Exhibits_Part_2.pdf

PDF 2 MB Posted Sep 26, 2019

Attached to: Maintenance Services for Beech Fork Lake Federal contract opportunity
Solicitation number: W91237-19-T-0062
Issued by: Department of the Army Corps of Engineers Engineering District Huntington

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Exhibit 2

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File	Type	Posted
B.01.08_W9123719T0062-0001.pdf	PDF	Oct 17, 2019
A.03.20_PRS_BBF_(attachment_f).pdf	PDF	Sep 27, 2019
W9123719T0062.pdf	PDF	Sep 26, 2019
Exhibits_Part_3.pdf	PDF	Sep 26, 2019
Exhibits_Part_1.pdf	PDF	Sep 26, 2019

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d. Brief project description, description of work to be performed, and location;

phases of work anticipated (these will require an AHA).

3. STATEMENT OF SAFETY AND HEALTH POLICY. Provide a copy of current corporate/company Safety and Health Policy Statement, detailing commitment to providing a safe and healthful workplace for all employees. The Contractor's written safety program goals, objectives, and accident experience goals for this contract should be provided.

4. RESPONSIBILITIES AND LINES OF AUTHORITIES. Provide the following:

a. A statement of the employer's ultimate responsibility for the implementation of his SOH program;

b. Identification and accountability of personnel responsible for safety at both corporate and project level. Contracts specifically requiring safety or industrial hygiene personnel shall include a copy of their resumes. Qualifications shall include the OSHA 30- hour course or equivalent course areas as listed here:

(1) OSH Act/General Duty Clause;

(2) 29 CFR 1904, Recordkeeping;

(3) Subpart C: General Safety and Health Provisions, Competent Person;

(4) Subpart D: Occupational Health and Environmental Controls, Citations and Safety Programs;

(5) Subpart E: PPE, types and requirements for use;

(6) Subpart F: understanding fire protection in the workplace;

(7) Subpart K: Electrical;

(8 Subpart M: Fall Protection;

(9) Rigging, welding and cutting, scaffolding, excavations, concrete and masonry, demolition; health hazards in construction, materials handling, storage and disposal, hand and power tools, motor vehicles, mechanized equipment, marine operations, steel erection, stairways and ladders, confined spaces or any others that are applicable to the work being performed.

c. The names of Competent and/or Qualified Person(s) and proof of competency/qualification to meet specific OSHA Competent/Qualified Person(s) requirements must be attached. The District SOHO will review the qualifications for acceptance;

d. Requirements that no work shall be performed unless a designated competent person is present on the job site;

e. Requirements for pre-task safety and health analysis;

f. Lines of authority;

g. Policies and procedures regarding noncompliance with safety requirements (to include disciplinary actions for violation of safety requirements) should be identified;

h. Provide written company procedures for holding managers and supervisors accountable for safety.

5. SUBCONTRACTORS AND SUPPLIERS. If applicable, provide procedures for coordinating SOH activities with other employers on the job site:

a. Identification of subcontractors and suppliers (if known);

b. Safety responsibilities of subcontractors and suppliers.

6. TRAINING.

a. Requirements for new hire SOH orientation training at the time of initial hire of each new employee.

b. Requirements for mandatory training and certifications that are applicable to this project (e.g., explosive actuated tools, confined space entry, crane operator, diver, vehicle operator, HAZWOPER training and certification, PPE) and any requirements for periodic retraining/recertification.

c. Procedures for periodic safety and health training for supervisors and employees.

d. Requirements for emergency response training.

> See paragraph 9.b. below for a list of requirements that may require emergency response training.

7. SAFETY AND HEAL TH INSPECTIONS.

a. Specific assignment of responsibilities for a minimum daily job site safety and health inspection during periods of work activity: Who will conduct (e.g., SSHO, PM, safety professional, QC, supervisors, employees - depends on level of technical proficiency needed to perform said inspections), proof of inspector's training/qualifications, when inspections will be conducted, procedures for documentation, deficiency tracking system, and follow-up procedures;

b. Any external inspections/certifications that may be required (e.g., USCG).

