N6945020R0010 SectionJ_Amend0004.pdf

N69450-20-R-0010 Amendment 0004

Section J – 0200000

Management and Administration

Attachment Number Attachment Title J-0200000-01 Definitions and Acronyms J-0200000-02 Required Conferences And Meetings J-0200000-03 Directives, Instructions and References J-0200000-04 Forms J-0200000-05 Government-Furnished Property, Materials, and Services J-0200000-06 Service Provider Information J-0200000-07 Asset Information J-0200000-08 Specification Information J-0200000-09 Characteristic Meter Readings Information J-0200000-10 NAVFAC MAXIMO Data Reporting J-0200000-11 NAVFAC MAXIMO System Access Procedures J-0200000-12 Commander, Navy Region Southeast Instruction 4101.1 J-0200000-13 Exhibit Line Item Numbers

Attachment J-0200000-01 Definitions and Acronyms

Definition Description Assessment A general term referring to either a survey or inspection of a facility to determine condition.

Asset A general term used to refer to an item, such as a component, system, building or facility, which is managed by an automated data management program.

Competent Person A person who has the professional experience and training necessary to identify existing and predictable hazards at a work or service environment, and who has the authority to take prompt and corrective action to eliminate or remove dangers from the environment.

One who can identify existing and predictable hazards in the working environment or working conditions that are dangerous to personnel and who has authorization to take prompt corrective measures to eliminate them.

Component Inventory Management Unit

(CIMU)

An organization of like-kind real property into manageable maintenance units. CIMU is a building component, group of components or component assemblies, serving a specific purpose in a facility that can be expected to follow a common and predictable lifecycle behavior. This class of non-equipment will include items such as exterior walls, exterior windows, interior finish, and roofs. This class of equipment will include items such as fan coil units, air handling units, lighting, and water closets. CIMUs can include one or more items of installed equipment typically subject to routine scheduled maintenance.

Confined Work Space A space that is large enough and so configured that a person may bodily enter a space (such as in tanks, vessels, silos, storage bins, hoppers, vaults, pits, and like spaces where there is limited means of entry) and is hindered or restricted from escaping during an emergency.

Construction Equipment Construction equipment refers to specialized heavy machinery that covers one industry and is specifically designed for executing construction work. Construction equipment requirements shall include a list of equipment establishing the size, quality, number of units, and unit prices. Construction equipment prices provided by the Contractor shall be the lowest price available considering the availability of equipment and the time constraints of the job. The direct equipment price shall be adjusted by all discounts and rebates that accrue to the Contractor.

All indirect cost associated with construction equipment, such as: the Contractor’s hourly composite trade wage, adjusted to allow for workforce productivity; sub-contractor cost, costs for pre-expended bin materials, shipping and handling, union agreements, crew sizes, hand tools, universal equipment (excluding construction equipment), mobilization, demobilization, payroll burdens and fringes, overtime, job (field) overhead (including clerical support, supervision, inspection, fees, taxes, licenses, permits, and insurance), general and administrative (home office) overhead, profit, and all other associated markups shall not be included in the equipment price since the cost for these items were included in the labor hour unit price bid. Additionally, time for job preparation, safety standby personnel, and similar indirect labor elements shall not be included.

Contracting Officer (KO) That individual with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings. The term includes certain authorized representatives of the Contracting Officer acting within the limits of their authority as delegated by the Contracting Officer.

Contracting Officer’s Representative (COR)

The individual appointed by the KO responsible for monitoring the Contractor’s technical compliance and progress, relative to assigned contract(s)/orders(s), based on the contract requirements specified in the PWS and in accordance with the PAP. The COR performs a variety of contract administration duties that includes oversight of PA, documenting and rating Contractor performance, reviewing invoices, and acceptance of

Amendment 0004 work. Assignment as a COR is a collateral duty typically performed by the FSCM or

SPAR.

