Evaluation PWS.docx

PERFORMANCE WORK STATEMENT (PWS)

Shuttle Service

1.0 DESCRIPTION OF SERVICES/INTRODUCTION: Shuttle services between Carderock Division Headquarters and the Washington Navy Yard.

2.0 BACKGROUND: The Naval Surface Warfare Center, Carderock Division (NSWCCD) has an ongoing requirement for shuttle bus services between the Carderock Division Headquarters, West Bethesda, MD and the Washington Navy Yard (WNY) Washington DC.

3.0 OBJECTIVE: The shuttle bus service is to transport employees between the Carderock Division Headquarters and the Washington Navy Yard on a regularly scheduled basis, Monday through Friday. The contractor shall furnish the vehicle, fuel, driver, maintenance on the vehicle and operating supplies necessary to provide regularly scheduled shuttle bus services for the NSWCCD. This service shall be provided for one year from date of mobilization. Mobilization shall be 10 days after award.

3.1 The contractor shall provide shuttle bus services for the following destinations in accordance with the schedule provided below.

Starting Location:

Carderock Division Headquarters Naval Surface Warfare Center 9500 MacArthur Blvd, West Bethesda, MD 20817.

Passenger pick-up and discharge location will be on Taylor Blvd, just east of the front steps of building 2.

Destination Washington Navy Yard – (WNY) Washington, DC Passenger pick-up and discharge location will be just outside the Navy Yard gate at Isaac Hull Ave. and "M" Street.

A dedicated telephone line is established (301) 538-8823 that the government technical point of contact (TPOC) shall monitor. The shuttle bus telephone line will be monitored during normal business hours for both contractor and government personnel regarding the schedule. In the event of a delay or change due to circumstances beyond the government and contractor’s control (i.e. weather, traffic, etc.) the contractor shall reach out to the TPOC and notify them of the situation and updated estimated time of arrival.

Shuttle bus service shall not be required on Office of Personnel Management (OPM) designated holidays.

In addition, any other day designated by Federal Statute, Executive Order or President’s proclamation, will be considered as a legal holiday. Closure due to inclement weather will be determined by the Office of Personnel Management (OPM). The Contractor is responsible for determining the government’s operating status. If NSWCCD or the WNY is closed or has its normal operating schedule modified by OPM, shuttle services would be suspended/modified accordingly. Contractor may also call 1-877-679-2231 to receive status of NSWCCD for that particular day. This service shall be throughout the hours specified as follows:

SHUTTLE BUS SCHEDULE

Carderock Division Headquarters Washington Navy Yard

Carderock Division Headquarters The shuttle stop will be located on Taylor Boulevard just to the east of the front steps of Building 2. This will allow shuttle bus passengers to wait for the bus in the Building 2 lobby during inclement weather.

Washington Navy Yard Due to the existing Threatcon set at the Navy Yard, the shuttle bus is currently prevented from entering the Navy Yard. Therefore, passengers will be picked-up and discharged just outside the Navy Yard gate at Isaac Hull Ave and M Street. Depending on the Washington Navy Yard’s security posture, a different location at the Navy Yard may be identified after award or during the period of performance of this BPA call.

3.2 The contractor shall provide a vehicle accommodating fifteen (15) passengers and a driver meeting all Navy, local, state and national safety and inspection requirements with the ability to transport employees performing official government business from Carderock Division Headquarters to the Washington Navy Yard and back.

3.3 The Contractor shall provide a driver for each vehicle it uses to provide shuttle services. The contractor shall ensure that every shuttle bus driver it provides possesses a valid state motor vehicle Driver’s license, is a U. S. Citizen and has appropriate vehicle credentials, as well as a driving record that has no more than two (2) current points.. The Contractor shall ensure all drivers received the required training, posess required certifications, and complete background screening within five (5) days of award/NTP.

