N6945020R0031_SectionJ.pdf

SECTION J

DOCUMENTS, EXHIBITS, AND OTHER ATTACHMENTS

TABLE OF CONTENTS

ATTACHMENT NUMBER ATTACHMENT TITLE

J-0200000-01 Definitions And Acronyms J-0200000-02 Wage Determinations J-0200000-03 Directives, Instructions and References J-0200000-04 Invoicing Procedures J-0200000-05 Forms J-0200000-06 Service Provider Information J-0200000-07 Asset Information J-0200000-08 Specification Information J-0200000-09 Characteristic Meter Reading J-0200000-10 NAVFAC Maximo Data Reporting J-0200000-11 Navfac Maximo System Access Procedures J-0200000-12 Government-Furnished Property, Materials, Equipment, and Services J-0200000-13 Commander, Navy Region Southeast Instruction 4101.1 J-0200000-14 Contractor Hazardous Material Inventory Log J-0200000-15 Exhibit Line Item Numbers

ATTACHMENT J-0200000-01

DEFINITIONS AND ACRONYMS

Definition Description 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.

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 Construction is the erection, installation, or assembly of a new facility; the expansion, extension, alteration, conversion, or replacement of an existing facility; or the relocation of a material/equipment from one installation to another. Construction includes equipment installed in and made a part of such facilities, and related site preparation, excavation, filling, and landscaping, or other land improvement. Davis-Bacon wages shall be paid for all construction work estimated at 32 hours or more.

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.

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.

Conventional Estimate Any labor-hour estimate for work tasks that cannot be estimated either directly from Means or using work content comparison Procedures. Such estimates will be well documented, be based on an acceptable maintenance estimating standard, and will be the total labor-hours and materials required to perform the specific task.

Davis-Bacon Work Within the indefinite quantity portion of the contract, each Task Order for maintenance, repair, equipment installation or minor construction/alteration work with total labor of 32 hours or more shall be subject to Davis-Bacon Act.

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.

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.

Fire Watch Any time welding is taking place in the vicinity of combustible material, a second person trained in fire extinguishing equipment use shall stand by with fire extinguishing equipment nearby in the event a fire breaks out. The fire watch shall be maintained for at least one-half hour after the completion of the welding to detect and extinguish possible smoldering fires. The Contractor will comply with the requirements of the most current version of the Army Corps of Engineers Safety and Health Manual, EM 385-1-1.

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:

$10,000.00 + ($10,000.00 x 10%) = $10,100.00

The Government will compensate the Contractor for the required parts and materials and not the total amount shown in Schedule of Non-Recurring 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.

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.

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.

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".

Monthly On-Site Labor Report

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

Performance Assessment

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

Performance Assessment Representative (PAR)

That individual designated by the KO to be responsible for the monitoring of Contractor performance.

Pleasing Appearance An appearance similar to the new finished appearance with only minor, unobjectionable deterioration resulting from normal wear and tear.

Productivity Factor A comparison of contractor work force performance to Means standards. Each bidder's productivity should be reflected in the total adjusted Means hour unit prices.

REGARDLESS OF THE EFFECTS OF ANY PRODUCTIVITY FACTOR, THE

SUCCESSFUL BIDDER SHALL COMPLY WITH ALL WAGE

DETERMINATIONS AND LABOR LAWS.

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 Control (QC) A method used by the Contractor to control the quality of goods and services produced.

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.

Service Work All service work estimated under 32 hours is subject to the Service Contract Act, and all service work estimated at 32 hours or more is subject to Davis-Bacon Act.

Site Miami, West Palm, and Dania Beach are each there own site and a SSHO/QC (this can be the same person) shall be present for all construction work and or work over $25,000.

Standing Job Orders Standing job orders are recurring maintenance work that is performed on a routine, periodic, or continual basis, and requires some degree of planning, estimating, and scheduling by the Contractor.

Task Order A Task Order (DD Form 1155) is a document prepared and issued to the Contractor by the KO to order indefinite quantity work.

