J-0200000-05-03 Crane and Rigging Gear Accident Report Form.pdf

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.

CRANE AND RIGGINGEAR 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):