3.4 The Contractor shall ensure all of its drivers are dressed in uniform or appropriate attire, and present a clean, neat appearance such as but not limited to, wearing a tucked in, stain free, odor free, fully intact polo or button up shirt, a stain free, odor free, fully intact pair of slacks/pants that do not have excessive holes, closed toe secure fitting shoes that are odor free and intact with no holes, a properly fitting, odor free, stain free, intact overcoat, at all times when performing under this Contract. The contractor shall ensure all of its drivers performing under the contract wear an identification badge (Defense Biometrics Identification System/DBIDS provided by the NSWC-Carderock Visitor Control Center) provided at no cost to the contractor. Contractor drivers performing under the contract are required to pass the background check necessary to obtain this badge. Contractor drivers performing under the contract shall wear this badge above the waist, completely visible at all times.

3.5 The Contractor shall ensure its personnel drive safely and exercise due regard when operating the motor vehicles for shuttle service. The Contractor shall report any instances of reckless driving or dangerous maneuvers the contractor become aware of during contract performance to the Government Project Manager. The Contractor shall investigate such instances of reckless driving or dangerous maneuvers such as but not limited to, illegal U turns, driving above the posted speed limit, hitting/riding up on curbs, striking other fixed or moving objects, performing turns with marginal space in front of oncoming traffic, etc. Upon being informed about such conduct (e.g., reported by passengers). The contractor shall address its personnel found to be engaged in driving recklessly or performing dangerous maneuvers. If Contractor personnel are found to be involved in more than one incident of reckless driving or performing dangerous maneuvers per calendar year, the contractor shall replace the driver assigned to this contract with another qualified driver (See Sections 3.3 and 3.4) within two (2) working days from the date of replacement. The Contractor shall remove Contractor personnel charged with driving under the influence (DUI) or equivalent charges (in either a work or personal capacity),within 24 hours from the time the Contractor knows or should’ve known of such charges.

3.6 If the vehicle breaks down, a replacement vehicle shall arrive at the designated location within one (1) hour of the breakdown.

3.7 In the event of a vehicular accident, the Contractor shall provide a report to the TPOC within 24 hours from the time of the accident using the form in attachment 002. Should injuries result from the vehicular accident, the Contractor shall submit the report immediately to the TPOC. Should the vehicular accident occur on Government property, Contractor personnel shall notify the security department located on the Government property prior to leaving the premises. Below is the contact information for each security office located at NSWCCD Headquarters and WNY:

· Security Office/Carderock Division Headquarters 301-227-1500

· Security Office /Washington Navy Yard 202-443-3333

3.8 The Contractor shall provide at his/her own expense the shuttle bus driver with the means to communicate (cell phone/radio transceiver) with the TPOC while conducting shuttle operations. If the means of communications is to be by radio, the Contractor must also provide a compatible radio transceiver for the TPOC. If the contractor communicates via cell phone, the contractor shall provide the TPOC the driver’s phone number. Drivers shall not use their cell phone while actively operating the motor vehicle.

3.9 The contractor shall support personnel requiring special needs for transportation. This shall include (but not be limited to) assisting visually impaired personnel onto and off of the vehicle, the loading/unloading of wheel chairs or walkers, and the assistance out of/into wheel chairs and seats on the vehicle. The contractor shall not be required to assist personnel more than 15 feet from the vehicle or destination site.

3.10 All shuttle buses/vans shall have a comfortable environment with seasonal climate control.

3.11 Prior to contract performance, the Contractor shall obtain vehicular liability and general public liability insurance. The Contractor shall maintain such insurance throughout the period of performance of the contract. The Contractor shall ensure all insurance required under the contract meets the minimum requirements identified by the state the motor vehicle is registered in. The Contractor shall provide a copy of the insurance policy to the Government within ten (10) days of contract award. The Contractor shall provide the Government an update on the Contractor’s insurance annually, or no more than one (1) day after the expiration date of the policy.