Contractor That entity or its representative responsible for the delivery of the services or materials specified in this contract, as designated by contract award. The term Contractor as used herein refers to both the prime Contractor and any subcontractors. The prime Contractor shall insure that subcontractors comply with the provision of this contract.

Contractor Representative That individual appointed by the Contractor, either orally or in writing, who has been assigned responsibility for executing the requirements of this contract.

Direct Material Costs The actual vendor invoice charges for materials used for performance of work under this contract. Direct material costs shall include transportation charges when such charges are included on the invoice by the vendor, as well as any discounts allowed for prompt payment and discounts or rebates for core value or salvage value that accrue to the Contractor. When questions arise concerning the cost of materials, material costs will be based on the lowest of quotes provided by the Contractor from at least three different commercial vendors for the direct material cost. The Government retains the right to obtain additional quotes in questionable situations. The lowest price will be used.

Electronic Operation And Maintenance And Support Information (eOMSI)

A set of consultant-prepared data and document files that contain detailed, as-built technical information that describes the efficient, economical and safe operation, maintenance and repair of a facility, plant, equipment or system throughout its life cycle.

Generally, it is prepared during construction and submitted upon completion of a new facility or major facility upgrade. eOMSI’s typically include asset information, staffing and budgeting information, supply support including critical spare parts, operating procedures, troubleshooting and diagnostic guides, extended warranty data, maintenance task frequencies and documentation, technical data, repair procedures and manufacturer’s product data. eOMSI data and document files are provided in electronic formats.

Equipment Tangible asset that is functionally complete for its intended purpose, durable, and non-expendable.

Facility A building or structure designed and created to serve a particular function.

Fixed Burden Rate (FBR) The additional costs (expressed in percent of direct material cost) for ordering, handling, and stockpiling materials and repair parts. For example, if the offeror's Fixed Burden Rate for materials in the Base Period is 10% then:

$100,000.00 + ($100,000.00 x 10%) = $110,000.00

The Government will compensate the Contractor for the required parts and materials and not the total amount shown in Schedule of Indefinite Delivery Indefinite Quantity Work.

Frequency Of Service Annual (A). Services performed once during each 12-month period of the contract at intervals of 335 to 395 days.

Biennial (B). Services performed once during each 24-month period of the contract at internals of 670 to 790 days.

Daily (D5). Services performed once each calendar day, Monday through Friday, including holidays unless otherwise noted.

Daily (D7). Services performed once each calendar day, seven days per week, including weekends and holidays.

Monthly (M). Services performed 12 times during each 12-month period of the contract at intervals of 28 to 31 calendar days.

Quarterly (Q). Services performed four times during each 12-month period of the contract at intervals of 80 to 100 calendar days.

Semiannual (SA). Services performed twice during each 12-month period of the contract at intervals of 160 to 200 calendar days.

Amendment 0004

Semimonthly (SM). Services performed 24 times during each 12-month period of the contract at intervals of 14 to 16 calendar days.

Three times weekly (3W). Services performed three times a week, such as Monday, Wednesday, and Friday.

Twice weekly (2W). Services performed twice a week, such as Monday and Thursday or Tuesday and Friday.

Weekly (W). Services performed 52 times during each 12-month period of the contract at intervals of six to eight calendar days.

Government Furnished Property (GFP)

Property in the possession of, or directly acquired by, the Government and subsequently furnished to the contractor for performance of a contract. Government furnished property includes, but is not limited to, spares and property furnished for repairs, maintenance, overhaul, or modification. Government furnished property also includes contractor acquired property if the contractor acquired property is a deliverable under a cost contract when accepted by the Government for continued use under the contract.

Hazardous Material (HM) A material that because of its quality, concentration, physical, chemical or infectious nature may pose a threat to human health or the environment if released or spilled into the environment or any material designated by the Department of Transportation (DOT) or any materials that require a SDS form as posing a potential threat while being transported. Hazardous materials are listed in 49 CFR Part 172.