Travel Time Time expended between the shop and the job site; waiting for vehicle; getting in and out of vehicle; loading and carrying a tool box; vehicle travel; unloading; walking from vehicle to job site; opening and closing doors; walking up and down stairs; using elevators; and access to secure or control areas.

Work Content Comparison

Work content comparison is a method of comparing a task that is not specifically defined in the Means Task Time Standards to a very similar task that is defined in the Means Task Time Standards.

Work Order (WO) A WO (NAVFAC 9-11014/21) is a document issued to the Contractor by the KO that requests the accomplishment of "Service Call Work".

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 price includes all indirect and direct costs associated with performing work. The price includes the Contractor’s hourly composite trade wage, adjusted to allow for workforce productivity;

costs for pre-expended bin materials, union agreements, crew sizes, hand tools, 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, and profit. Additionally, time for job preparation, safety standby personnel, and similar indirect labor elements are included.

Acronym Title ACO Administrative Contracting Officer BW Biweekly CDR Contract Discrepancy Report CIA Controlled Industrial Area CMMS Computerized Maintenance Management System COR Condition of Readiness

CSR

DBH Diameter at Breast Height DoD Department of Defense 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 GFE Government-furnished Equipment GFF Government-furnished Facilities GFM Government-furnished Materials GPWS Guide Performance Work Statements HCA Head Contracting Agency ICP Integrated Contingency Plan IDIQ Indefinite Delivery Indefinite Quantity IPM Integrated Pest Management IPMIS Integrated Pest Management Information System IPMP Integrated Pest Management Plan KO Contracting Officer LAN Local Area Network M Monthly MSDS Material Safety Data Sheets NAVFAC Naval Facilities Engineering Command NMCI Navy Marine Corps Intranet NOSC Navy-On-Scene Coordinator PAP Performance Assessment Plan PAR Performance Assessment Representative PAW Performance Assessment Worksheet PEO Program Executive Officer PM Project Manager PRCSP Permit Required Confined Space Program PWS Performance Work Statement Q Quarterly QC Quality Control SC Security Clearances SM Semimonthly SPAR Senior Performance Assessment Representative TE Technical Exhibit VIQ Variation in Quantity WBS Work Breakdown Structure

ATTACHMENT J-0200000-02

WAGE DETERMINATIONS

The following wage determinations are applicable to this contract, the current versions of which will be incorporated into the contract as the options are exercised. The wage determinations in their entirety can be found at beta.sam.gov.

For services covered by Service Contract Labor Standards (formerly known as the Service Contract Act of 1965):

Wage Determination No.: 2015-4536 Revision No.: 15 Date Of Revision: 12/23/2019 Area: Florida County of Broward

Wage Determination No.: 2015-4544 Revision No.: 14

Area: Miami-Dade County in Florida

Wage Determination No.: 2015-4574 Revision No.: 12

Area: Florida County of Palm Beach

Wage Determination No: 1986-0452 Revision No: 45 Date Of Revision: 02/03/2020 Elevator Services Area: Florida Counties of Broward, Collier, Dade, Hendry, Martin, Monroe, Palm Beach

For services covered by Construction Wage Rate Requirements (formerly known as the Davis-Bacon Act):

General Decision Number: FL20200197 02/21/2020 Construction Type: Building County: Broward County in Florida

General Decision Number: FL20200215 02/28/2020

County: Miami-Dade County in Florida

General Decision Number: FL20200220 02/21/2020

County: Palm Beach County in Florida

ATTACHMENT J-0200000-03

DIRECTIVES, INSTRUCTIONS, AND REFERENCES

Reference Title

CNRSEINST 4101.1 Navy Region Southeast Energy Management Program

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

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

OPNAVINST 5090.1B Environmental and Natural Resources Manual http://www.wdol.gov/

OPNAVINST 5100.23F Navy Occupational Safety and Health Program Manual

UFGS 01 35 26 Unified Facilities Guide Specifications

ATTACHMENT J-0200000-04

INVOICING PROCEDURES

For WAWF invoicing requirements, see clause 252.232-7006 WIDE AREA WORKFLOW PAYMENT

INSTRUCTIONS.

