SOW Attachment (5) Activity Hazard Analysis Form.docx
DOCX document 25 KB Posted
- Attached to
- NSWCPD Bldg. 4 - VRF Heat Pump Installation
- Solicitation number
- N6449825R4054
About this file
The document is an Activity Hazard Analysis (AHA) form template for a federal contract, designed to systematically identify and assess workplace risks. The form provides a structured matrix for evaluating potential hazards by calculating Risk Assessment Codes (RAC) based on probability and severity, ranging from Extremely High Risk (E) to Low Risk (L). Key requirements include periodic review of the AHA at monthly supervisory safety meetings, updating the document when procedures or hazards change, and mandating that each employee review and sign the AHA before starting work. The form is part of a solicitation (N6449825R4054) by the Naval Surface Warfare Center, Philadelphia Division for a HVAC installation project at Building 4 in the Philadelphia Naval Business Center.
The related federal contract opportunity involves procuring and installing a two-pipe variable refrigerant flow (VRF) heat pump system, including an outdoor unit, four ceiling cassette units, associated controls, refrigerant and drain piping, electrical wiring, and related accessories. The project is a small business set-aside with a 135-day completion timeline, to be performed between 0700-1600 Monday through Friday. The acquisition will use a negotiated, best-value procurement process with initial technical and price proposals submitted simultaneously. Performance and payment bonding are required, and the government reserves the right to award the contract based on initial proposals without further discussions.
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Text version
EM385-1-1 (30NOV14) UFGS 103526 11/15
Activity Hazard Analysis (AHA)
Contractor Name ( Performing the Work):
Overall Risk Assessment Code (RAC) (Use highest code )
Foreman Signature (Pe r forming the Wor k):
AHA Prepared by (Name/Title):
| Activity/Work Task: |
| Risk Assessment Code (RAC) Matrix |
AHA Signature Log #
Probability
| Contract Number: |
| Severity |
| Frequent |
| Likely |
| Occasional |
| Seldom |
| Unlikely |
| Date Prepared: |
| Catastrophic |
| E |
| E |
| H |
| H |
| M |
| Project Location: |
| Critical |
| E |
| H |
| H |
| M |
| L |
| PRIME CONTRACTOR SECTION: REV IEW ED BY: SIGNATUR E REQUIRED |
| Marginal |
| H |
| M |
| M |
| L |
| L |
| SSHO Signature: |
| Negligible |
| M |
| L |
| L |
| L |
| L |
| QC Manager Signature: |
| Step 1: Review each Hazard with identified |
"Controls". Determine RAC (see above).
Prime Superintendent Signature:
RAC CHART
| Notes: |
| Probability: Likelihood the activity will cause a Mishap (Near Miss, Incident, or Accident). Identify as Frequent, Likely, Occasional, Seldom or Unlikely |
E = Extremely High Risk
| Identify as Catastrophic, Critical, Marginal, or Negligible |
| H = High Risk |
Step 2: Identify the RAC (probability vs. severity) as E, H, M, or L for each "Hazard" on AHA.
Annotate the overall highest RAC at the top of the AHA
M= Moderate Risk
L = Low Risk
| Job Steps (Work Sequences) |
| Specific Anticipated Hazards |
| Controls |
| RAC |
| Job Steps (Work Sequences) |
| Specific Anticipated Hazards |
| Controls |
| RAC |
| Equipment to be used |
| Training Requirements & Competent or Qualified Personnel Name(s) |
| Inspection Requirements |
UFGS 013526 11/15 1.9 Government reserves the right to require the Contractor to revise and resubmit the AHA if it f ails to ef f ectively identif y the w ork sequences; specific anticipated hazards, site conditions, equipment, materials, personnel and the control measures to be implemented.
UFGS 013526 1.9.1 Review the AHA list periodically (at least monthly) at supervisory safety meetings, update w hen procedures, scheduling or hazards change.
UFGS 013526 1.9.2 Each employee perf orming w ork...must review the AHA and sign a signature log f or that AHA prior to starting w ork. The SSHO must maintain a signature log on site f or every AHA
Standard SOW Attachment (5) Activity Hazard Analysis Form
File details come from the government source that posted it. Updated .