Hazardous Waste (HW) Any discarded solid waste (liquid, semi-solid, solid, or gaseous) that meets the definition of a hazardous waste by USEPA or the Navy. In accordance with RCRA, a solid waste is a listed hazardous waste if it is specifically listed, or it is a characteristic hazardous waste if it exhibits the characteristics of ignitability, corrosivity, reactivity, or toxicity.

Hazardous Waste Management Plan

In accordance with OPNAVINST 5090.1C, every Navy shore activity that generates HW shall develop and use a Hazardous Waste Management Plan or a Hazardous Waste management component in its P2 Plan and EMS. A Hazardous Waste Management Plan shall:

Identify applicable federal and local regulations pertaining to the generation and management of hazardous waste.

Identify training requirements and describe procedures for obtaining training and maintaining training records.

Assign responsibilities for the generation, designation, handling, storage, treatment, disposal, and all documentation.

Describe all hazardous waste generation and management procedures.

Include or reference the hazardous waste minimization plan and goals.

Include or reference contingency plans and emergency response procedures.

The plan shall be kept up to date to include changes in hazardous waste generation and management procedures, as well as changes in applicable federal, and local hazardous waste regulations. The plan shall include or reference minimization procedures sufficient to achieve DOD minimization goals. Tenant activities are covered by the host CO's Hazardous Waste Management Plan.

Hazardous Waste Manifest

A hazardous waste manifest as defined in 40 CFR 260 is required for the transport of hazardous waste. The installation commanding officer (ICO) or the ICO’s designated representative shall retain signature authority for hazardous waste manifests.

Infrastructure Condition Assessment Program

(ICAP)

A Navy automated data management program that utilizes historical asset lifecycle data and a structured assessment process to evaluate the condition facilities and their components.

Inspection A rigorous, detailed assessment of the condition of a facility performed to generate a fundable scope and cost estimate for prioritization and funding of maintenance and repair.

Amendment 0004

Integrated Maintenance Program (IMP)

IMP is a recurring state-of-the-art, reliability-centered inspection, testing, maintenance and repair program that determines best practices for managing the functions and consequences of failures of facilities equipment and system components. IMP encompasses accepted commercial practices, including reactive, preventive, predictive and proactive maintenance, into one optimal program. The IMP approach gives the Contractor full responsibility to maintain systems and equipment and perform repairs whenever necessary to ensure equipment and systems are operational and remain in a constant state of readiness. Service orders will not be issued for accomplishment of repairs on systems and equipment maintained under IMP.

Job or Work Order An authorization for work that requires planning and estimating and has an individual line of accounting for financial and performance evaluation.

Joint Task Force (JTF) Commissions

Each JTF Commission lasts for one week (7 days). The Government will provide the Commission schedule at least two weeks in advance to the actual Commission begin date; however, Commissions may be canceled at any time. Commissions are held at McCalla Airfield (Camp Justice, Expeditionary Legal Complex (ELC), and the CLOe OMC Buildings.)

Less-than-90-day Accumulation Areas or Storage Facilities

Temporary HW storage areas where HW may be stored for up to 90 days without a RCRA permit.

Maintenance And Repair The preservation or restoration of a piece of equipment, system, or facility to such condition that it may be effectively used for its designated purposes. Maintenance/repair may be adjustment, overhaul, reprocessing, or replacement of constituent parts or materials that are missing or have deteriorated by action of the elements or usage, or replacement of the entire unit or system if beyond economical repair.

Monthly On-Site Labor Report

A compilation of all Contractor and subcontractor employee-hours involved in delivering contract services on a Government property.

NAVFAC MAXIMO A specially configured software version of MAXIMO®, a commercially available computerized maintenance management system (CMMS), adopted by NAVFAC for enterprise facility asset data management. The terms “MAXIMO”, “NAVFAC MAXIMO” or “Government’s MAXIMO” shall be used interchangeably in the document.