A proper invoice must include the following items:

(1) Name and address of the contractor

(2) Invoice date and invoice number (Invoices for the firm fixed price portion should not be dated earlier than the first of every month)

(3) Contract number (delivery order number if applicable)

(4) Description of services performed

(5) Name and address of contracting office to which payment request is being sent Contracting Officer NAVFAC SE, FEAD Key West NOSCs

NAVFAC ATLANTIC

6506 HAMPTON BLVD

NORFOLK, VA 23508-1278

UIC N62470

(6) Name, title, phone number, and email address of person to notify in the event of a defective invoice

ATTACHMENT J-0200000-05

FORMS

1) Contract Significant Incident Report (CSIR)

2) Contractor Crane Operating Checklist For Critical Lifts

3) WHE Accident Report (Crane and Rigging Gear)

4) Crane And Rigging Gear Near Miss Report

Samples of all forms are provided below.

Initial Report Follow-up Report Final Report

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 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

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

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

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:

Additional Witnesses:

Yes

Yes No

4. Contract Information Type of Contract:

A/E BOS CLEAN Construction Design Build

FSCC FSSC JOC RAC Service

Other_______________________________ A/E BOS

CLEAN Construction Design Build FSCC FSSC JOC RAC Service

Contract Number & Title:

Industrial Group & Industrial Type:

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

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:

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 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?

Yes

No 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?

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 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?

Yes No Yes

• 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 factor?

• 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 factor?

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

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

Yes No Yes

No

• 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.

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

(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 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.

THOGEN 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

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

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?

(2) INSPECTION/MAINTENANCE - Did inadequately or improperly maintained equipment, tools, workplace, etc., create or worsen any hazards that contributed to the accident? Would better equipment, facility, work site or work activity inspections have helped avoid the accident?

(3) PERSONS PHYSICAL CONDITION - Do you feel that the accident would probably not have occurred if the employee was in “good” physical condition? If the person involved in the accident had been in better physical condition, would the accident have been less severe or avoided altogether? Was overexertion a factor?

(4) OPERATION PROCEDURES - Did lack of or inadequacy within established operating procedures contribute to the accident? Did any aspect of the procedures introduce any hazard to, or increase the risk associated with the work process? Would establishment or improvement of operating procedures reduce the likelihood of similar accidents?

(5) JOB PRACTICES - Were any of the provision of the Safety and Health Requirements Manual (EM 385-1-1) violated? Was the task being accomplished in a manner which was not in compliance with an established job hazard analysis or activity hazard analysis? Did any established job practice (including EM 385-1-1) fail to adequately address the task or work process? Would better job practices improve the safety of the task?

(6) HUMAN FACTORS - Was the person under undue stress (either internal or external to the job)?

Did the task tend toward overloading the capabilities of the person: i.e., did the job require tracking and reacting to many external inputs such as displays, alarms, or signals? Did the arrangement of the workplace tend to interfere with efficient task performance? Did the task require reach strengths, endurance, agility, etc., at or beyond the capabilities of the employee? Was the work environment ill-adapted to the person? Did the person need more training, experience, or practice in doing the task?

Was the person inadequately rested to perform safely?

(7) ENVIRONMENTAL FACTORS - Did any factors such as moisture, humidity, rain, snow, sleet, hail, ice, fog, cold, heat, sun temperature changes, wind, tides, floods, currents, terrain; dust, mud, glare, pressure changes, lighting, etc., play a part in the accident?

(8) CHEMICAL AND PHYSICAL AGENT FACTORS - Did exposure to chemical agents (either single shift exposure or long-term exposure such as dusts, fibers, (asbestos, etc.), silica, gases (carbon, monoxide, chlorine, etc.), mists, steam, vapors, fumes, smoke, other particulates, liquid or dry chemicals that are corrosive, toxic, explosive or flammable, by-products of combustion or physical agents such as noise, ionizing radiation, non-ionizing radiation (UV radiation created during welding, etc.) contribute to the accident/incident?

