19Q0220_Attachment_(I)_SRF_Local_Standard_Item.pdf

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FY-19

SRF-JRMC

LOCAL STANDARD ITEM

FY-19

ITEM NO: 099-903YO

DATE: 24 JUL 2017

CATEGORY: I

1. SCOPE:

1.1 Title: Requirements for Contractor Cranes, Multi-Purpose Machines and Material Handling Equipment at Naval Facilities; accomplish

2. REFERENCES:

2.1 Industrial Safety and Health Law (Roudou Anzen Eisei Hou)

2.2 Enforcement Order of Industrial Safety and Health Law (Roudou Anzen Eisei Hou Shikou Rei)

2.3 Ordinance on Industrial Safety and Health (Roudou Anzen Eisei Kisoku)

2.4 Safety Ordinance for Cranes, etc. (Kuren tou Annzen Kisoku)

2.5 Construction Code for Mobile Cranes (Idoushiki Kuren Kouzou Kikaku)

2.6 Construction Code for Overload Preventive Devices (Kuren matawa Idoushiki no Kuren no Kahuka Boushi Souchi Kouzou Kikaku)

2.7 Safety Guidelines for Rigging Work (Tamakake Sagyou no Anzen ni Kakawaru Guideline)

2.8 NAVFAC P-307, Management of Weight Handling Equipment

3. REQUIREMENTS:

3.1 Notify the SUPERVISOR one day prior to bringing any Weight Handling Equipment (WHE), (cranes, multi-purpose machines, material handling equipment that may be used in a crane-like application, rigging gear, below the hook lifting devices, and etc.) to lift suspended loads on Naval facilities. If emergent conditions require performance of work outside the scope of the contract, notify the Contracting Officer immediately.

3.2 Complete a certificate of compliance (Attachment A), and validate that the requirements of 2.1 through 2.7 and Paragraph 11.1 of 2.8 have been met prior to bringing or using any contractor WHE to lift suspended loads on Naval facilities.

3.2.1 Maintain written documentation of the last weight test of the crane and all related WHE on site.

3.3 Ensure that WHE and personnel comply with the following requirements:

3.3.1 Personnel performing weight handling shall have an understanding of all signs, notices, and operating instructions, and be familiar with the applicable hand signals prescribed by Article 71 of 2.4 for the type of crane in use. When

N6264919Q0220 Attachment I

2 of 14 ITEM NO: 099-903YO requested, submit a description of authorized hand signals used to accomplish weight handling operations at SRF-JRMC to the SUPERVISOR.

3.3.2 Personnel performing weight handling shall be familiar with the weight handling requirements in 2.1 through 2.7 and shall be trained and qualified as required by host nation standards. All personnel working on the job site shall also be trained to not stand under or in the fall zone of a suspended load.

Certifications shall be available on the crane or in the contractor’s on-site office for weight handling operations.

3.4 Inspect WHE in accordance with 2.1 through 2.7. Require contractors mark or label all WHE with company name, or other means, to identify the WHE to its owner if left unattended. Submit an example of company markings to the SUPERVISOR when requested.

3.4.1 Maintain certification records on site available for review during all work.

(V) "INSPECT CRANE"

3.5 Contractor shall:

3.5.1 Ensure all inspections are performed in accordance with 2.1 through

2.7 (daily, monthly, quarterly, and yearly), and retain the current documentation of inspections. Documents shall be readily available onsite when requested.

3.5.1.1 Perform daily pre-use inspections and operational tests on all load hoisting and lowering mechanisms, boom hoisting and lowering mechanisms, swinging mechanisms, traveling mechanisms (if to be used that day), and safety devices. Develop pre-use check sheet according to operation manual by Original Equipment Manufacturer. The check sheets shall be used for daily inspection and made available for review upon request.

3.5.2 Cranes that have to be re-rated shall be in accordance with 2.1 through 2.6 and documentation maintained on site.

3.5.3 Have an operational anti-two-block device or a two-block damage prevention feature is enabled and operational for all points of two-blocking. Ensure operators have been trained not to bypass safety devices (e.g., anti-two block devices, Load Moment Indicator) during lifting operations.