3.12 The Government shall not be responsible for citations issued to the drivers, or for damages occurring as result of accidents involving contractor-owned or leased vehicles.

3.13 The contractor shall have passengers sign in/out of the shuttle log including their name, code, departing location, arriving location, and respective times. Each sheet shall have the date, driver name, and total number of passengers. The shuttle log shall be completed each day, even if there are no passengers for that day. The contractor shall submit copies of this log no later than the fifth working day of each month to the designated TPOC. See attached shuttle log form in Attachment 001.

3.14 The conduct of Contractor personnel conduct shall not be imputed on the Government. The Contractor’s personnel shall observe and comply with all local policies and procedures concerning fire, safety environmental protection, sanitation, security, and possession of firearms or other lethal or illegal weapons or substances. The Contractor is responsible for ensuring that any Contractor personnel providing services under this contract conduct themselves and perform services in a professional, safe, and responsible manner. Contractor employees shall comply with all applicable DoD and local requirements that establish uniform policies governing smoking in and around Government Owned buildings and motor vehicles. The Contractor shall remove from the job site any employee for reasons of misconduct or security. In accordance with DOD Directive 5500.7-R, “Joint Ethics Regulation” Contractor personnel must avoid being improperly influenced in the execution of their duties under the contract. The Contractor shall pay particular attention to the acceptance of gifts/ gratuities, and on non-disclosure of sensitive or classified information. The Contractor shall ensure its employees’ conduct complies with 41 U.S.C. 423, relative to release of acquisition-related/procurement information or actions or discussions, which may prejudice future competitions. The Contractor shall ensure its personnel do not conduct political related activities or events on US Navy Facilities.

4.0 SPECIAL QUALIFICATIONS: Current Commercial Class C Driver’s License

5.0 APPLICABLE DOCUMENTS

N/A

6.0 GOVERNMENT FURNISHED EQUIPMENT/PROPERTY/INFORMATION

N/A

7.0 DELIVERABLES: The contractor shall provide deliverables as described in the PWS/SOW.

8.0 SECURITY REQUIREMENTS: All contractor personnel performing services on government sites shall obtain a Defense Biometrics Identification System (DBIDS) badge. Upon NTP or contract award, the contractor shall provide DBIDS applications to the TPOC for review and signature. All contractor personnel shall obtain their DBIDS badges from the Visitor Control Center located at the front gate of the NSWC-Carderock West Bethesda site prior to the commencement of work. DBIDS badges include a background check of the applicant and the NSWC-Carderock West Bethesda site retains the right to refuse a DBIDS badge dependent upon the background check results. Contractor personnel are required to renew DBIDS badges prior to its expiration and shall return all DBIDS badges to the Visitor Control Center upon the completion of the contract or the separation of the contractor personnel from the contract.

Shuttle Daily Log Driver Name: Date:

Att 001

Total Passengers:

Initial Report Follow-up Report Final Report

Contractor Significant Incident Report (CSIR)

1. General Information

Contracting Activity/ROICC Office:

NSWC-Carderock

2. Personal Information

3. Witness Information

Additional Witnesses: Yes No (List any additional witnesses on a separate sheet and attach.)

Contractor Significant Incident Report (CSIR)

4. Contract Information

Prime Contractor Name/Address/Phone & Fax No:

Safety Manager (Last, First, MI): Insurance Carrier:

Sub Contractor Name/Address/Phone & FAX No:

Safety Manager (Last, First, MI): Insurance Carrier:

5. Accident Description

Describe the accident in detail in your words: (Use the back of page if you need additional space)

Direct Cause(s) of Accident:

Contractor Significant Incident Report (CSIR)

Indirect Cause(s) of Accident:

Action(s) taken to prevent re-occurrence or provide on-going corrective actions:

List PPE Used:

Type of Construction Equipment (Make, Model, Serial #, VIN#) Involved:

Was Hazardous Material Spilled/Released? Yes No Please List Hazardous Material(s) Involved:

Who provided first aid or cleanup of mishap site?