Non-RCRA Regulated Waste

Waste that is not regulated as a hazardous waste under RCRA; however, is waste may be regulated by other federal or local regulations including but not limited to TSCA, Clean Air Act, Clean Water Act or other regulations and statues. Examples include Used Oil, Universal Waste, Oily Water, antifreeze, etc.

Non-RCRA regulated waste (while not meeting the definition of a Hazardous Waste) must be managed according to its applicable regulations and may not be discarded into the general trash.

Non-Regulated Solid Waste (Debris and Rubbish)

Waste not associated with an industrial process such as refuse and scraps resulting from preparation, cooking, dispensing, and consumption of food. Non-hazardous construction and demolition wastes such as dimension and non-dimension lumber, plywood, chipboard, and hardboard are included.

Partnering The terms “partnering” and “partnership” used herein shall mean a relationship of open communication and close cooperation that involves both Government and Contractor personnel working together for the purpose of establishing a mutually beneficial, proactive, cooperative environment within which to achieve contract objectives and resolve issues and implementing actions as required.

Performance Assessment A method used by the Government to provide some measure of control over the quality of purchased goods and services received.

Amendment 0004

Performance Assessment Representative (PAR)

The individual(s) assigned as a Technical Point of Contact (TPOC) / Subject Matter Expert (SME) to the COR to perform duties as the on-site representative who assesses Contractor performance. The PAR periodically observes Contractor performance, reviews delivered services, reviews quality management corrective actions, periodically assesses and documents Contractor performance on PAWs and the MPAS, and communicates findings as necessary with the Contractor, SPAR, and COR.

Pre-Expended Bin Materials And Supplies

The minor materials and supplies that are incidental to the job, for which the total direct cost of any one material line item shown on the material estimate is $10.00 or less.

Examples of pre-expended bin materials and supplies include, but are not limited to, solder, lead, flux, electrical connectors, electrical tape, fuses, nails, screws, bolts, nuts, washers, spacers, masking tape, sand paper, solvent, cleaners, lubricants, grease, oil, rags, mops, glue, epoxy, spackling compound, joint tape, plumbers tape and compound, clips, welding rods, and touch up paint.

Property Administrator An authorized representative of the Contracting Officer who is responsible for administering contract property requirements, terms and conditions of the contract

Property Management Program

A Government program established for the purpose of reviewing and approving the Contractor’s Property Management Plan and System through performance of a system analysis whenever government property is in the possession of the Contractor.

Quality Assurance (QA) The planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled.

Quality Control (QC) The observation techniques and activities used to fulfill requirements for quality.

R. S. Means A data collection and organization system developed by R. S. Means Company which can be used to prepare accurate, dependable construction estimates and budgets in a variety of ways. The Contractor shall use the latest edition. Material prices are based on a national average and computed labor costs are based on a 30-city national average.

An estimate prepared using this data is called a "Means estimate"; data may simply be referred to as "Means".

Real Property Inventory Equipment (RPIE)

A Government owned or leased individual pieces of equipment, apparatus, or fixture that are essential to the function of the real property (i.e. plumbing, electrical, heating, cooling and elevators). It is physically attached to, integrated into, and built in or on the property.

Individual RPIE’s can be combined to make a CIMU to facilitate facilities management.

An individual RPIE can also be a CIMU if the equipment is complex enough to require its own management planning.

Regulated Waste Any hazardous, non-hazardous, industrial process waste (aka special waste), e-waste, and/or off-specification HM, which because of its physical characteristics, chemical make-up or biological nature requires either special handling procedures and permitting, or poses an unusual threat to human health, equipment, property, or the environment.

Examples include (but are not limited to) liquid sludge, pastes, and/or filter cakes, chemical compounds and/or petroleum products, fine powders or highly dusty materials, spent blast media and/or grit, demolition wastes from industrial facilities, debris and/or residues from spill cleanup work, underground storage tank remediation materials, pollution control wastes, ash from fires, furnaces, boilers or incinerators, off-specification products, other materials that have the potential to be a hazardous waste.

