

2. Concrete and Masonry Work:

When providing project oversight pouring/placing or demolishing concrete the employees shall wear all required Personal Protective Equipment to reduce eye, skin, face, and head injury. All regulations will be followed according to OSHA 1926, Subpart Q. It is recommended that the employees wear pants and long sleeve shirts and don the proper hand, foot, eye, and face protection.

3. Cranes, Derricks, Lifts, and Hoists:

Employees or contractors that operate cranes, derricks, lifts, and hoists must complete specialized training for certification and authorization. All cranes onsite shall meet or exceed OSHA 29 CFR 1926, Subpart N. The crane service company shall have a licensed operator, crane inspection information, proper crane setup, proper rigging and lifting equipment, and follow and stay within all lifting charts. The crane company will need to have a certified rigger onsite with proper communication between them and the operator (radios and hand signals). When utilizing cranes, derricks, lift, and hoists be aware of obstacles and obstructions including electrical power lines and ditches or trenches. Proper fall protection must be utilized when occupying such equipment.

4. Employee Health (First Aid / Blood Borne Pathogen):

When first aid situations arise, local emergency response systems shall be the primary source of emergency first aid. Ensure a viable and reliable source to contact first responders is present and functional within the worksite and ensure employees or contractors be properly instructed in how to access the system, e.g., by dialing 911. If working in rural areas where there is no coverage by a local emergency medical response system, make provisions for acceptable emergency transportation. Ensure that job sites or vehicles have a properly stocked and approved first aid kit.

To ensure compliance with FAA Blood Borne Pathogen rules and regulations make sure of the following;

• Appropriate engineering and work practice controls are in place.

• Ensure that appropriate personal protective equipment is available at the project site.

• Ensure the worksite is maintained in a clean and sanitary condition.

• Any spills of blood or other potentially infectious material on work surfaces are cleaned with an appropriate disinfectant.

All incidents resulting in first aid treatment should be reported in the same manner as any other occupational injury or illness as described in FAA Order 3900.19B, Chapter 7, Mishap Reporting and Investigation.

If you require further assistance with respect to first aid or blood borne pathogen requirements, please refer to FAA Order 3900.19B, Chapter 17 - Bloodborne Pathogens Control Program, FAA Order 3900.19b, Chapter 22 - First Aid Program, PASS CBA, Article 52, Section 15, NATCA CBA, Article 53, Section 5, OSHA - 29 CFR 1910.1030 - Bloodborne pathogens, , PASS CBA, Article 52, Sections 8 and 15, NATCA CBA, Article 53, Sections 5 and 7, and OSHA - 29 CFR

1910.151 - Medical and First Aid.

5. Excavations, Trenching, or Boring:

All excavations, trenches, and boring activities shall adhere to the OSHA regulations within 29 CFR 1926, Subpart P. Employees should be aware of the hazards of open trenches, operation of vehicles and machinery near excavations, and familiar with trench protective systems.

6. Fall Protection:

Employee working at heights greater than four (4) feet or near an unprotected edge should use be protected by a safety net, guardrails, or personal fall arrest/restraint system. The employee/ contractor should follow all OSHA regulations and FAA order 3900.63, Fall Protection Program.

The use of buckets trucks, cherry pickers, and man lifts require specific training on that piece of equipment. The employee/contractor should follow the manufacturer’s instructions for safe operations. The use of a Personal Fall Arrest System may be required for safe operation at heights while elevated work platform is in use.

7. Fire and Explosion Hazards:

Fire and explosion hazards are prevalent in virtually every job site. Maintain effective fire protection and prevention programs at the job site throughout all phases of the construction, repair, alteration, or demolition work. Ensure the availability of proper fire protection and suppression equipment throughout each phase of the project. Guidance on fire and explosion hazards on the job site can be found within 29 CFR 1910 Subparts E,G,H,L,N,Q,R and Z, 29 CFR 1926 Subparts C,D,F,H,J,K,R,S,T and U and FAA Order 3900.19B, Chapter 24.

8. Fire Life Safety:

An emergency action plan should be established to identify exit routes and means of egress in case of an emergency. Good housekeeping practices are required to ensure a safe means of egress and to eliminate a possible fuel source for fires. For additional reference regarding fire life safety, refer to OSHA CFR 1910 Subpart L.