8. ACCIDENT REPORTING. The Contractor shall identify person(s) responsible to provide the following:

a. Exposure data (man-hours worked);

b. Accident investigations, reports, and logs: Report all accidents as soon as possible but not more than 24 hours afterwards to the Contracting Officer/Representative (CO/COR). The contractor shall thoroughly investigate the accident and submit the findings of the investigation along with appropriate corrective actions to the CO/COR in the prescribed format as soon as possible but no later than five (5) working days following the accident. Implement corrective actions as soon as reasonably possible;

c. The following require immediate accident notification:

(1) A fatal injury;

(2) A permanent total disability;

(3) A permanent partial disability;

(4) The hospitalization of three or more people resulting from a single occurrence;

(5) Property damage of $200,000 or more.

9. PLANS (PROGRAMS, PROCEDURES) REQUIRED BY THE SAFETY

MANUAL. Based on a risk assessment of contracted activities and on mandatory OSHA compliance programs, the Contractor shall address all applicable occupational risks and compliance plans. Using the EM 385-1-1 as a guide, plans may include but not be limited to:

a. Layout plans (04.A.01 );

b. Emergency response plans:

(1) Procedures and tests (01.E.01);

(2) Spill plans (01.E.01, 06.A.02);

(3) Firefighting plan (01.E.01, Section 19);

(4) Posting of emergency telephone numbers (01.E.05);

(5) Man overboard/abandon ship (Section19.A.04);

(6) Medical Support. Outline on-site medical support and off- site medical arrangements including rescue and medical duties for those employees who are to perform them, and the name(s) of on-site Contractor personnel trained in first aid and CPR. A minimum of two employees shall be certified in CPR and first aid per shift/site (Section 03.A.02; 03.D);

£. Plan for prevention of alcohol and drug abuse (01.C.02);

g. Site sanitation plan (Section 02);

e. Access and haul road plan (4.8);

f. Respiratory protection plan (05.G);

g. Health hazard control program (06.A);

h. Hazard communication program (06.8.01);

i. Process Safety Management Plan (06.8.04);

j. Lead abatement plan (06.8.05 & specifications);

k. Asbestos abatement plan (06.8.05 & specifications);

I. Radiation Safety Program (06.E.03.a);

m. Abrasive blasting (06.H.01);

n. Heat/Cold Stress Monitoring Plan (06.1.02)

o. Crystalline Silica Monitoring Plan (Assessment) (06.M) ;

p. Night operations lighting plan (07.A.08);

q. Fire Prevention Plan (09.A);

r. Wild Land Fire Management Plan (09.K);

s. Hazardous energy control plan (12.A.01);

t. Critical lift Plan (16.H);

u. Contingency plan for severe weather (19.A.03);

v. Float Plan (19.F.04);

w. Site-Specific Fall Protection & Prevention Plan (21.C);

x. Demolition plan (to include engineering survey) (23.A.01);

y. Excavation/trenching plan (25.A.01 );

z. Emergency rescue (tunneling) (26.A.);

aa. Underground construction fire prevention and protection plan (26.D.01 );

bb. Compressed air plan (26.1.01);

cc. Formwork and shoring erection and removal plans (27.C);

dd. PreCast Concrete Plan (27.D);

ee. Lift slab plans (27.E);

ff. Steel erection plan (27.F.01);

gg. Site Safety and Health Plan for HTRW work (28.fil;

hh. Blasting Safety Plan (29.A.01 );

ii. Diving plan (30.A.13);

jj. Confined space Program (34.A).

10. RISK MANAGEMENT PROCESSES. Detailed project-specific hazards and controls shall be provided by an Activity Hazard Analysis (Ol.A.13) for each major phase/activity of work.

11. ABBREVIATED APP for LIMITED-SCOPE SERVICE, SUPPLY AND R&D CONTRACTS. If service, supply and R&D contracts with limited scopes are awarded, the contractor may submit an abbreviated Accident Prevention Plan.

This APP shall address the following areas at a minimum. If other areas of the EM 385-1-1 are pertinent to the contract, the contractor must assure these areas are addressed as well.

a. Title, signature, and phone number of the plan preparer.

b. Background Information to include: Contractor; Contract number; Project name; Brief project description, description of work to be performed, and location (map); The project description shall provide a means to evaluate the work being done (see AHA requirements in 01.A.13) and associated hazards involved.