All RW may be used or unused excess hazardous materials. Laboratory analysis may be required to verify the waste is not a RCRA-regulated hazardous waste.

Response Time The time allowed the Contractor after initial notification of a work requirement to be physically on the premises at the work site with appropriate personnel, tools, equipment, and materials, ready to perform the work required.

Sampling Plan Plan and procedures to conduct sampling, field testing and laboratory analysis for a defined testing objective.

Amendment 0004

Satellite Accumulation Areas

Designated approved areas, at or near the point of generation and under the control of the operator generating the waste, where no more than 55 gallons (cumulative total) of all types of HW or 1 quart of acutely HW may be accumulated. The 55-gallon limit does not include non RCRA regulated waste, universal waste and used oil etc.

Spill Prevention Control and Countermeasure (SPCC) Plan

The SPCC Plan establishes engineering controls including procedures, methods, equipment and other requirements to prevent the discharge of oil into or upon navigable waters. The Plan includes procedures for oil spill prevention, measures to contain spills and an established spill drill exercises to ensure effective countermeasures in the event of oil spill.

System An assemblage of mechanically and/or electrically interlocked parts, equipment and/or components forming a unitary whole.

Unit Priced Labor (UPL) Hour

The unit price bid by the Contractor to perform one hour of work-in-place. With the exception of direct material and construction equipment costs, the unit priced labor hour price shall include all indirect and direct costs associated with performing work, such as:

the Contractor’s hourly composite trade wage, adjusted to allow for workforce productivity; sub-contractor cost, costs for pre-expended bin materials, shipping and handling, wage determinations, union agreements, crew sizes, hand tools, equipment, universal equipment (excluding construction equipment), mobilization, demobilization, payroll burdens and fringes, overtime, job (field) overhead (including clerical support, supervision, inspection, fees, taxes, licenses, permits, and insurance), general and administrative (home office) overhead, profit, and all other associated markups. Any indirect cost or additional markups not allowed in the definition of direct materials shall be included in the UPL price. Additionally, time for job preparation, safety standby personnel, and similar indirect labor elements are included.

Universal Equipment Universal equipment refers to equipment that can cover two or more industries and is commercially employed in execution of operation, maintenance, and repair work, such as: Aerial Work Platforms, Backhoes, Cranes, Dump Trucks, Excavators, Generators, Graders, Lifts, Loaders, Man Lifts, Monitoring and Test Equipment, Pumps, Tractors, Trailers, etc.

Universal Waste (UW) Universal Waste (UW) (defined in 40 CFR Part 273) means batteries, fluorescent lamps, some pesticides, and mercury-containing equipment formally classified as a HW, but that are now subject to less stringent regulations, when recycled if recycling is available.

Utility Infrastructure Condition Assessment Program (UICAP)

A comprehensive assessment processes for planning, managing, and executing Navy utility infrastructure inspections.

Amendment 0004

Acronym Title ACO Administrative Contracting Officer BW Biweekly CDR Contract Discrepancy Report CIA Controlled Industrial Area CIMU Component Inventory Management Unit CMMS Computerized Maintenance Management System CNSSI Committee on National Security Systems Instruction COR Contracting Officer Representative COR Condition of Readiness DBH Diameter at Breast Height DCR Direct Condition Rating DoD Department of Defense DoDI Department of Defense Instruction DoN Department of Navy DRMO Defense Reutilization Management Office EPA Environmental Protection Agency EPCRA Emergency Planning and Community Right-to-Know Act FAR Federal Acquisition Regulation FFP Firm Fixed Price FIFRA Federal Insecticide, Fungicide, and Rodenticide Act FSC Facility Support Contract FSCM Facility Support Contract Manager GIS Geospatial Information System GFE Government-furnished Equipment GFF Government-furnished Facilities GFM Government-furnished Materials HCA Head Contracting Agency ICAP Infrastructure Condition Assessment Program ICP Integrated Contingency Plan IDIQ Indefinite Delivery Indefinite Quantity iNFADS Internet Navy Facilities Asset Data Store IPM Integrated Pest Management IPMIS Integrated Pest Management Information System IPMP Integrated Pest Management Plan KO Contracting Officer LAN Local Area Network M Monthly MAP Maintenance Action Plan MDI Mission Dependency Index MEP Mechanical, Electrical and Plumbing MPAS Monthly Performance Assessment Summary MRI Mission Readiness Index MSDS Material Safety Data Sheets NAVFAC Naval Facilities Engineering Command NIST National Institute of Standards and Technology NIST SP National Institute of Standards and Technology Special Publication NMCI Navy Marine Corps Intranet NOSC Navy-On-Scene Coordinator PAP Performance Assessment Plan PAR Performance Assessment Representative PAW Performance Assessment Worksheet