3.5.4 Have a boom hoist disconnect, shutoff, or hydraulic relief to automatically stop the boom hoist when the boom reaches a predetermined high angle.

3.6 Conduct a joint verification with the Government representative to ensure that a legible and indelible completed copy of Attachment A is maintained on the crane, multi-purpose and material handling equipment used in a crane-like application to lift suspended loads. The following certification and testing documentation shall be on site prior to entry and use on any Naval facility:

3.6.1 Crane, multi-purpose and material handling equipment used in a crane-like application to lift suspended loads certification.

3.6.2 Load testing.

3.6.3 Yearly, monthly, and daily inspection logs.

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3.6.4 Rope/sling certifications.

3.6.5 Operator certifications/designations.

3.6.6 Designation of person performing log inspections.

3.6.7 Cranes that are permanently located on a Naval facility shall have a quarterly joint verification.

3.7 Develop and maintain on site critical lift plan in accordance with Paragraph 11.1.g of 2.8. Submit the written plan to the SUPERVISOR when requested.

3.8 Report verbally to the SUPERVISOR as soon as practicable, but not later than four hours, after any WHE accident. Notify the SUPERVISOR any near miss or unplanned occurrence as soon as practicable. The contractor shall certify (Attachment A and B) that the operators, riggers and company officials are aware of the actions required in the event of an accident, near miss, or unplanned occurrence.

3.8.1 Secure the accident site and protect evidence until released by the

SUPERVISOR.

3.8.1.1 Conduct an accident investigation to establish root cause(s) of any WHE accident, near miss, or unplanned occurrences.

3.8.2 Do not continue weight handling operations until the cause is determined and corrective actions have been implemented to the satisfaction of the

SUPERVISOR.

3.8.3 A crane accident is when any of the following occurs during crane or multi-purpose machine operations when rigging gear is attached to a crane hook, which results in:

3.8.3.1 Personnel injury or death. (Minor injuries that are

inherent in any industrial operation, including strains and repetitive motion related injuries, shall be reported by the normal personnel injury reporting process of the activity in lieu of these requirements.)

3.8.3.2 Material or equipment damage.

3.8.3.3 Dropped load. (includes any part of the load or rigging gear and any item lifted with the load or rigging gear) (See 4.3)

3.8.3.4 Derailment. (See 4.3)

3.8.3.5 Two-blocking. (See 4.3)

3.8.3.6 Overload. (See 4.3)

3.8.3.7 Collision. (avoidable contact between the load, crane, and/or other objects). Avoidable contact is defined as contact that would have been prevented with proper lift planning and execution. (See 4.3)

3.8.4 A rigging accident is when any of the following occurs during a rigging operation that does not involve a crane and results in:

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3.8.4.1 Personnel injury or death. (Minor injuries that are inherent in any industrial operation, including strains and repetitive motion related injuries and not required to be reported.

3.8.4.2 Material or equipment damage that requires the damaged item to be repaired because it can no longer perform its intended function. This does not include superficial damage such as scratched paint, minor lagging damage, or normal wear on rigging gear.

3.8.4.3 Dropped load (Includes any part of the load or rigging gear and any item lifted with the load or rigging gear). (See 4.4)

3.8.4.4 Two-blocking of a powered hoist. (See 4.4)

3.8.4.5 Overload of rigging equipment. (See 4.4)

3.8.5 Provide a preliminary report of the event to the SUPERVISOR as soon as practicable, but not later than eight hours.

3.8.6 Submit one legible copy, in approved transferrable media, of the accident report consisting of a summary of circumstances, and explanation of cause(s), and corrective actions taken, using Attachment C to the SUPERVISOR within 15 working days of each accident.

3.8.7 Submit one legible copy, in approved transferrable media, of the near miss and unplanned occurrence report consisting of a summary of circumstances, and explanation of cause(s), and corrective actions taken, using Attachment D to the SUPERVISOR within 15 working days of each accident.

3.9 Notify personnel of lifting operations by audible alerts when initiating crane operations or when approaching personnel (e.g., whistles or horns). Audible alerts shall be utilized throughout the lifting evolution.