Any blood-borne pathogen exposure, other than EMTs? Yes No

Who?

List OSHA and WM-385-1-1 standards that were violated:

Was site secured and witness statements taken immediately? Yes No

By Whom?

6. Injury Illness/Fatality Information

Severity of Injury/Illness:

Fatality Temporary Disabillity Permanent Total Disability Permanent Partial Disability

Lost Workday Case Involving Days Away From Work Recordable Workday Case Involving Restricted Duty

Nature of Injury/Illness for Primary Body Part (Examples: Amputation, Burn, Hernia):

Type of Accident (Examples: Fall same level, Lifting, Bitten, Exerted):

Source of Accident (Examples: Crane, Carbon Monoxide, Ladder, Welding Equipment):

7. Casual Factors (Explain answers on supplementary sheet)

8. OSHA Information

(Attach Copy) Dollar amount of Penalties:

9. Report Preparer

Title:

Employer: Phone #:

Signature:

CONTRACTOR SIGNIFICANT INCIDENT REPORT (CSIR) INSTRUCTIONS

Complete Sections Appropriate to Incident (Rev. 06/02).

NOTE: THE ATTACHED CSIR FORM IS TO BE USED BY CONTRACTORS TO RECORD THE RESULTS OF THEIR ACCIDENT/INCIDENTS INVESTIGATIONS AND SHALL BE PROVIDED TO THE CONTRACTING OFFICER WITHIN THE REQUIRED TIMEFRAMES.

GENERAL. Complete a separate report for each person who was injured in the accident. A report needs to be completed for all OSHA recordable accidents, property damage in excess of $2000.00 (This amount is for record purposes only. GOV is not required to enter property damage reports into FAIR database if it is less than $10,000.00.), WHE accidents, or near miss/high visibility mishaps. Please type or print legibly. Appropriate items shall be marked with an “X” in box(es), non-applicable sections shall be marked “N/A”. If additional space is needed, provide the information on a separate sheet of paper and attach to the completed form.

Mark the report:

INITIAL – If this form is being used as initial notification of a Fatality or High Visibility Mishap. The initial form is due within 4 hours of a serious accident. A form marked ‘Follow-up’ or ‘Final’ is required within 5 days.

FOLLOW-UP – If you are providing additional information on a report previously submitted.

FINAL – If you are providing a completed report and expect no changes.

SECTION 1 – GENERAL INFORMATION

CONTRACTING ACTIVITY/ROICC OFFICE - Enter the name and address of the Contracting Office administering the contract under which the mishap took place (e.g. ROICC MCBH, ROICC NORFOLK, PWC GUAM, etc.).

ACCIDENT CLASSIFICATION - INJURY/ILLNESS/FATALITY/PROPERTY DAMAGE/-PROCEDURAL ISSUES/- ENVIRONMENTAL/LESSONS LEARNED/OTHER – Mark the appropriate block(s) if the incident resulted in any of these conditions.

INVOLVING - If the mishap involved any of the conditions listed under “Involving” mark the appropriate box(es). Specific questions associated with each of these conditions are available from the Contracting Officer to assist you in your investigation. When these questions are used they shall be attached as part of this report.

SECTION 2 - PERSONAL INFORMATION

NAME - Enter last name, first name, middle initial of person involved.

AGE - Enter age.

SEX - Enter M for Male and F for Female.

JOB TITLE/DESCRIPTION - Enter the job title/description assigned to the injured person (e.g. carpenter, laborer, surveyor, etc.).

EMPLOYED BY - Enter employment company name of the person involved.

SUPERVISOR’S NAME & TITLE - Enter name and title of the immediate supervisor.

WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK? - For the purpose of this section “trained” means the person has been provided the necessary information (either formal and/or on-the-job (OJT) training) to competently perform the activity/task in a safe and healthful manner.