9. Hazard Communication:

• Familiarize yourself with the applicable FAA and OSHA standards regarding hazard communication.

• Obtain from SSC or create a list of the hazardous chemicals in the workplace.

• Obtain material safety data sheets for all chemical substances in the workplace.

• Ensure that all containers are labeled.

• Request and review the District SSC Written Hazard Communication Programs.

Guidance on Hazard Communication include, FAA Order 3900.19B, Chapter 19, FAA Order 6000.54, Airway Facilities Hazard Communication Program, PASS CBA, Article 52, Section 10, http://www.faa.gov/documentLibrary/media/order/occ_safety/order3900/media/ch17.pdf http://www.faa.gov/documentLibrary/media/order/occ_safety/order3900/media/ch22.pdf https://employees.faa.gov/org/staffoffices/ahr/emp_labor_management_relations/labor_relations/agreements/media/07-02-00%20PASS-AF%20-%20Bus%200067.pdf https://employees.faa.gov/org/staffoffices/ahr/emp_labor_management_relations/labor_relations/agreements/media/NATCA_2009_BU_0053_0061_1545.pdf https://employees.faa.gov/org/staffoffices/ahr/emp_labor_management_relations/labor_relations/agreements/media/NATCA_2009_BU_0053_0061_1545.pdf http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 https://employees.faa.gov/org/staffoffices/ahr/emp_labor_management_relations/labor_relations/agreements/media/NATCA_2009_BU_0053_0061_1545.pdf http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10122 http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10122 https://employees.faa.gov/employee_services/safety/occ_safety/order3900/media/ch19.pdf http://www.faa.gov/documentLibrary/media/Order/6000_54.pdf http://www.faa.gov/documentLibrary/media/Order/6000_54.pdf https://employees.faa.gov/org/staffoffices/ahr/emp_labor_management_relations/labor_relations/agreements/media/07-02-00%20PASS-AF%20-%20Bus%200067.pdf and OSHA - 29 CFR 1910.1200 - Hazard Communication. If you need further assistance regarding hazard communication, contact the District Safety and Environmental Compliance Manager (SECM) or EOSH contract support staff at the pertinent Technical Support Center

(TSC).

10. Hazardous Energy (Construction):

Based on the parameters of the project, lockout/tag out is required. The contractor/employee is responsible for creating equipment specific lockout/tag out procedures for this project. Refer to the Engineering Services Standard Operating Procedures (SOP) Hazardous Energy for work requirements regarding lockout / tag out. For reference regarding hazardous energy lockout / tag out, refer to OSHA (29 CFR 1910.147 and 1960) and by FAA Order 3900.19B.

11. Hearing Conservation:

Based on the project parameters, the potential for employees or the contractor to be exposed to high intensity and frequent high levels of noise exist. When conducting project oversight, ensure the use of appropriate personal protective equipment (PPE) to reduce noise level exposure of the employee or contractor. When the lack of suitable determination for the selection of proper PPE is not offered, ensure the most stringent PPE is available. This would include the use of ear plugs and ear muffs in combination. Utilize PPE when noise levels become uncomfortable for the individual. For further guidance regarding hearing conservation, refer to OSHA 1910 Subpart G and FAA Order390.19B, Chapter 21, Hearing Conservation Program.

12. Housekeeping

• During the course of construction, alteration, or repairs maintain the following:

• Form and scrap lumber with protruding nails, and all other debris, shall be kept cleared from work areas, passageways, and stairs, in and around buildings or other structures.

• Walkways shall be kept clear of obstructions.

• Combustible scrap and debris shall be removed at regular intervals during the course of construction.

• Containers shall be provided for the collection and separation of waste, trash, oily and used rags, and other refuse.

• Containers used for garbage and other oily, flammable, or hazardous wastes, such as caustics, acids, harmful dusts, etc. shall be equipped with covers.

• Garbage and other waste shall be disposed of at frequent and regular intervals.

13. Lead Based Paint:

The poles have not been surveyed for the presence of lead based paint (LPB). All painted surfaces should be assumed to contain LBP unless determined otherwise through appropriate testing.