Amendment 0004

Acronym Title PM Project Manager PM Planned Maintenance or Preventative Maintenance PRCSP Permit Required Confined Space Program PWS Performance Work Statement PWO Public Works Officer Q Quarterly QC Quality Control RPIE Real Property Inventory Equipment RSL Remaining Service Life SC Security Clearances SM Semimonthly SPAR Senior Performance Assessment Representative TE Technical Exhibit VIQ Variation in Quantity WBS Work Breakdown Structure

Amendment 0004

Attachment J-0200000-02 Required Conferences And Meetings

Required Conferences and Meetings Frequency Administrative and Coordination Meetings As scheduled by the KO Pre-performance Conference As scheduled by the KO Performance Assessment Board Meetings As scheduled by the KO Partnering Sessions Refer to Section C 0200000 Spec Item 2.3.3 Installation Energy Management Refer to Section C 0200000 Spec Item 2.10.1 All Others As scheduled by the KO.

Attachment J-0200000-03

Directives, Instructions, and References

All revisions and replacements of listed References and Technical Documents take precedent of those listed.

Reference Title 29 CFR 1910 Occupational Safety and Health Standards

29 CFR 1926 Safety and Health Regulations for Construction

40 CFR 82 Federal Solid Waste Disposal

40 CFR 136 Code of Federal Regulations (Protection of Environment)

40 CFR 261 Identification and Listing of Hazardous Waste

40 CFR 262 Generators of Hazardous Waste

40 CFR 263 Transporters of Hazardous Waste

40 CFR 264 Owners and Operators of Hazardous Waste Treatment, Storage, and Disposal Facilities

40 CFR 265 Interim Status Standard for Owners and Operators of Hazardous Waste Treatment Storage, and Disposal Facilities

49 CFR 171 General Information, Regulations, and Definitions

49 CFR 172 Hazardous Materials, Tables, and Hazardous Materials

49 CFR 178 Shipping Container Specification

ASME B30.22 Articulating Boom Cranes

ASME B30.3 Tower Cranes

ASME B30.5 Mobile and Locomotive Cranes

ASME B30.8 Floating Cranes and Floating Derricks

Commander Navy Region Southeast Instruction 4101.1

Commander Navy Region Southeast Energy Management Program Instruction 4101.1

DFARS Clause 252.247-7023 Transportation of Supplies By Sea

DoD Directive 6050.16 Establishing and Implementing Environmental Standards at Overseas Installations

EM 385-1-1 U.S. Army Corps of Engineers Safety and Health Requirements

EP 1110-1-8 (Vol. 11) July 03 or latest revision) Chapter 2

US Army Corp of Engineers “Construction Equipment Ownership and Operating Expense Schedule

EXECUTIVE ORDER 13148 Greening the Government through Leadership in Environmental Management

Executive Order 13423 Strengthening Federal Environmental, Energy, and Transportation Management

