J-0200000-05-03 Crane and Rigging Gear Accident Report Form.pdf
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- Attached to
- PAX FSS Amendment 005 and Current CBAs
- Solicitation number
- N4008020R0001
About this file
This document contains an accident report form and instructions for reporting crane and rigging gear accidents at naval facilities. The form collects details about the accident such as date, location, weather conditions, equipment involved, cause of the accident, corrective actions taken, and concurrences from supervisors. Report preparers are instructed to submit the completed form via fax or email to the Navy Crane Center within 24 hours of an accident occurring. The level of detail required in the form indicates it is used for official accident investigation and record-keeping purposes.
The related federal contract opportunity is a solicitation for facility support services at Naval Air Station Patuxent River in Maryland. The services include custodial work, pest control, grounds maintenance, pavement clearance, and transportation services. The contract will be a performance-based IDIQ awarded under NAICS code 561210 with a $41.5 million size standard set aside for small businesses. The solicitation includes a description of recurring and non-recurring work items under the contract and notes that changes have been made since a draft version was posted, including the NAICS code and set aside designation.
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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):
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