14. Lightning Safety:

Know your local weather patterns and if lightening is observed, avoid water, open areas, metal object, and go to a building or vehicle. Suspend outdoor activities for 30 minutes after the last observed lightning or thunder. When working with power equipment, ensure the use of lightening arresters.

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10099

15. NEPA:

The project qualifies for a Categorical Exclusion, per FAA Order 1050.1F, Paragraph 5-6.3.a.

16. Personal Protective Equipment (PPE):

Following review of the project scope of work, the EOSH Coordinator has determined that PPE is required for this project. PPE should consist of gloves, hard hats, hearing protection, reflective vests, safety glasses, and safety boots / shoes. OSHA 1926 Subpart E and FAA Order 3900.19B JC Supplement; Personal Protective Equipment Program provides guidance and instructions on the selection, use, and maintenance of PPE.

17. Slips, Trips & Falls:

• Wear proper footwear with slip-resistant soles.

• Ensure that work environments are properly maintained through good housekeeping practices.

• Keeping walking areas free of electrical cords and wires.

• Provide sufficient lighting in walkways, eliminating uneven floor surfaces.

• Pay attention to your surroundings.

Guidance on slips, trips, and falls can be found within 29 CFR 1910 Subpart D- Walking Working Surfaces, 29 CFR 1926.500 (Subpart X)-Ladders, ANSI A1264.1 Safety Requirements for Workplace Floor and Wall Openings, Stairs and Railing Systems, and FAA Order 3900.19B, Chapter 10.

18. Thermal Stress:

Exposure to extreme heat or cold may result in occupational illnesses or injury. Ensure proper clothing and work practices are utilized to minimize the effects of thermal stress. Check local weather conditions prior to site activities and if questions arise concerning thermal stress, contact an EOSH coordinator.

19. Two Person Rule To comply with OSHA regulations and FAA orders, a “Two Person Rule” will be implemented, which prohibits employees from working alone under certain situations where there are employees working at heights, where employees are working with electrical systems over 50v, where employees are at risk of electrocution, or where medical emergency response is not readily available, must be trained in first aid and CPR. In each case, the second person must be trained in first aid and CPR.

20. Walking-Working Surfaces:

The employer should protect their employees from floor openings when working on the jobsite.

OSHA 1910, Subpart D specifies worker safety and eliminating falls from stairs, scaffolding, ladders, and working platforms by outlining handrail requirements, tread heights, safe ladder usage, and the proper selection of fall protection methods. OSHA 1910.22 provides guidance on how to assist in the elimination of potential hazardous conditions by practicing good housekeeping and keeping aisles and passageways free of any clutter, materials, or debris. FAA Order 3900.63 covers all walking and working surfaces and fall protection requirements for construction and installation projects within the FAA. If not specified, use the more stringent of the two sources for fall protection requirements (e.g.- Duty to provide fall protection).

21. General:

Safety Data Sheets (SDS) for hazardous materials already present in the workplace shall be provided by the SSC and ZOB District. Contractors shall identify and provide SDS’s for all hazardous materials brought into the work area by themselves or their sub-contractors. All Personal Protective Equipment shall be worn at all times to protect from head, eye, face, and foot injuries. Please contact any of the following personnel if any environmental, health or safety issues arise:

ZOB District SECM/EPS Garry Gavin 440-774-0827 NISC John Guty 440-774-0828 NISC EOSH Coordinator Stephen Diblik 847-294-7709

22. PRE-CONSTRUCTION CHECKLIST:

This checklist (see Attachments, below) is intended to be used as a tool by RE/COTRs, designated facility POCS, or SSC managers who oversee construction and maintenance activity that potentially have Occupational Safety, Health, and Environmental (OSH/E) related impacts on AT/AF operations. This tool shall be used, as appropriate, during critical phases of construction and maintenance activities (e.g. the pre-construction meeting, 30-60 days prior to commencement of work, weekly/daily construction meetings, etc.). Emphasis should be placed on using this checklist as a tool to assess as well as reassess hazards as the project progresses.

