J-0200000-08 Crane and Rigging Gear Near Miss Report.pdf

COMNAVREGMIDLANTINST 1126 2 .lA

. 6 FEB 2013

FOR OFFICIAL USE ONLY

CRANE AND RIGGING GEAR ACCIDENT REPORT

Accident Category: D Crane Accident D Rigging Gear Accident From: To: Navy Crane Center UIC: Bldg. 491 NNSY

Portsmouth, VA 23709 Fax: 757-967-3808

Activity:

I Report No:

Crane No: I Category: Accident Date: I Time: hrs:

,1 Category of Service: OsPs 0GPS I Crane Type: I Crane Manufacturer:

Was Crane/Rigging Gear Being Used in SPS: Oves 0No Was Crane/Rigging Gear Being Used in a Complex Lift/Critical Non-Crane

Riaainq Operation: n Yes n No Location: Weather:

Crane Capacity: I Hook Capacity: I Weight of Load on hook:

Fatality or Permanent Disability? Oves 0No Material/Property Cost Estimate:

Reported to NAVSAFECEN? Oves 0No

Accident Type:

D Personal Injury D Overload D Derail D Damaged Rigging Gear

D Load Collision D Two Blocked D Dropped Load D Damaged Crane

D Crane Collision D Damaged Load D Other: Specify

Cause of Accident:

0 Improper Operation 0 Equi pment failure 0 lnadequate Visibility

D Improper Rigging D Switch Alignment D inadequate Communication

D Track Condition D Procedural Failure D Other: Specify

Chargeable to :

D Crane Walker D Rigger D Operator

D Maintenance D Management/Supervision D Other: Specify

Crane Function:

0Travel 0Hoist D Rotate D Lu11ing 0 Telescoping D Other 0NJA

Is this accident indicative of a recurring problem? Oves 0No If yes, list Acc ident 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: I Phone: E-mail: Code: I Date:

Concurrences: (Include Code Siqnature and Date) Code: Date:

Code: Date:

Certifying Official (Crane Accident Only): Code: Date:

Enclosure (9)

COMNAVREGMIDLANTINST 11262.lA

. 6 FEB 2013

FOR OFFICIAL USE ONLY

CRANE AND RIGGING GEAR ACCIDENT REPORT (CONT)

Brief Description:

Background and Detailed Description:

2 Enc l osure (9 )

COMNAVREGMIDLANTINST 1126 2.lA

· 6 FEB 2013

FOR OFFI CIAL USE ONLY

CRANE AND RIGGING GEAR NEAR MISS REPORT

Near Miss Category: D Crane Near Miss D Rigging Gear Near ::vtiss

From: To: Navy Crane Center Bldg. 491 NNSY Portsmouth, VA 23709

UIC: Fax (757) 967-3808 nfsh_ncc_accident@navy.mil

Activity: j Report No.

Crane/Equipment No.: I Category: I Near Miss Date: I Time:

Hrs.

Category of Service: Crane Equipment type: Crane Equipment manufacturer:

0SPS 0GPS

Location: I Weather:

Crane/Equipment Capacity: Hook capacity: Weight of Load on Hook:

Is this near miss indicative of a recurring problem? LJ Yes LJNo If yes, list report numbers:

In the space below, include a brief description of the event and corrective actions taken to prevent recurrence:

Preparer: /Phone: / Email: Date:

Certifying Official : I Code: Date:

Enclosu re (1 0)