TYPE OF TRAINING - Indicate the specific type of training (classroom or on-the-job) that the injured person received before the accident happened.

DATE OF MOST RECENT FORMAL TRAINING/TOPICS DISCUSSED - Enter the month, day, and year of the last formal training completed that covered the activity/task being performed at the time of the accident. List topics that were discussed at the training identified above.

SECTION 3 - WITNESS INFORMATION

The following applies to Witness #1 and Witness #2:

WITNESS NAME - Enter last name, first name, middle initial of the witness.

JOB DESCRIPTION/TITLE - Enter the job title/description assigned to the witness (e.g. carpenter, laborer, surveyor, etc.).

EMPLOYED BY - Enter the name of the employment company of the witness.

SUPERVISORS NAME - Enter name of immediate supervisor of the witness.

ADDITIONAL WITNESSES - Provide same information, as above, for each witnesses. Use additional pages if necessary.

SECTION 4 - CONTRACTOR INFORMATION

TYPE OF CONTRACT - Mark appropriate box. A/E means architect/engineer. If “OTHER” is marked, specify type of contract on line provided.

CONTRACT NUMBER/TITLE - Enter complete contract number and tile of prime contract (e.g. N62477-85-C-0100, 184 Pearl City Hsg. Revitalization).

CONSTRUCTION INDUSTRIAL GROUP AND INDUSTRIAL TYPE – This is the type of construction that will be done at this project.

Contractor Significant Incident Report (CSIR) Instructions

1. First, you must choose the Industrial Group. You have 4 choices to choose from: (NOTE! Review of the Industrial Types below and knowing what the projects scope of work is will assist you in deciding what the Industrial Group should be.)

a. Buildings

b. Heavy Industrial

c. Infrastructure

d. Light Industrial

2. Once you have chosen the Industrial Group, you now select the Industrial Type. You have multiple choices under each Group, chose the one you feel fits the project most closely because on most projects there won’t be an exact match:

a. Buildings:

(1) Communications Ctr.

(2) Dormitory/Hotel

(3) High-rise Office

(4) Hospital

(5) Housing

(6) Laboratory

(7) Low-rise Office

(8) Maintenance Facility

(9) Parking Garage

(10) Physical Fitness Ctr.

(11) Restaurant/Nightclub

(12) School

(13) Warehouse

b. Heavy Industrial:

(1) Chemical Mfg.

(2) Electrical (Generating)

(3) Environmental

(4) Metals Refining/Processing

(5) Mining

(6) Natural Gas Processing

(7) Oil Exploration/Production

(8) Oil Refining

(9) Pulp and Paper

c. Infrastructure:

(1) Airport

(2) Electrical Distribution

(3) Flood Control

(4) Highway

(5) Marine Facilities

(6) Navigation

(7) Rail

(8) Tunneling

(9) Water/Wastewater

d. Light Industrial:

(1) Automotive Assembly/Mfg.

(2) Consumer Products Mfg.

(3) Foods

(4) Microelectronics Mfg.

(5) Office Products Mfg.

(6) Pharmaceuticals Mfg.

CONTRACTOR’S NAME/ADDRESS/PHONE NUMBER

(1) PRIME - Enter the exact name (title of firm), address, phone and fax numbers of the prime contractor.

(2) SUBCONTRACTOR - Enter the exact name, address, phone and fax numbers of any subcontractor involved in the accident.

SAFETY MANAGER’S NAME

(1) PRIME - Enter the name of the prime contractor safety manager.

(2) SUBCONTRACTOR - Enter the name of the subcontractors safety manager.

INSURANCE CARRIER

(1) PRIME - Enter the exact name/title of the prime’s insurance company. Policy number not required.

(2) SUBCONTRACTOR - Enter the exact name of the subcontractor’s insurance company. Policy number not required.