Contractor's APP shall address the identified hazards involved and the control measures to be taken.

c. Statement of Safety and Health Policy detailing their commitment to providing a safe and healthful workplace for all employees.

d. Responsibilities and Lines of Authorities -to include a statement of the employer's ultimate responsibility for the implementation of his SOH program;

Identification and accountability of personnel responsible for safety at all levels to include designated site safety and health officer (SSHO) and associated qualifications. The District SOHO will review the qualifications for acceptance.

e. Training - new hire SOH orientation training at the time of initial hire of each new employee and any periodic retraining/recertification requirements.

f. Procedures for job site inspections - assignment of responsibilities and frequency.

g. Procedures for reporting man-hours worked and reporting and investigating any accidents as soon as possible but not more than 24 hours afterwards to the Contracting Officer/Representative (CO/COR). An accident that results in a fatal injury, permanent partial or permanent total disability shall be immediately reported to the Contracting Officer.

h. Emergency Planning. Employees working alone shall be provided an effective means of emergency communication. This may be cellular phone, two way radio or other acceptable means. The selected means of communication must be readily available and must be in working condition.

i. Drinking Water provisions, toilet and washing facilities.

j. First Aid and CPR training (at least two employees on each shift shall be qualified/certified to administer first aid and CPR) and provision of first aid kit (types/size).

k. Personal Protective Equipment.

(1) WORK CLOTHING - Minimum Requirements. Employees shall wear clothing suitable for the weather however minimum requirements for work shall be short-sleeve shirt, long pants (excessively long or baggy pants are prohibited) and leather work shoes. If analysis determines that safety-toed (or other protective) footwear is necessary (i.e., mowing, weed-eating, chain saw use, etc), they shall be worn.

(2) Eye and Face Protection. Eye and face protection shall be worn as determined by an analysis of the operations being performed HOWEVER, all involved in chain saw use, chipping, stump grinding, pruning operations, grass mowing, weed-eating and blowing operations shall be provided safety eyewear (Z87.1) as a minimum.

(3) Hearing Protection. Hearing protection must be worn by all those exposed to high noise activities (to include grass mowing and trimming, chainsaw operations, tree chipping, stump grinding and pruning).

(4) Head Protection. Hard hats shall comply with ANSI Z89.1 and shall be worn by all workers when a head hazard exists. At a minimum, hard hats shall be worn when performing activities identified in (2) above.

(5) High Visibility Apparel shall comply with ANSI/I SEA 107, Class 2 requirements at a minimum and shall be worn by all workers exposed to vehicular or equipment traffic.

(6) Protective Leg chaps shall be worn by all chainsaw operators.

( (7) Gloves of the proper type shall be worn by persons involved in activities that expose the hands to cuts, abrasions, punctures, burns and chemical irritants.

(8) If work is being performed around water and drowning is a hazard, PFDs must be provided and worn as appropriate.

I. Machine Guards and safety devices. Lawn maintenance equipment must have appropriate guards and safety devices in place and operational.

m. Hazardous Substances. When any hazardous substances are procured, used, stored or disposed, a hazard communication program must be in effect and MSDSs shall be available at the worksite. Employees shall have received training in hazardous substances being used. When the eyes or body of any person may be exposed to corrosives, irritants or toxic chemicals, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within 10 seconds of the worksite.

n. Traffic control shall be accomplished in accordance with DOT's MUTCD.

o. Control of Hazardous Energy (Lockout/Tagout). Before an employee performs any servicing or maintenance on any equipment where the unexpected energizing or startup of the equipment could occur, procedures must be in place to ensure adequate control of this energy.

p. Driving, working on (i.e., working with equipment/mowers) while on slopes, working from/in boats/skiffs, etc shall also be considered and dealt with accordingly.

Exhibit E

Partial Listing of Safety Requirements

Exhibit E

PARTIAL LISTING OF SAFETY AND SECURITY REQUIREMENTS

1. The following is a clarification of the Corps of Engineers' policy concerning the use of personal protective equipment for contract employees as defined in the EM 385-1-1, Safety and Health Requirements Manual.

