CSRS_Instructions.docx

Initial Report Follow-up Report Final Report

Contractor Significant Incident Report (CSIR)

1. General Information Contracting Activity/ROICC Office:

Accident Classification:

Injury Fatality Environment Procedural Issues Lessons Learned Illness Property Damage Other______________________________

Involving:

Diving Equip/Mrt Ver/Mat Handling (Man-Lift/Elevated Platform) Waterfront/Marine Demolition/Renovation Fall from Ladder Fall from Scaffold Other___________________

Electrical Fall from Roof Fire

2. Personal Information Name (Last, First, MI): Age: Sex:

Job Title/Description: Employed By:

What type of training was received (OJT, classroom, etc)?

Date of the most recent formal training and topics discussed?

3. Witness Information Witness #1: Name (Last, First, MI): Job Title/Description:

Employed By: Supervisor Name (Last, First, MI):

Witness #2: Name (Last, First, MI): Job Title/Description:

Employed By: Supervisor Name (Last, First, MI):

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

Contractor Significant Incident Report (CSIR) 1

4. Contract Information Type of Contract:

CLEAN

Service

Other__

Contract Number & Title: Industrial Group & Industrial Type:_____________________________

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 Date of Accident: Time of Accident: Exact Location of Accident:

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) 2

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?

Contractor Significant Incident Report (CSIR) 3

6. Injury Illness/Fatality Information

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)

Contractor Significant Incident Report (CSIR) 4

8. OSHA Information

(Attach Copy) Dollar amount of Penalties:

9. Report Preparer

Contractor Significant Incident Report (CSIR) 5

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

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

Contractor Significant Incident Report (CSIR) Instructions 2 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:

Contractor Significant Incident Report (CSIR) Instructions 3

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)

ENVIRONMENT CONDITION TEMPERATURE EXTREME (INDOOR) WEATHER (ICE, RAIN, HEAT, ETC.) FIRE, FLAME, SMOTE (NOT TABACCO) NOISE

RADIATION LIGHT VENTILATION

TOBACCO SMOKE STRESS (EMOTIONAL) CONFINED SPACE

CHEMICAL, PLASTIC, ETC.

DRY CHEMICAL - CORROSIVE DRY CHEMICAL - TOXIC

DRY CHEMICAL - EXPLOSIVE DRY CHEMICAL - FLAMMABLE LIQUID CHEMICAL - CORROSIVE LIQUID CHEMICAL - TOXIC LIQUID CHEMICAL - EXPLOSIVE LIQUID CHEMICAL - FLAMMABLE PLASTIC

WATER MEDICINE

MACHINE OR TOOL

HAND TOOL (POWERED: SAW, GRINDER, ETC.) HAND TOOL (NON POWERED)

MECHANCIAL POWER TRANSMISSION APPARATUS GUARD, SHIELD (FIXED, MOVEABLE, INTERLOCK) VIDEO DISPLAY TERMINAL

PUMP, COMPRESSOR, AIR PRESSURE TOOL HEATING EQUIPMENT

WELDING EQUIPMENT

INANIMATE OBJECT BOX, BARREL, ETC. PAPER

METAL ITEM, MINERAL NEEDLE

GLASS

SCRAP, TRASH, WOOD FOOD

CLOTHING, APPAREL, SHOES

MACHINE OR TOOL

HAND TOOL (POWERED: SAW, GRINDER, ETC.) HAND TOOL (NON POWERED)

MECHANCIAL POWER TRANSMISSION APPARATUS GUARD, SHIELD (FIXED, MOVEABLE, INTERLOCK) VIDEO DISPLAY TERMINAL

PUMP, COMPRESSOR, AIR PRESSURE TOOL HEATING EQUIPMENT

WELDING EQUIPMENT

INANIMATE OBJECT BOX, BARREL, ETC. PAPER

METAL ITEM, MINERAL NEEDLE

GLASS

SCRAP, TRASH, WOOD FOOD

CLOTHING, APPAREL, SHOES

VEHICLE

AS DRIVER OF PRIVATELY OWNED, RENTAL VEH.