(9) OFFICE FACTORS - Did the fact that the accident occurred in an office setting or to an office worker have a bearing on its cause? For example, office workers tend to have less experience and training in performing tasks such as lifting office furniture. Did physical hazards within the office environment contribute to the hazard?

(10) SUPPORT FACTORS - Was the person using an improper tool for the job? Was inadequate time available or utilized to safely accomplish the task? Were less than adequate personnel resources (in terms of employee skills, number of workers, and adequate supervision) available to get the job done properly? Was funding available, utilized and adequate to provide proper tools, equipment, personnel, site preparation, etc.

(11) PERSONAL PROTECTIVE EQUIPMENT - Did the person fail to use appropriate personal protective equipment (gloves, eye protection, hard-toed shoes, respirator, etc) for the task or environment? Did protective equipment provided or worn fail to provide adequate protection from the hazard(s)? Did lack of or inadequate maintenance of protective gear contribute to the accident?

(12) DRUGS/ALCOHOL - Is there any reason to believe the person’s mental or physical capabilities, judgment, etc., were impaired or altered by the use of drugs or alcohol? Consider the effects of prescription medicine and over the counter medications as well as illicit drug use. Consider the effect of drug or alcohol induced “hangovers”.

(13) JOB/ACTIVITY HAZARD ANALYSIS - Was a written Job/Activity Analysis completed for the task being performed at the time of the accident? If one was made, did it address the hazard adequately or does it need to be updated? If none made, will one be made? These may also need to be addressed in the Corrective Actions Taken section. Mark the appropriate box. If one was made, attach a copy of the analysis to the report.

(14) MANAGEMENT - Did the lack of supervisor or management support play a part in the mishap?

Mark the appropriate box.

SECTION - 8 OSHA INFORMATION - Complete this section if applicable

SECTION 9 - REPORT PREPARER

Providing a completed CSIR to the Contracting Officer is the PRIME CONTRACTOR’S RESPONSIBILITY. Enter the name, date of report, title, employer, phone number and signature of person completing the accident report and provide it to the Contracting Officer, or his representative, responsible for oversight of that contractor activity. NOTE! If prepared by other than the Prime Contractor, a person employed by the Prime Contractor must sign that they have reviewed and concur with the report and it’s findings (e.g. company owner, project supervisor/foreman, Safety Officer, etc.).

ATTACHMENT "A"

CONTRACTOR CRANE OPERATING CHECKLIST FOR CRITICAL LIFTS YES NO

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

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

3 Is the crane level and on firm ground?

4 Are outriggers required?

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

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

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

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

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

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

11 Is the lift swing path clear of obstructions?

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

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

14 Are personnel prevented from entering the load fall zone?

15 Is the crane operator's attention diverted?

16 Are proper signals being used at all times?

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

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

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

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

21 Is the lift a critical lift?

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

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

Contractor Name (Print Legibly):

Contractor Name (Signature):

Location: Date:

CRANE AND RIGGING GEAR ACCIDENT REPORT

Accident Category: Crane Accident Rigging Gear Accident From:

UIC:

To: Navy Crane Center Bldg. 491 NNSY Portsmouth, VA 23709

Activity:

Report No:

Crane No:

Category:

Accident Date:

Time: hrs:

Category of Service: SPS GPS Crane Type:

Crane Manufacturer:

Was Crane/Rigging Gear Being Used in SPS: Yes

Was Crane/Rigging Gear Being Used in a Complex Lift/Critical Non-Crane Rigging Operation:

Location:

Weather:

Crane Capacity:

Hook Capacity:

Weight of Load on hook:

Fatality or Permanent Disability? Yes

N

Material/Property Cost Estimate:

Reported to NAVSAFECEN? Yes

N

Accident Type:

