J-0200000-04a-d_revised.pdf

MCB Butler 20-2001 J-0200000-04(a), Page 9 of 10

Attachment J-0200000-04(a)

CONTRACTOR INCIDENT REPORT SYSTEM (CIRS) INSTRUCTIONS

Complete Only Sections Appropriate to Incident (Rev. 03/11).

NOTE: THE ATTACHED CIRS 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 pages 5-6. A report needs to be completed for all OSHA recordable accidents and property damage cases. Please type or print legibly. Appropriate items shall be Checkd/Bolded, 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: (Check/Bold) 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.

Incident Information Section 1 Contract Information – Incident Information Prime Contractor: Name as it appears on contract documents.

Cage Code: If known.

Contract Number: Number as it appears on the contract documents.

Installation: Name of installation where incident occurred.

Task Order #: Insert number if applicable.

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.).

Contractor Contact Information: (Contractor point of contact information for the individual responsible for completing the form) Self Explanatory

Section 2 Incident Type: Check/Bold most applicable category, if you select Industrial you must Check/Bold at least one additional category from the Industrial Incident Additional Information Section.

Section 3 General Information Incident Information 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.).

Describe the Accident in Detail in your words: 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 4 (Fully Explain What Allowed or Caused the Incident - Incident Information) below before completing.

Exact Location of Accident: Enter facts needed to locate the accident scene (e.g. installation/project name, building/room number, street, direction and distance from closest landmark, etc.).

Were Hazardous Material(s) Involved Yes No

J-0200000-04(a), Page 10 of 10

Section 4 Fully Explain What Allowed or Caused the Incident - Incident Information 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).

Additional Action Taken: Fully describe all the actions taken, anticipated, and recommended to eliminate the cause(s) and prevent reoccurrence of similar accidents/illnesses. Continue in the additional box and or on additional sheets of paper if necessary to fully explain and attach to the completed report form.

Please Include a Begin Date and Estimated Completion Date in Description

(1) Begin: Enter the date when the corrective action(s) identified above will begin.

(2) Est. End Date - Enter the date when the corrective action(s) identified above will be completed.

Section 5 Contributing Factors Incident Information: Check/Bold appropriate items fill in information where required Other Contributing Factors: Describe in detail any additional contributing factors not listed in previous information provided.

Section 6 Attached Documents: Provide the appropriate information for each document/file attached or uploaded.

Injured Data Person # Complete Pages 5 and 6 for each injured person at the upper right hand corner of page 5 and 6 differentiate between each person by using a numerical value (e.g. Person #1, Person #, Person #3, etc.)

Section 1 Injured Data: Fill in all applicable information, Check/bold appropriate responses.

Section 2 General Information:

Check/bold appropriate responses

Section 3 Injury/Illness Fatality Information: Check/bold appropriate responses Part of Body 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.).

Attachment J-0200000-04(a) If Yes, Explain What Hazardous Materials Were Involved and Why: Check or Bold appropriate block and list name(s) and quantities of hazardous materials spilled/released during the mishap. List why the hazardous chemicals were being used.

Activity at the time of incident: What type of work/task was being performed by the injured when the injury took place or property damage occurred.

Personal Protective Equipment– Check/Bold appropriate items 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.)

MCB Bulter 20-2001 J-0200000-04(B), Page 3 of 3

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.

Attachment J-0200000-04(b)

Attachment J-0200000-04(c) Forms

ATTACHMENT "A"

CONTRACTOR CRANE OPERATING CHECKLIST FOR CRITICAL LIFTS YES NO

1 Does the operator know the weight of the load to be lifted?

2 Is the load to be lifted within the crane manufacturer's rated capacity in its present configuration?

3 Is the crane level and on firm ground?

4 Are outriggers required?

5 If so, are outriggers fully extended and down, and the load off the wheels?

If blocking is required, is the entire surface of the outrigger pad supported, and is the blocking material of sufficient strength to safely support the loaded outrigger pad?

If outriggers are not used, is the crane rated for on-rubber lifts by the manufacturer's load chart?

Is the swing radius of the crane counterweight clear of people and obstructions and accessible areas within the swing area barricaded to prevent injury, damage and unplanned encroachment?

9 Has the hook been centered over the load in such a manner to prevent swing (deflection, side loading, load-moment)?

10 Is the load well secured and balanced in the sling or lifting device before it is lifted (free and clear) more than a few inches?

11 Is the lift swing path clear of obstructions?

12 If rotation of the load being lifted is hazardous, is tag line or restraint line being used?

13 Are personnel prevented from standing or passing under a suspended load?

14 Are personnel prevented from entering the load fall zone?

15 Is the crane operator's attention diverted?

16 Are proper signals being used at all times?

17 If radio communications are used is the frequency isolated to the crane team?

18 Do the operations ensure that side and tip loading is prohibited?

Are start and stop motions in a smooth fluid motion (no sudden acceleration or deceleration)?

20 If operating near electric power lines, are the rules and guidelines understood and adhered to as specified in NAVFAC P-307?

21 Is the lift a critical lift?

If so, are critical lift regulations understood, check-off sheets initialed and signed off, and was there an interactive brief conducted with associated personnel?

23 Is Attachment "A" current, filled out completely, and posted in the crane?

Contractor Name (Print Legibly):

Contractor Name (Signature):

Location: Date:

J-0200000-04(c), Page 1 of 1

J-0200000-04(d), Page 2 of 2

Attachment J-0200000-04(d) Forms

CRANE AND RIGGING GEAR NEAR MISS 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 nfsh_ncc_accident@navy.mil. The fax number is (757) 967-3808.

1. Near Miss Category: Indicate either crane or rigging gear near miss.

2. From: The naval activity that is responsible for reporting the near miss and UIC number.

3. Activity: The naval activity where the near miss took place.

4. Report No.: The activity assigned near miss 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. Near Miss Date: The date the near miss occurred.

8. Time: The time (24 hour clock) the near miss 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 near miss (e.g., mobile, bridge), if applicable.

11. Crane Manufacturer: The manufacturer of the crane (e.g., Dravo, Grove, P&H), if applicable.

12. Location: The detailed location where the near miss took place (e.g., building 213, dry dock 5).

13. Weather: The weather conditions at time of the near miss (e.g., wind, rain, cold).

14. Crane Capacity: The certified capacity of the crane (e.g., 120,000 pounds), if applicable.

15. Hook Capacity: The capacity of the hook involved in the near miss at the maximum radius of the operation, if applicable.

16. Weight of Load on Hook: If applicable, the weight of the load on the hook.

17. Is this a recurring problem?: Check yes or no. Identify any other similar near misses or accidents.

18. Situation Description/Corrective Actions: Self-explanatory.

19. Preparer: Self-explanatory.