SECTION 5 - ACCIDENT DESCRIPTION

DATE OF ACCIDENT - Enter the month, day, and year of accident.

TIME OF ACCIDENT - Enter the local time of accident in military time. Example: 14:30 hrs (not 2:30 p.m.).

EXACT LOCATION OF ACCIDENT - Enter facts needed to locate the accident scene (installation/project name, building/room number, street, direction and distance from closest landmark, etc.).

DESCRIBE THE ACCIDENT IN DETAIL. Fully describe the accident in the space provided. If property damage involved, give estimated dollar amount of damage and/or repair costs involved. If additional space is needed continue on a separate sheet and attach to this report. Give the sequence of events that describe what happened leading up to and including the accident. Fully identify personnel and equipment involved and their role(s) in the accident. Ensure that relationships between personnel and equipment are clearly specified. Ensure questions below regarding direct cause(s), indirect cause(s), and actions taken are answered. NOTE! Review questions in Section 7 below before completing.

DIRECT CAUSE(S) - The direct cause is that single factor which most directly lead to the accident. See examples below. INDIRECT CAUSE(S) - Indirect cause are those factors, which contributed to, but did not directly initiate the occurrence of the accident.

Examples for Direct and Indirect Cause:

1. Employee was dismantling scaffold and fell 12 feet from unguarded opening.

Direct cause: Failure to provide fall protection at elevation Indirect causes: Failure to enforce safety requirements: improper training/motivation of employee (possibility that employee was not knowledgeable of fall protection requirements or was lax in his attitude toward safety); failure to ensure provision of positive fall protection whenever elevated; failure to address fall protection during scaffold dismantling in phase hazard analysis.

2. Private citizen had stopped his vehicle at intersection for red light when vehicle was struck in rear by contractor vehicle. (note contractor vehicles was in proper safe working condition.)

Direct cause: Failure of contractor driver to maintain control of and stop contractor vehicle within safe distance.

Indirect cause: Failure of employee to pay attention to driving (defensive driving).

ACTION(S) TAKEN TO PREVENT RE-OCCURRENCE OR PROVIDE ON-GOING CORRECTIVE ACTIONS. Fully describe all the actions taken, anticipated, and recommended to eliminate the cause(s) and prevent reoccurrence of similar accidents/illnesses. Continue on back or additional sheets of paper if necessary to fully explain and attach to the complete report form.

CORRECTIVE ACTION DATES -

(1) Beginning - Enter the date when the corrective action(s) identified above will begin.

(2) Anticipated Completion - Enter the date when the corrective action(s) identified above will be completed. PERSONAL PROTECTIVE EQUIPMENT (PPE) - Mark appropriate box(es) and list PPE which was being used by the injured person at the time of the accident (e.g. protective clothing, shoes, glasses, goggles, respirator, safety belt, harness, etc.)

TYPE OF CONTRACTOR EQUIPMENT - Enter the Serial Number, Model Number and specific type of equipment involved in the mishap (e.g. dump truck (off highway), crane (rubber tire), pump truck (concrete), etc.).

WAS HAZARDOUS MATERIAL SPILLED/RELEASED? - Mark appropriate block and list name(s) of any reportable quantities of hazardous materials spilled/released during the mishap.

WHO PROVIDED FIRST AID OR CLEAN-UP OF MISHAP SITE? - List name(s) of individual(s) and employer, if known.

ANY BLOOD-BORNE PATHOGEN EXPOSURE, OTHER THAN EMT? - Mark appropriate block and list name(s) of individual(s) and employer, if known.

LIST OSHA AND/OR EM 385-1-1 STANDARDS THAT WERE VIOLATED. - Self explanatory.

WAS SITE SECURED AND WITNESS STATEMENT TAKEN IMMEDIATELY? - Mark appropriate block and list by whom.

SECTION 6 - INJURY/ILLNESS/FATALITY INFORMATION

SERVERITY OF INJURY/ILLNESS – Mark appropriate box.