This is not meant to be a complete review of required safety equipment, but is simply provided to answer some of the more common questions concerning our safety policy.

The items of equipment listed below should be issued to each employee or made readily available for employee's use, when the work environment requires it:

a. Safety shoes - All employees except park aids performing traffic surveys and clerical personnel are to wear hard-toe safety shoes at all times. For those not required to wear steel toed safety shoes, leather work shoes shall be worn.

b. Hard hats - Hard hats are to be worn when operating or working around equipment that lifts overhead (e.g. backhoe-end loader) or working at ground level around mowing equipment. Hard hats will not be required when operating a riding mower, unless other mowing equipment is present. Hard hats will be required during construction type activities and wildfire suppression.

c. Safety glasses or goggles - Safety glasses with side shields or goggles are to be worn when operating equipment or working around equipment that may cause harm from flying debris (e.g. weed eaters), and when using power or hand tools.

d. Welders - Full face welder's helmets are to be worn during electric arc welding operations, and appropriate shields or warning shall be given or posted to protect other persons from the flash. During oxyacetylene welding or cutting, appropriate goggles or full face shield shall be worn.

e. Gloves - The proper type gloves are to be worn when there is a danger of burns, cuts, scrapes, scratches, wood splinters, or other injury to employee's hands.

f. Ear protection - Ear plugs or muffs shall be worn when operating any device that has been determined to produce 85 decibels or greater on a time-weighted average. It is the Contractor's responsibility to determine the noise level of your equipment. Each piece of equipment that exceeds 85dB(A) rating should be labeled to indicate the need for hearing protection.

g Protective leg chaps - Protective leg chaps are to be worn when operating equipment such as a chain saw.

h. P.F.D's (Personal Flotation Device/Life Jacket) - P.F.D's are to be worn at all times when working around the water or on board watercraft.

i. Safety cans - Containers for flammable liquids shall be labeled and meet the requirements specified in Section 9.B.

j. Seat belts - Seat belts are to be worn at all times when operating, or being transported by motor vehicles and when operating mobile equipment with rollover protection.

k. Safety vests - High-visibility apparel meeting, at minimum, ANSl/ISEA 07-2004 Performance Class 2 requirements, shall be worn when employees are working along roadways.

I. Lock-Out/Tag-Out - Lock-Out/Tag-Out procedures will be used in accordance with EM385-1-1, Section 12 and in coordination with project personnel.

m. Respiratory Protection - For work involving hazardous atmospheres, Contractors will provide a written Respiratory Protection Plan, which includes training and medical clearance. Section 05.G

2. The Contractor shall conduct monthly safety meetings and weekly "tool box" safety meetings in accordance with EM 385-1-1, Safety and Health Requirements Manual. The Contractor may contact the COR about upcoming work planned, to determine appropriate subjects for the monthly safety meetings.

The Government makes no guarantee that the list of upcoming work planned, will actually be ordered nor will work ordered be restricted to said list. The Contractor shall inform the COR of the date, time, and place of the monthly safety meeting, a minimum of 7 days prior to the meeting.

3. Great emphasis will be given to the development and proper use of Activity Hazard Analysis (AHA).

When ordered, AHAs will be developed in detail, utilized during job performance, and available to employees at the job site.

4. Transporting employees and equipment to worksites:

a. Vehicles used to transport staff and equipment must be well maintained and never overloaded. Each vehicle occupant must have a seat belt available to him or her and must wear the belt.

b. Personnel and tools must be kept apart during travel. Tools and tool boxes must be secured in a manner which will prevent their causing injury in case of a sudden stop or collision.

c. Tool box lids must be securely latched or locked.

5. Contractor vehicles involved in liter pick-up along project and public roads must be equipped with an orange rooftop revolving light, a rear mounted warning sign and reflective warning tape on the bumper.

Employees performing liter pickup along public and project roads must wear High-visibility apparel meeting, at minimum, ANSl/ISEA 07-2004 Performance Class 2 requirements.