AS PASSENGER OF PRIVATELY OWNED, RENTAL VEH. DRIVER OF GOVERNMENT VEHICLE

PASSENGER OF GOVERNMENT VEHICLE COMMON CARRIER (AIRLINE, BUS, ETC.) AIRCRAFT (NOT COMMERCIAL)

BOAT, SHIP, BARGE

ANIMATE OBJECT DOG

OTHER ANIMAL PLANT

INSECT

HUMAN (VIOLENCE)

HUMAN (COMMUNICABLE DISEASE) BACTERIA, VIRUS (NOT HUMAN CONTACT)

MATERIAL HANDLING EQUIPMENT EARTHMOVER (TRACTOR, BACKHOE, ETC.) CONVEYOR (FOR MATERIAL AND EQUIPMENT) ELEVATOR, ESCALATOR, PERSONNEL HOIST HOIST, SLING CHAIN, JACK

CRANE FORKLIFT

HANDTRUCK , DOLLY

PERSONAL PROTECTIVE EQUIPMENT

PROTECTIVE CLOTHING, SHOES, GLASSES, GOGGLES RESPIRATOR, MASK

DIVING EQUIPMENT SAFETY BELT, HARNESS PARACHUTE

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?

Contractor Significant Incident Report (CSIR) Instructions 4

OPSNOTE 2009-001

23 December 2008 Prepared by: OPS/CI

From: Operations Officer To: Operations Supervisors and Managers

Subj: ENGAGING SENIOR CONTRACTOR MANAGEMENT ON SAFETY INCIDENTS

Encl (1) Field Office Safety Action Matrix

(2) Mishap Review Board Standard Presentation Template

1. To emphasize NAVFAC MIDLANT’s “Zero” incident policy on Contractor Significant Incidents, the following guidance identifies the level of engagement with a principal of the prime contractor responsible for the incident. Use enclosure (1) as a guide when determining the appropriate level of action on any contractor safety incident. In addition to the required reports (CIR) being entered into the ESAMS database, enclosure (2) is the standard presentation format to be used at the Mishap Review Board.

· Preventive Engagement: Before the start of on-site construction activity, typically at the Pre-Con, the FEAD or OICC/ROICC Office will make it clear to contractor representatives that Safety is NAVFAC MIDLANT’s top priority. The contractor shall be told that safety oversight is the responsibility of the prime contractor and all Safety incidents (including a near miss) shall be reported immediately. Depending on the seriousness of the event, a senior Government Representative at our field office will contact a principal of the firm to discuss corrective measures that will prevent reoccurrence (including actions taken by responsible subcontractors). The Contractor’s response is expected to be proportional to severity of the incident. Non- compliance notices and retainage shall be used when appropriate. In addition, contractor badges may be revoked from individuals determined to be unsafe.

· Near Miss (not self-reported): Head of the FEAD or OICC/ROICC SGE will make contact with a principal of the prime contractor within 2 work-days of the observation. The contractor will be advised that we expect that he will follow up this notification with a specific action or actions clearly intended to prevent the near miss incident from reoccurring. The contractor’s actions should be completed within 7 calendar days from the phone call. Contractor self-reporting of near misses should be encouraged. This is a clear indication that the contractor is active in their safety program.

· Safety Incident with no lost time: Head of the FEAD or OICC/ROICC SGE will make personal telephone contact with a principal of the prime contractor within 2 work-days of the incident, with a follow-up in writing. The contractor will be advised that we expect a written response, within 7 calendar days, that describes in detail the short and long term corrective actions that will be taken to prevent reoccurrence.

· Safety Incident with lost time: PWO/OICC/ROICC will make personal telephone contact with a principal of the prime contractor within 24 hours of the incident. The contractor will be advised that we expect a written response within 5 calendar days that describes in detail the short and long time corrective actions that will be taken to prevent reoccurrence. In addition, the prime contractor, and any subcontractor involved in the incident are expected to meet with the head of the FEAD or OICC/ROICC SGE at the site to review the written response and establish a detailed schedule for completion of the short and long term corrective actions.

2. If the contractor or subcontractors have not successfully responded to a near miss or incident, or more than two incidents occur with the same contractor or subcontractor during a calendar year, the matter shall be immediately elevated to the PWO/OICC/ROICC for interaction with the contractor principals. Any subsequent lack of adequate response or multiple lost time incidents should be elevated for additional interaction with the company by OPS/XO/CO. In no case shall safety be compromised due to contractor inaction or tardy responses – if contractor site activities are deemed unsafe, with a strong probability of additional incidents occurring, then the work activity or project should be suspended until corrective actions can be completed.

J. V. HECKMANN

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