ESTIMATED DAYS LOST - Enter the estimated number of workdays the person will lose from work. Update when final data is known.

ESTIMATED DAYS HOSPITALIZED - Enter the estimated number of workdays the person will be hospitalized. Update when final data is known.

ESTIMATED DAYS RESTRICTED DUTY - Enter the estimated number of workdays the person, as a result of the accident, will not be able to perform all of their regular duties. Update when final data is known.

BODY PART(S) AFFECTED - Enter the most appropriate primary and when applicable, secondary, etc. body part(s) affected (e.g. arm: wrist: abdomen: single eye; jaw : both elbows: second finger: great toe: collar bone: kidney, etc.).

NATURE OF INJURY/ILLNESS FOR PRIMARY BODY PART - Enter the most appropriate nature of injury/illness (e.g. amputation, back strain, dislocation, laceration, strain, asbestosis, food poisoning, heart conditions, etc.).

TYPE AND SOURCE OF INJURY/ILLNESS - Type and Source Codes are used to describe what caused the incident.

(1) TYPE Code stands for an “Action” (Example: Worker, installing conduit, lost his balance and fell five feet from a ladder. Type Code: Fell different levels”.) Select the most appropriate Type of injury from the list below:

TYPE OF INJURY/ILLNESS

CONTACTED WITH (INJURED PERSON MOVING) CONTACTED BY (OBJECT WAS MOVING)

FELL, SLIPPED, TRIPPED

SAME LEVEL/DIFFERENT LEVEL/NO FALL

EXERTED

LIFTED, STRAINED BY (SINGLE ACTION) STRESSED BY (REPEATED ACTION)

PUNCTURED, LACERATED

PUNCTURED BY/CUT BY/STUNG BY/BITTEN BY

TRAVELING IN

(2) SOURCE Code stands for an “object or substance.” (Example: Worker, installing conduit, lost his balance and fell five feet from a ladder. Source Code: “Ladder”.) Select the most appropriate Source of injury from the list below:

SOURCE OF INJURY/ILLNESS

BUILDING OR WORKING AREA WALKING/WORKING AREA STAIRS/STEPS

LADDER FURNITURE

BOILER/PRESSURE VESSEL EQUIPMENT LAYOUT WINDOWS/DOORS ELECTRICITY

DUST, VAPOR, ETC.

DUST (SILICA, COAT, ETC.) FIBERS

ASBESTOS GASES

CARBON MONOXIDE

MIST, STEAM, VAPOR, FUME WELDING FUMES PARTICLES (UNIDENTIFIED)

MEDICINE

FORKLIFT

HANDTRUCK , DOLLY

SECTION 7 - CAUSAL FACTORS

Review thoroughly. Answer each question by marking the appropriate block. NOTE! If any answer is yes, explain in section 5 above.

(1) DESIGN - Did inadequacies associated with the building or work site play a role? Would an improved design or layout of the equipment or facilities reduce the likelihood of similar accidents? Were the tools or other equipment designed and intended for the task at hand?

(2) INSPECTION/MAINTENANCE - Did inadequately or improperly maintained equipment, tools, workplace, etc., create or worsen any hazards that contributed to the accident? Would better equipment, facility, work site or work activity inspections have helped avoid the accident?

(3) PERSONS PHYSICAL CONDITION - Do you feel that the accident would probably not have occurred if the employee was in “good” physical condition? If the person involved in the accident had been in better physical condition, would the accident have been less severe or avoided altogether? Was overexertion a factor?

(4) OPERATION PROCEDURES - Did lack of or inadequacy within established operating procedures contribute to the accident? Did any aspect of the procedures introduce any hazard to, or increase the risk associated with the work process? Would establishment or improvement of operating procedures reduce the likelihood of similar accidents?