Specifically, this checklist is intended to:

• Promote sensitivity to potential OSH/E hazards associated with projects and stress the importance of not disrupting NAS operations. Assist in identifying and validating potential project hazards and associated risks

• Assist in preventing safety and health incidents/accidents and facility shutdowns

• Ensure appropriate contractor measures and controls are in place to address potential project hazards

• Facilitate discussion with the contractor regarding plans to prevent minimize potential incidents/accidents

• Enhance coordination between OSH/E professionals, project personnel and contractors

• Facilitate review of critical FAA OSH/E procedures with contractors

• Raise OSH/E awareness

This checklist relies on the training and professional judgment of the user. OSH/E personnel should be consulted as needed.

A facility POC with a thorough understanding of facility procedures and equipment considerations should participate in the site walk-through.

Central Service Area Environmental, Occupational Safety and Health (EOSH) Project Review Checklist

Rev. 05/06/2011 Page 1 of 4

PROJECT Replace Tilt-Down Pole JON DATE 5/28/2020

JCN 1604986 Transmittal

Revised? REGION

Great Lakes DISTRICT Cleveland

SSC Cleveland Radar SSC

FACILITY

LOCATION

Elyria, OH FACILITY

TYPE

RTR FACILITY

ID

DJB

ENGINEER

TITLE

Sary Sancen Project Engineer

EHS

Stephen Diblik EOSH Professional

SUPERVISOR

Chris Keil Manager, OPS Infrastructure Support Center, Chicago

CODE AJW-2C15C CODE AJW-2C15H CODE AJW-2C15C

SIGNATURE

Issue Yes No

Action Items and Notes

If YES, always coordinate with EOSH Specialist

AIR EMISSIONS

CLEAN AIR ACT

(CAA)

Replace and/or install new emission sources such as boilers, incinerators, storage tanks, engine generators, painting booths, space heaters, equipment using CFCs or Halon, etc.

NOTE:

1. Review federal and state requirements for new or modified sources.

ASBESTOS Will activity potentially impact presumed or known asbestos containing materials (ACM)?

NOTE: It is not anticipated that any ACM will be impacted by this project.

If drilling, demolition, coring, or other required project work involves the disturbance or contact with suspect presumed asbestos containing materials, or known asbestos containing materials, stop work and contact an EOSH Coordinator. If previously unidentified materials are observed during construction, these materials should be presumed to contain asbestos and be treated as asbestos containing materials.

1. Check Index of Asbestos and Lead Paint Surveys to see if the facility has been surveyed for asbestos. Index available from the FOPOC and ANS-500.

FEDERAL

INSECTICIDE

FUNGICIDE AND

RODENTICIDE

ACT (FIFRA)

Does the project require the application of pesticides and/or herbicides?

1. Review FAA Order 1050.17, FIFRA implementing regulations, 40 CFR Parts 152, 162, and 171 and State regulations.

CHLOROFLUORO

-CARBONS (CFC)

Is CFC containing equipment being replaced, installed or disposed? (I.e. refrigeration systems, Halon systems, HVAC systems, etc.)

1. Review project plans and specifications

COMPRESSED

GAS

Are compressed gasses utilized?

NOTE: All welding, cutting and brazing activities must follow the SOP

PROCEDURES FOR WELDING,

CUTTING AND BRAZING.

1. Review Project plans, specifications and work procedures. Will welding or cutting take place?

ENVIRONMENTAL

DUE DILIGENCE

AUDIT (EDDA)

Acquire, lease and/or dispose of land property?

1. Review Project plans and specifications

Rev. 05/06/2011 Page 2 of 4

NATIONAL

ENVIRONMENTAL

POLICY ACT

(NEPA)

Does the project potentially impact the environment with respect to noise, water quality, air quality, wetlands, flora and fauna, wildlife, historic and archeological sites, endangered species & other protected areas?

NOTE: The project qualifies for a Categorical Exclusion, per FAA Order 1050.1F, Paragraph 5.6.3a.

1. Review Project plans and specifications.

ENERGY Install new lighting, HVAC, or environmental controls?

FLUORESCENT

LAMPS

Dispose, install or recycle fluorescent lamps?

FUEL STORAGE

TANKS

Install, remove and/or replace an underground or aboveground storage tank or piping? If the project is new construction, is an existing UST and/or piping near the project site being impacted?

1. Check Storage Tank Inventory available from the Regional FST Manager or the FOPOC or ANI Representative.

2. Review Project plans and specifications.

WA…