SECURITY REQUIREMENTS

1. The Contractor shall cooperate with the Government in providing for the security of Government property. Some examples of the security measures expected include:

a. Closing and locking all gates and doors which were opened to allow Contractor personnel access for work.

b. Ensure that only Government personnel or authorized Contractor personnel enter secured areas. The COR or his representative shall be informed immediately if any unauthorized persons enter a secured area.

c. Secure or maintain constant surveillance on all pilfer able items to prevent theft. Provide control to ensure that Government furnished equipment, property, or materials are utilized only for contract-purposes.

Exhibit F

Safety Forms

Activity Hazard Analysis, CELRH-2796 OSHA's Form 300 Log of Work Related Injuries and Illnesses

Accident Investigation Report, ENG-3394

ACTIVITY HAZARD ANALYSIS (AHA) , 1. DATE PREPARED (YYYYMMDDJ

Foruseofthisfonn, see EM 385-1-1: the proponent agency is CELRH-SO.

4. CONTRACT NUMBER (If Appl/cable) 5. BRIEF PROJECT DESCRIPTION

2. PROJECT NAME

3. RISK ASSESSMENT CODE (RAC Per AR 385-10 and DA Pamphlet 385-10)

6. TELEPHONE NUMBER 17. PREPARER'S E-MAIL ADDRESS 8. PREPARED BY (Last, First Ml and Tit/s) 19. PREPARER'S SIGNATURE

10. REVIEWERS COMMENTS AND RECOMMENDATIONS

11. REVIEWER'S E-MAIL ADDRESS 12. REVIEWED BY (Last, First Ml and Tdle) I 13. DATE REVIEWED (YYYYMMDD) I 14. REVIEWER'S SIGNATURE

15. ADDITTONAL COMMENTS AND RECOMMENDATIONS AS PROJECT PROGRESSED OR FUTURE ADDITIONAL SAFETY CONSIDERATIONS THAT NEED TAKEN INTO ACCOUNT

16a. RECOMMENDED PROTECTIVE CLOTHING AND EQUIPMENT m >< :::r C"

CELRH FORM 2642, MAY 2010

E •EXTREMELY HIGH RISK

H•HIGHRISK

M • MODERATE RISK

L=LOWRISK

tr~;~;~~ffit~l.Wl:ILU';:;;i!.f;,\1<(3?t':l¥J;~~~1'$lf".:'tt~~::;f;:T11

PREVIOUS EDITIONS ARE OBSOLETE.

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VERSION 1.1

I '5 N i

ACTIVITY HAZARD ANALYSIS CHECKLIST

1. Are all blocks in the top 1 /3 of the form completed including:

Project:

Date:

Job:

Estimated Starting Date:

Prepared by:

Recommended Protective Clothing and Equipment:

Reviewed by:

Page __ of __ _

Positions Assigned to do Job:

2. Does the "Job" block include the job request number and sufficiently descriptive information to understand the tasks to be performed?

3. Is all the protective equipment necessary for all phases of the work listed in PART I?

4. Are all job steps listed and numbered consecutively in Part I including if applicable but not limited to:

a. Inspection of equipment and safety gear.

b. Loading and unloading of personnel and equipment.

c. Transportation to and from the job site.

d. Setting up equipment and safety markers.

e. Performance of tasks.

f. Securing job site while it is unattended.

g. Clean-up and storage of safety gear and equipment.

5. Are all hazards associated with each job step in Part I listed in Part II opposite the appropriate job step?

Hazards may include but are not limited to:

a. Potential injuries during loading and unloading of equipment.

b. Potential injuries from improperly loaded and/or secured equipment and vehicles during transportation to and from job site.

c. Potential injuries from failure to follow defensive driving procedures or wear seat belts and shoulder harnesses to and from job site.

d. Potential electrical shock and/or fire hazards.

How to Fill Out the Log 'I1te Log of HW'k..Nda.Wl lujt~rieJ. a:-td Jll-n1t!i~l·.s i.~ u>t-<l to dmify work-ndawd injuri"" aml Hln:t~s...'K":i and tn note the exrenr. and ~en~rity of ~a(h ea:ii:c. \Vhen an incident ocoins1 u.re the Log to t'«.Ord .'>pe~-:i:fic ~fora.ib abour. what bappt>ncd and how it happened.