3.10 Suspend crane operations when sustained wind velocity is over 10 meter per second (m/sec), (approximately 23 miles per hour [mph] equal 20 knots) for more than 10 minutes, gusting wind velocity is over 16 m/sec (approximately 36 mph equal 31 knots); or when high/gale wind warnings are in effect by Naval Oceanography Antisubmarine Warfare Center, Yokosuka.

4. NOTES:

4.1 "the SUPERVISOR" used in this item shall read "NAVSUP Fleet Logistics Center (FLC) Yokosuka, Code 201, and SRF-JRMC Lifting and Handling Department, Code 740 Accident Prevention Team".

4.2 Bilingual copies of Certificate of Compliance and Contractor Crane and Rigging Operation Checklist are available from SRF-JRMC Lifting and Handling Department, Code 700 for SRF-JRMC projects and SRF-JRMC Weight Handling Equipment Branch, Code S950 for SRF-JRMC Detachment Sasebo projects respectively.

4.3 The requirements 3.8.3.3 through 3.8.3.7 are considered crane accidents even though no material damage or injury occurs.

4.4 The requirements 3.8.4.3 through 3.8.4.5 are considered rigging accidents even though no material damage or injury occurs.

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4.5 Naval Oceanography Antisubmarine Warfare Center, Yokosuka referred to in

3.10 is available at:

https://metoc.ndbc.noaa.gov/ProductFeeds-portlet/img/noacyoko/fiveday_yoko.htm

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ATTACHMENT A

APPENDIXP‐CONTRACTOR CRANE (OR ALTERNATE MACHINE USED TO LIFT

SUSPENDED LOAD) AND RIGGING GEAR REQUIREMENTS

CERTIFICATE OF COMPLIANCE

コンプライアンス証書

This certificate shall be signed by an official of the company that provides cranes (or multi-purpose machines, material handling equipment, or construction equipment used to lift loads suspended by rigging gear) for any application under this contract. Post a completed certificate on each crane or alternate machine (or in the contractor's on-site office for rigging operations) brought onto Navy property.

本証明書は本契約の下でクレーン（玉掛け用具で荷物を吊上げるための多目的機器・MHEト・建設機器）または玉掛け用具をあらゆる使途に提

供する会社の役員が署名するものとする。記入済みの証書を海軍施設内に持ち込む各クレーン又は代替機械（玉掛け作業の場合には契約業者 の現場事務所内）に掲示すること。

CONTRACTING OFFICER’S POINT OF CONTACT (Government Representative):

契約担当官の連絡先（アメリカ政府代表者）：

PHONE :

電話番号：

PRIME CONTRACTOR / PHONE:

主契約業者/電話番号：

CONTRACT NUMBER :

契約番号：

CRANE OR ALTERNATE MACHINE SUPPLIER/PHONE (if different from prime contractor): クレーン又は代替機械の供給業者/電話番号（主契約業者と異なる場合）：

CRANE OR ALTERNATE MACHINE

NUMBER (i.e., ID number) :

CRANE OR ALTERNATE MACHINE MANUFACTURER/TYPE/CAPACITY :

クレーン又は代替機械の製造者/形式/容量：

CRANE OR ALTERNATE MACHINE OPERATOR'S NAME (S)

クレーン又は代替機械の運転士名（複数可）

I certify that 私は以下を証明します。

1. The above noted crane or alternate machine and associated rigging gear conform to applicable OSHA regulations (host country regulations for naval activities in foreign countries) and applicable ASME B30 standards. The following OSHA regulations and ASME standards apply:

上述のクレーン又は代替機械およびすべての玉掛け用具は該当するOSHA（アメリカ労働省労働安全保健局）の規則（アメリカ国外に駐留する海

軍基地においては現地の法令および規則）および該当するASMEB30または他の規格に準拠している。以下のOSHA規則およびASME B30規格

が適用される：＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

2. The operators noted above have been trained and are qualified for the operation of the above noted crane(s) or alternate machine(s).

上述の運転士は、上述のクレーン又は代替機械を運転する訓練を受け、かつ、運転資格を有する。

3. The operators noted above have been trained not to bypass safety devices during lifting operations.

安全装置及び運転補助装置はすべて、有効かつ正常に作動する。上述の運転手は、吊り上げ作業中に安全装置及び運転補助装置を解除しな

いよう、教育を受けている。

4. The operators, riggers and company officials are aware of the actions required in the event of an accident as specified in the contract.