(5) JOB PRACTICES - Were any of the provision of the Safety and Health Requirements Manual (EM 385-1-1) violated? Was the task being accomplished in a manner which was not in compliance with an established job hazard analysis or activity hazard analysis? Did any established job practice (including EM 385-1-1) fail to adequately address the task or work process? Would better job practices improve the safety of the task?

(6) HUMAN FACTORS - Was the person under undue stress (either internal or external to the job)? Did the task tend toward overloading the capabilities of the person: i.e., did the job require tracking and reacting to many external inputs such as displays, alarms, or signals? Did the arrangement of the workplace tend to interfere with efficient task performance? Did the task require reach strengths, endurance, agility, etc., at or beyond the capabilities of the employee? Was the work environment ill-adapted to the person? Did the person need more training, experience, or practice in doing the task? Was the person inadequately rested to perform safely?

(7) ENVIRONMENTAL FACTORS - Did any factors such as moisture, humidity, rain, snow, sleet, hail, ice, fog, cold, heat, sun temperature changes, wind, tides, floods, currents, terrain; dust, mud, glare, pressure changes, lighting, etc., play a part in the accident?

(8) CHEMICAL AND PHYSICAL AGENT FACTORS - Did exposure to chemical agents (either single shift exposure or long- term exposure such as dusts, fibers, (asbestos, etc.), silica, gases (carbon, monoxide, chlorine, etc.), mists, steam, vapors, fumes, smoke, other particulates, liquid or dry chemicals that are corrosive, toxic, explosive or flammable, by-products of combustion or physical agents such as noise, ionizing radiation, non-ionizing radiation (UV radiation created during welding, etc.) contribute to the accident/incident?

(9) OFFICE FACTORS - Did the fact that the accident occurred in an office setting or to an office worker have a bearing on its cause? For example, office workers tend to have less experience and training in performing tasks such as lifting office furniture. Did physical hazards within the office environment contribute to the hazard?

(10) SUPPORT FACTORS - Was the person using an improper tool for the job? Was inadequate time available or utilized to safely accomplish the task? Were less than adequate personnel resources (in terms of employee skills, number of workers, and adequate supervision) available to get the job done properly? Was funding available, utilized and adequate to provide proper tools, equipment, personnel, site preparation, etc.

(11) PERSONAL PROTECTIVE EQUIPMENT - Did the person fail to use appropriate personal protective equipment (gloves, eye protection, hard-toed shoes, respirator, etc) for the task or environment? Did protective equipment provided or worn fail to provide adequate protection from the hazard(s)? Did lack of or inadequate maintenance of protective gear contribute to the accident?

(12) DRUGS/ALCOHOL - Is there any reason to believe the person’s mental or physical capabilities, judgment, etc., were impaired or altered by the use of drugs or alcohol? Consider the effects of prescription medicine and over the counter medications as well as illicit drug use. Consider the effect of drug or alcohol induced “hangovers”.

(13) JOB/ACTIVITY HAZARD ANALYSIS - Was a written Job/Activity Analysis completed for the task being performed at the time of the accident? If one was made, did it address the hazard adequately or does it need to be updated? If none made, will one be made? These may also need to be addressed in the Corrective Actions Taken section. Mark the appropriate box. If one was made, attach a copy of the analysis to the report.

(14) MANAGEMENT - Did the lack of supervisor or management support play a part in the mishap? Mark the appropriate box.

SECTION - 8 OSHA INFORMATION - Complete this section if applicable SECTION 9 - REPORT PREPARER Providing a completed CSIR to the Contracting Officer is the PRIME CONTRACTOR’S RESPONSIBILITY. Enter the name, date of report, title, employer, phone number and signature of person completing the accident report and provide it to the Contracting Officer, or his representative, responsible for oversight of that contractor activity. NOTE! If prepared by other than the Prime Contractor, a person employed by the Prime Contractor must sign that they have reviewed and concur with the report and it’s findings (e.g. company owner, project supervisor/foreman, Safety Officer, etc.).

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