FGS Final Governing Standards

NAVSTAGTMOINST

1710.10

Outdoor Recreational and Wildlife Instruction

NAVSTAGTMOINST 5090.1 Hazardous Waste Management Plan

NAVSTAGTMOINST 5090.4 Standard Operating Procedures for Landfill

NAVSTAGTMOINST 5090.7 Pollution Control Procedures for Oil and Hazardous Substances

NAVSTAGTMOINST 5090.8 Asbestos Program Management

NAVSTAGTMOINST

5100.13

Hazardous Material/Excess Hazardous Material Control and Safety Program

Amendment 0004

NAVSTAGTMOINST

Instruction 11300.3 series

GTMO Base Energy Conservation Regulation

NAVSTAGTMOINST

Instruction 4400.2B

Consolidated Hazardous Material Reutilization and Inventory Management Program.

NAVSTAGTMOINST

6242.1B

Domestic Animal Control Program

NAVFAC P-300 Management of Transportation Equipment

NAVFAC P-306 Testing and Licensing of Construction Equipment Operators Equipment operators

NAVFAC P-307 Testing and licensing of weigh handling and Construction equipment operators

NAVFAC Instruction 11330.14A, Safe Drinking Water at Naval Shore Activities

NFPA (all) National Fire Protection Association Standards

OPNAVINST 4100.5D Energy Management

Chapter 21, OPNAVINST 5090.1

OVERSEAS ENVIRONMENTAL COMPLIANCE ASHORE

OEBGD Overseas Environmental Baseline Guidance Document

OPNAV Instruction 4100.5 Series

Energy Management

OPNAVINST 6240.3 Environmental Protection Manual

P.L. 91-596 Occupational Safety and Health Act

SECNAV Instruction 4100.9A Department of the Navy (DON) Shore Energy Management UFGS 01 35 26 Unified Facilities Guide Specifications

UFC 1-201-01 Non-Permanent DOD Facilities In Support of Military Operations

DOD SEC DEF Directive Unmanned Aerial Vehicle Systems Prohibition

Attachment J-0200000-04

Forms

Description Clearance Request For Excavation Operation Form (COMNAVBASEGTMOINST 11300.4G) Contractor Hazardous Material Inventory Log (EPRCA) Contractor Crane Operating Checklist for Critical Lifts NAVFAC Contractor Incident Report WHE Accident Report (Crane and Rigging Gear)

COMNAVBASEGTMOINST 11300.4G

(DATE)

FROM: ___________________________________________ PHONE EXT.: ____________________

(ORGANIZATION)

TO: DIGGING PERMIT PROGRAM MANAGER, FMED, PUBLIC WORKS DEPARTMENT

U.S. NAVAL STATION, GUANTANAMO BAY, CUBA

SUBJ: CLEARANCE REQUEST FOE EXCAVATION OPERATION

REF: (a) COMNAVBASEGTMOINST 11300, 4G

1. PER REFERENCE (a), REQUEST THAT A CLEARANCE FOR EARTH EXCAVATION BE ISSUED FOR THE

PROJECT DESCRIBED BELOW.

A. LOCATION: _________________________________________________________________

B. TYPE OF EXCAVATION: ______________________________________________________

C. REASON: ___________________________________________________________________

D. EQUIPMENT TO BE USED: ____________________________________________________

E. DESIRED START DATE: ______________________________________________________

F. ANTICIPATED COMPLETION DATE: ___________________________________________

2. A DRAWING SHOWING THE AREA OF EXCAVATION IS ATTACHED. THE PROJECT SITE HAS ALSO BEEN

STAKED OR MARKED WITH SPRAY PAINT TO SHOW THE LIMITS OF CONSTRUCTION.

REQUESTOR NAME SIGNATURE

SERVICE ORDER TYPE:

- REGULAR AUTHORIZED BY: _________________________________________

- EMERGENCY GOVERNMENT REPRESETATIVE

Initial Report Follow-up Report Final Report

Contractor Significant Incident Report (CSIR)

1. General Information Contracting Activity:

Accident Classification:

Injury Fatality Environment Procedural Issues

Lessons Learned

Illness Property Damage

Other_______________________________

Involving:

Confined Space Equip/Mrt Ver/Mat Handling (Heavy Construction Equip.)