上述の運転士、玉掛け作業員、及び会社役員は、核当する契約に指示するとうり事故発生時に必要な対応を認識している。

5. Signal persons used in construction work are qualified in accordance with 29 CFR 1926.1428.

建設作業で利用される合図者は、29 CFR 1926.1428に基づき資格を有している。

6. Riggers are qualified in accordance with NAVFAC P-307. paragraph 11.1.K.

玉掛け作業員は、NAVFAC P-307の 11.1.K項に基づき資格を有している。

7. All personnel working on the job site have been trained to not stand under a load or in the fall zone of a suspended load unless specifically allowed by USACE EM 385-1-1.

核当する作業現場で作業をする者は全て、USACE EM 385-1-1 により特別に許可を受けてない限り 品物の下や宙吊りの品物の落下危険区域

に立ち入らないよう 教育を受けている。

COMPANY OFFICIAL SIGNATURE :

会社役員の署名：

DATE :

日付：

COMPANY OFFICIAL NAME/TITLE :

会社役員の氏名/役職名：

POST ON CRANE (OR ALTERNATE MACHINE) (IN CAB OR VEHICLE)

クレーン（又はクレーンに代わる機器）に掲示 （運転室または車両）

(or in the contractor’s on-site office for rigging operations) （当該機器が関与しない玉掛けのみの作業については業者の現場事務所内に掲示）

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ATTACHMENT B

CONTRACTOR CRANE OR RIGGING OPERATION CHECKLIST

契約業者クレーンまたは玉掛け作業チェックリスト

YES

はい

NO

いいえ

N/A 該当なし

1 Is the Certificate of Compliance, P-1, in the operator’s cab (or in the contractor’s on-site office for rigging operations) with the current operator’s name listed?

最新の運転士名が記載されたコンプライアンス証書(P-1)が運転室内に掲示してあるか？(玉掛け作業については業者の現場事務所内）

2 Is the crane/machine transited to and from the job site correctly? Are the OEM instructions for travel being followed?

クレーン/機器は作業現場に適切に搬入、搬出されているか。製造元の走行の指示に従っているか？

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

運転士は吊り上げる品物の重量(質量)を把握しているか？

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

吊り荷の重量は、現状のクレーン構成においてクレーン/機械の製造元が定める定格容量の範囲内か？

5 Are outriggers/stabilizers required and, if so, are they properly extended and down?

アウトリガーまたはスタビライザーは必要か？アウトリガーが必要な場合、アウトリガーは完全に張り出されて設置しているか？

6 If outrigger/stabilizers are used, and the wheels are not off the ground is this the correct setup in accordance with the OEM?

アウトリガーまたはスタビライザーを使用する場合にタイヤが地面から浮いていない これはOEMに従った正しい設置方法か？

7 Is the crane/machine level and on firm ground, or if the ground is not firm are adequate supporting materials provided?

クレーン/機器は水平で堅固な地面に設置されている、堅固な地面でない場合、適切な敷板が設置されているか？

8 If supporting materials are provided, is the entire surface of the outrigger/stabilizer pad supported and is the supporting material of sufficient strength to safely support the loaded outrigger/stabilizer pad?

敷板が必要な場合、アウトリガーパッド全面が受けられているか。敷板材は、荷重を受けたアウトリガーパッドを安全に支持する適切な強度

があるか？

9 If outriggers/stabilizers are not used, is the crane/machine rated for on-rubber lifts by the OEM’s load chart?

アウトリガーを使用しない場合、当該クレーン/機器は、OEMの定格総荷重表にタイヤ接地状態での吊り上げが設定されているか？

10 Is the swing radius of the crane counterweight clear of people and obstructions and are accessible areas within the swing area barricaded to prevent injury or damage?

クレーンのカウンターウエイト旋回範囲内に人や障害物がないか？旋回範囲内に立ち入り可能な区域はケガや損傷を防止するために閉鎖され ているか？

11 Has the hook been centered over the load in such a manner to minimize swing?

フックは荷振れを最小限にするために吊り荷の重心の真上に位置しているか？

12 Is the load well secured and balanced in the sling or lifting device after it is lifted a few inches for verification?