Personal Injury Overload Derail Damaged Rigging Gear

Load Collision Two Blocked Dropped Load Damaged Crane

Crane Collision Damaged Load Other:

Specify

Cause of Accident:

Improper Operation Equipment Failure Inadequate Visibility

Improper Rigging Switch Alignment inadequate Communication

Track Condition Procedural Failure Other:

Specify

Chargeable to:

Crane Walker Rigger Operator

Maintenance Management/Supervision Other:

Specify

Crane Function:

Travel Hoist Rotate Luffing Telescoping Other N/A Is this accident indicative of a recurring problem? Yes No If yes, list Accident Report Nos :

ATTACH COMPLETE AND CONCISE SITUATION DESCRIPTION AND CORRECTIVE/PREVENTIVE

ACTIONS TAKEN AS ENCLOSURE (1). Include probable cause and contributing factors. Assess damages and define responsibility. For equipment malfunction or failure, include specific description of the component and the resulting effect or problem caused by the malfunction or failure List immediate and long term corrective/preventive

Preparer:

Phone:

E-mail:

Code:

Date:

Concurrences: (Include Code, Signature and Date)

Certifying Official (Crane Accident Only):

CRANE AND RIGGING GEAR ACCIDENT REPORT INSTRUCTIONS

This form is designed for fax transmission without a cover page or by e-mail and, with enclosures and signatures, shall be the official document. Electronic submission will be accepted without signatures but the names of the preparer, concurring personnel, and certifying official (for crane accidents only) shall be filled in. The e-mail address is m_nfsh_ncc_accident@navy.mil. The fax number is (757) 967-3808.

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

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

3. Activity: The naval activity where the accident took place.

4. Report No.: The activity assigned accident number (e.g., 95-001).

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

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

7. Accident Date: The date the accident occurred.

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

9. Category of Service: Check the applicable service (SPS as defined by NAVSEA 0989-030-7000).

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

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

12. SPS: Was the crane or rigging gear being used in an SPS lift?

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

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

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

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

17. Hook Capacity: The capacity of the hook involved in the accident at the max radius of the operation, if applicable.

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

19. Fatality or Permanent Disability?: Check yes or no.

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

21. Reported to NAVSAFECEN?: Self-explanatory.

22. Accident Type: Check all that apply.

23. Cause of Accident: Check all that apply.

24. Chargeable to: Check all that apply.

25. Crane Function: Check all functions in operation at time of accident. Check N/A if a rigging gear accident.

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

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

28. Preparer: Self-explanatory.

29. Concurrences: Self-explanatory.

30. Certifying Official (Crane Accidents Only): Self-explanatory.

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

32. Background and Detailed Description: Provide the relevant background in a descriptive timeline of preconditions leading up to the event, as well as a detailed description of the event.

33. Corrective Actions: List all short term and long term corrective actions that are taken to prevent recurrence of the incident. Short Term Corrective Actions are those actions taken that will allow return to work in short time frame.

Long Term actions are more ‘programmatic’ in nature and typically include: process revision, changes in training, ‘mistake proofing’, etc.

CRANE AND RIGGING GEAR NEAR MISS REPORT

Near Miss Category: Crane Near Miss Rigging Gear Near Miss

From:

UIC:

To: Navy Crane Center Bldg 491 NNSY Portsmouth, VA 23709 Fax (757) 967-3808 nfsh_ncc_accident@navy.mil

Activity: Report No:

Crane/Equipment No: Category: Near Miss Date: Time:

hrs

Category of Service:

SPS GPS Crane /Equipment Type:

Crane/Equipment Manufacturer:

Location: Weather:

Crane/Equipment Capacity: Hook Capacity: Weight of Load on Hook:

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

If yes, list report numbers:

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

Preparer:

Phone and email

Code Date

CRANE AND RIGGING GEAR NEAR MISS INSTRUCTIONS

This form is designed for fax transmission without a cover page or by e-mail and, with enclosures and signatures, shall…