Hazardous Material

Crane and Rigging Equip/Mrt Ver/Mat Handling (Material Handling)

Trenching/Excavation

Diving Equip/Mrt Ver/Mat Handling (Man-Lift/Elevated Platform)

Waterfront/Marine Operations

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:

Supervisor Name (Last, First, MI) & Title:

Was the person trained to perform this activity/task?

Yes No

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):

Supervisor Name (Last, First, MI):

Witness #2: Name (Last, First, MI):

Supervisor Name (Last, First, MI):

Additional Witnesses:

Yes

No

4. Contract Information Type of Contract:

A/E BOS CLEAN Construction Design Build

FSCC FSSC

JOC RAC 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)

(List any additional witnesses on a separate sheet and attach.)

Direct Cause(s) of Accident:

Indirect Cause(s) of Accident:

Action(s) taken to prevent re-occurrence or provide on-going corrective actions:

Corrective Action Beginning Date:

Anticipated Completion Date:

Personal Protective Equipment:

Available and used Available and not used

Not Required

Not related to Mishap Wrong PPE for job

List PPE Used:

Type of Construction Equipment (Make, Model, Serial #, VIN#) Involved:

Was Hazardous Material Spilled/Released?

Please List Hazardous Material(s) Involved:

Who provided first aid or cleanup of mishap site?

Any blood-borne pathogen exposure, other than EMTs?

Who?

List OSHA and EM-385-1-1 standards that were violated:

Was site secured and witness statements taken immediately?

By Whom?

6. Injury Illness/Fatality Information Severity of Injury/Illness:

Fatality

Lost Workday Case Involving Days Away From Work

Temporary Disabillity

Recordable Workday Case Involving Restricted Duty

Permanent Total Disability Other Recordable Case

Recordable First Aid Case

Permanent Partial Disability Non-Recordable Case

No Injury

Estimated Days Lost:

Estimated Days Hospitalized:

Estimated Days Restricted Duty:

List Primary Body Part Affected:

List Other Body Part(s) Affected:

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. Causal Factors (Explain answers on supplementary sheet) Design – Design of facility, workplace, or equipment was a factor?

Inspection/Maintenance – Inspection & Maintenance procedures were a factor?

Persons Physical Condition – In your opinion, the physical condition of the person was a factor?

Operation Procedures – Operating procedures were a

Job Practices – One or more job safety/health practices not being followed when the accident occurred contributed to the accident?

Human Factors – One or more human factors, such as a person’s size or strength contributed to the accident?

Environmental Factors – Heat, cold, dust, sun, glare, etc., Chemical and Physical Agent Factors – Exposure to chemical agents, such as dust, fumes, mist, vapors, or physical agents such as noise, radiation, etc., contributed to the accident?

Office Factors – Office setting such as lifting office furniture, carrying, stooping, contributed to the accident?

Support Factors – Inappropriate tools/resources were provided to perform the task?

PPE – Improper selection, use or maintenance of PPE

Drugs/Alcohol – In your opinion, were drugs or alcohol a

Job Hazard Analysis – The lack of an adequate (IAW- EM-385-1-1 Sec 01.A) activity hazard analysis was a contributing factor.

Amendment 0004

Job Hazard Analysis – JHA was not site specific and/or did not address the type of work/operations performed when the mishap occurred.

Management – A lack of adequate supervision contributed to the accident.

Management – Inadequate information was provided at pre con meeting.

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.

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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.

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

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(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 subcontractor’s 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.).

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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 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

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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

STRUCK

BY/AGAINST

CONTACTED

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)

CAUGHT

ON/IN/BETWEEN

EXPOSED

INHALED/INGESTED/ABSORBED/EXPOS

ED TO

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:

SOURCE OF INJURY/ILLNESS

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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)

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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…