吊り荷を数インチ吊り上げた後に(地切り)、玉掛け用具がバランス良く保たれた状態であることを確認しているか？

13 Is the lift and rotation path clear of obstructions?

吊り上げ及び旋回経路に障害物がないか？

14 If rotation of the load being lifted is hazardous, is a tagline or other restraint being used?

吊り上げ中の荷が回ると危険な場合には、補助または誘導ロープを使用しているか？

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

人が吊り荷の下に立入らないよう、または通行しないような対策がされているか？

16 Is the operator paying full attention to the signal person?

運転士は合図者に注意を払っているか？

17 Are proper signals being used? Is the operator responding properly to the signals? Are radios used for blind lifts?

正しい合図が使われているか？運転士は、合図に対し適切に反応しているか。品物が見えない吊上げに無線機を利用しているか？

18 Are empty hooks lashed or otherwise secured during travel to prevent swinging?

フックは、移動中の揺れを防止するためにロープ等で縛り付けるか、または固定されているか？

19 Does the operator remain at the controls while the load is suspended?

運転士は、品物が吊り上げられている間、運転に就いているか？

20 Does the operator ensure that side loading is prohibited?

運転士は、吊り荷の横引きが禁止されていることを徹底しているか？

21 Are personnel prevented from riding on a load?

吊り荷の上に人が乗ってないか？

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

始動と停止の動作はスムーズな動きか(急加速又は急減速がないこと)？

23 Is the lift a critical lift?

実施中のクレーン作業は、危険度の高い作業(クリティカルリフト)であるか？

24 If so, is a lift plan provided and understood and check-off sheets initialed and signed off?

上記に該当する場合、吊り上げ計画が作成され理解されているか、計画書にはイニシャルと署名が記載されているか？

25 If overhead power lines are in the vicinity, is a critical lift plan provided addressing the requirements of 29 CFR 1926.1407-1411?

送電線付近での作業の場合、クリティカルリフト計画を作成し、規則や指針(P-307 Figure 10.30)を理解し、それを順守しているか？

Figure P-2 (1 of 2) 図 P-2 （1/2） P-2

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ATTACHMENT B

(Con’t)

YES

はい

NO

いいえ

N/A 該当なし

If pick and carry operations are allowed and performed, are OEM directions followed (e.g. rotation lock engaged, boom centered over front or rear, etc.)?

吊り荷走行が認められており、これを実行する場合、製造元の指示に準拠しているか？

(例、旋回ロックを掛ける、ブームを前方または後方に向けて中心の置く等)

27 When the crane/machine is left unattended, is it in a safe condition?

クレーン/機器が無人の状態にあるとき、安全な状態におかれているか？

28 Is rigging gear undamaged and acceptable for the application?

玉掛け用具に損傷がなく、かつ用途に適したものか？

Does rigging gear meet applicable ASME or host nation standards (e.g., ASME B30.9 for slings, B30.10 for hooks, B30.26 for rigging hardware such as shackles, safety hoist rings, and eyebolts, B30.20 for below the hook lifting devices)?

玉掛け用具は、該当するASME、又は現地の規格(JIS)に適合しているか？（例えばASME B30.9 スリング、B30.10 フック、 B30.26 シャック

ル、セーフティーホイストリング、アイボルト等の金具、B30.20 フックに取り付ける吊り上げ装置等）

30 Was the rigging gear inspected prior to use?

玉掛け用具の使用前点検を行ったか？

31 Is sling protection used to protect slings (especially synthetic slings) and equipment from damage due to abrasion and sharp corners and edges?

鋭利な角部や縁でスリング(特にナイロンスリング)や機械が損傷を受けないように当て物が使用されているか？

32 Is the rigging gear used in accordance with its working load limit? Is the working load limit marked on the rigging gear?

使用する玉掛け用具の安全使用荷重に従ってその玉掛け用具を使用しているか？

玉掛け用具に安全使用荷重が表示されているか？

33 Are positive latching devices (or “mousing”) used on crane and rigging hooks?

クレーンフック及び玉掛け用具のフックに外れ止めが使われているか？または、フックが閉じられているか？

34 If a mobile crane is used on a barge, are all rules of 29 CFR 1926.1437(construction) being followed?

台船上で移動式クレーンを使用する場合、29 CFR 1926.1437(建設)の全ての規則に従っているか？

If a mobile crane is used on a barge are the outriggers/stabilizers blocked or are the crawlers traveling in a defined space as allowed by 29 CFR 1926.1437 (construction)?

クレーンが台船上で使用されている場合はアウトリガーやスタビライザーは固定されているか、

また29 CFR 1926.1437(建設)によって許可されたクローラーで走行しているか？

36 For floating cranes, are rules of 29 CFR 1915 (ship repair) or 29 CFR 1926.1437 (construction) being followed?

海上クレーンを使用する場合、29 CFR 1915(艦船修理)、29 CFR 1926.1437(建設)の規則に従っているか？

If a multi-purpose machine, forklift, or construction equipment is being used, is there proof from the OEM (or qualified PE) that the machine is approved for suspended load lifting and is there a load chart?

多目的機械、フォークリフト、建設機械を使用する場合、該当機械がOEMによって吊り荷を揚重することを許可され、さらに定格総荷重表が

あるか？

38 If a personnel lift is being performed with a crane or base mounted hoist, are all requirements of NAVFAC P-307, paragraph 11.1.g (5) for a crane or 11.1.m for a base mounted hoist being followed?

クレーンで人員を揚重する場合、NAVFAC P-307. 11.1.g(5)と11.1.mに従って行われているか？

Contractor:

契約業者名:

Subcontractor:

下請け業者名:

Location:

作業現場:

Date:

日付:

Notes:

注記:____________________________________________________________________________________________

Signature of Government Representative:

契約担当官の代表者の署名:

Figure P-2 (2 of 2) 図 P-2 （2/2） P-2

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ATTACHMENT C

CRANE AND RIGGING ACCIDENT REPORT

Accident Category: Crane Accident Rigging Accident Reporting Activity:

UIC:

Copy To: Navy Crane Center Bldg. 491 NNSY Portsmouth, VA 23709 Fax: 757-967-3808

Activity Responsible for the Accident:

UIC:

Report No:

Accident Location: Accident Date: Time:

BOS Contractor: Yes No If Yes, Contract No: Contractor Equip. Yes No

Crane No: Crane Type: Category: Crane OEM:

Crane Capacity: Hoist Capacity: Weight of Load on hook: Weather:

Complex Lift or Complex Non-Crane Rigging Operation? Yes No

Lost Work Days? Yes No Fatality or Permanent Disability? Yes No Material/ Property Cost Estimate:

Accident Type (check all that apply):

Personal Injury Overload Two Blocked Power Line Contact

Dropped Load Derail Crane Collision Damaged Crane

Damaged Rigging Gear Damaged Load Load Collision Other: Specify Cause of Accident (check all that apply):

Improper Operation Equipment Failure Inadequate Visibility

Improper Rigging Switch Alignment Inadequate Communication

Track Condition Procedural Failure Other: Specify

Responsibility (check all that apply):

Crane Walker Rigger Operator Signal Person

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 root 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.

INCLUDE: Printed Name, Code and Date.

Preparer: Phone: E-mail: Code: Date:

Concurrence Code: Date:

Concurrence WHE Program Manager (if Applicable) Code: Date:

Certifying Official (Crane Accident Only):

12 of 14 ITEM NO: 099-903YO

CRANE AND RIGGING ACCIDENT REPORT INSTRUCTIONS

This form is designed for e-mail transmission, and with enclosures shall be the official document. Electronic submission will be accepted 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.

1. Accident Category: Indicate either crane accident or rigging accident.

2. Reporting Activity/UIC: The activity and unit identification code responsible for reporting the accident.

3. Activity Responsible for the Accident/UIC: Self-explanatory.

4. Report No.: The activity assigned accident number (e.g., Activity UIC-FY-CA-01).

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

6. Accident Date: The date the accident occurred.

7. Time: The time (24 hour clock) the accident occurred (e.g., 1300).

8. Is the responsible party a BOS Contractor? Check yes or no. If yes, enter contract number.

9. Was the crane/equipment owned by a contractor? Check yes or no.

10. Crane No.: The activity assigned crane number (e.g., PC-5), if applicable.

11. Crane Type: The type of crane involved in the accident (e.g., mobile, bridge), if applicable.

12. Category: Identify category of crane (i.e., 1, 2, 3, or 4), if applicable.

13. Crane OEM: The original equipment manufacturer of the crane (e.g., Samsung, Grove, P&H), if applicable.

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

15. Hoist Capacity: The capacity of the hoist involved in the accident at the max radius of the operation, if applicable.

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

17. Weather: The weather conditions at time of accident (e.g., wind, rain, cold).

18. Complex lift: Was the crane or rigging gear being used in a complex lift? Check yes or no.

19. Lost Work Days? Check yes or no.

20. Fatality or Permanent Disability: Check yes or no.

21. Material/Property Cost Estimate: Estimate total cost of damage resulting from the accident.

22. Accident Type: Check all that apply.

23. Cause of Accident: Check all that apply.

24. Responsibility: 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. If yes, list Accident Report numbers.

27. Preparer: Printed name must be provided.

28. Concurrences: Printed name must be provided.

29. Certifying Official (Crane Accidents Only): Printed name must be provided.

Enclosure (1) Brief Description: No more than one paragraph summarizing the resultant incident.

Root Cause 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.

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.

13 of 14 ITEM NO: 099-903YO

ATTACHMENT D

NEAR MISS AND UNPLANNED OCCURRENCE REPORT

Near Miss Category: Crane Near Miss Rigging Near Miss

Unplanned Occurrence Reporting Activity:

UIC:

Copy To: Navy Crane Center Bldg. 491 NNSY Portsmouth, VA 23709 Fax: 757-967-3808

Activity Responsible for the Near Miss:

UIC:

Report No:

Location: Near Miss Date: Time:

BOS Contractor: Yes No If Yes, Contract No: Contractor Equip.

Yes No

Crane No: Crane Type: Category: Crane OEM:

Crane Capacity: Hoist Capacity: Weight of Load on hook: Weather:

Complex Lift or Complex Non-Crane Rigging Operation? Yes No

Is this near miss indicative of a recurring problem? Yes No

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

Brief description:

Root cause:

Corrective Actions:

INCLUDE: Printed Name, Code and Date unless otherwise specified.

Preparer: Phone: E-mail: Code: Date:

14 of 14 ITEM NO: 099-903YO

CRANE AND RIGGING NEAR MISS INSTRUCTIONS

This form is designed for e-mail transmission 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.

1. Near Miss Category: Indicate crane near miss, rigging near miss, or unplanned occurrence.

2. Reporting Activity/UIC: The activity and unit identification code responsible for reporting the near miss.

3. Activity Responsible for the Near Miss/UIC: Self-explanatory.

4. Report No.: The activity assigned near miss number (e.g., Activity UIC-FY-CA-01).

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

6. Near Miss Date: The date the near miss occurred.

7. Time: The time (24 hour clock) the near miss occurred (e.g., 1300).

8. Is the responsible party a BOS Contractor? Check yes or no. If yes enter contract number.

9. Is the crane/equipment owned by a contractor? Check yes or no.

10. Crane No.: The activity assigned crane number (e.g., PC-5), if applicable.

11. Crane Type: The type of crane involved in the near miss (e.g., mobile, bridge), if applicable.

12. Category: Identify category of crane (i.e., 1, 2, 3, or 4), if applicable.

13. Crane OEM: The original equipment manufacturer of the crane (e.g., Samsung, Grove, P&H), if applicable.

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

15. Hoist Capacity: The capacity of the hoist involved in the near miss at the max radius of the operation, if applicable.

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

17. Weather: The weather conditions at time of accident (e.g., wind, rain, cold).

18. Complex lift: Was the crane or rigging gear being used in a complex lift?

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

20. Brief Description: No more than one paragraph summarizing the resultant incident.

21. Root Cause 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.

22. Corrective Actions: List all short term and long term corrective actions that were/will be 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.