If your cornpany has more than one establislunem or >ite. you must keep sep:m1!e recoi-,h. for eud1 ph;'Sical kw:ation that is ~'Xpeetcd to remoin in Of"'ration for ont• yccn.r Ol longer.

We have g_i\.'en yon se..,e·ral copies -0f the

m;uiy as you need<

The Sum:mary - a separ;:i.t~ form shows the W<lrk-n•h1ted injury and ilh1ess tools for the yc-.1r in c-.M:h .;ategory. ,\t the eud of the ""'"r. count the nmu.ber <>f incidents in eath tategm·y artd transfer the totals from the l./Jg to the Summmy Then pobC the Stt!'i'!mttry in a ·.dsible location so d1at your en1ployc<."S- are a.ware of htjuries a..<td iHnttssr.s ocoi.rring in their workplat.c.

You don't post !be tog. You post only tltto Summary at the 4ttd of they.om-.

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~ ~·;i # '" n (2) (3J (4l (5) 1s)

(For safety staff only)

REPORT NO.

PERSONNEL CLASSIFICATION

GOVERNMENT

D CIVILIAN D MILITARY

EROC CODE UNITED STATES ARMY CORPS OF ENGINEERS

ACCIDENT INVESTIGATION REPORT

For use of this form, see Help Menu and USACE Supplement to AR 385-40 The proponent agency is CESO

ACCIDENT CLASSIFICATION

REQUIREMENT

CONTROL SYMBOL:

CEEC-S-8 (R2)

INJURY/ILLNESS/FATAL PROPERTY DAMAGE MOTOR VEHICLE INVOLVED DIVING

0 D FIRE INVOLVED D OTHER D D

D D FIRE INVOLVED D OTHER D D CONTRACTOR

D PUBLIC D FATAL D OTHER

D D

2. PERSONAL DATA

a. NAME (Last, First Ml.) b.AGE

f. JOB SERIES/TITLE g. DUTY STATUS AT TIME OF ACCIDENT

DON DUTY 0TDY

DOFF DUTY

3. GENERAL INFORMATION

a. DATE OF ACCIDENT b. TIME OF ACCIDENT c. EXACT LOCATION OF ACCIDENT d. CONTRACTOR'S NAME (YYYYMMDD) (Military Time) hrs.

e. CONTRACT NUMBER

D CIVIL WORKS D MILITARY

O OTHER (Specify)

f. TYPE OF CONTRACT

D CONSTRUCTION D SERVICE

ONE D DREDGE

D OTHER (Specify)

g. HAZARDOUSffOXIC WASTE

ACTIVITY

(1) PRIME

D SUPERFUND D DERP (2) SUBCONTRACTOR

0 IRP 0 OTHER (Specify)

4. CONSTRUCTION ACTIVITIES ONLY (Fill in line and corresponding code number in box from list· see help menu)

a. CONSTRUCTION ACTIVITY (CODE) b. TYPE OF CONSTRUCTION EQUIPMENT (CODE)

5. INJURY/ILLNESS INFORMATION (Include name on line and corresponding code number in box for items e, f& g ·see help menu)

a. SEVERITY OF ILLNESS/INJURY (CODE) b. ESTIMATED c. ESTIMATED DAYS d. ESTIMATED DAYS

DAYS LOST HOSPITALIZED RESTRICTED DUTY

e. BODY PART AFFECTED (CODE) g. TYPE AND SOURCE OF INJURY/ILLNESS (CODE)

PRIMARY

SECONDARY

(CODE)

f. NATURE OF ILLNESS/ INJURY (CODE) SOURCE

6. PUBLIC FATALITY (Fifi in line and correspondence code number in box ·see help menu)

a. ACTIVITY AT TIME OF ACCIDENT (CODE) b. PERSONAL FLOTATION DEVICE U E . . F xh1b1t

#I DYES D NO LJ N/A

ENG FORM 3394, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 1 of 13 Pages

7. MOTOR VEHICLE ACCIDENT

a. TYPE OF VEHICLE b. TYPE OF COLLISION c. SEAT BEL TS USED NOT USED NOT APPLICABLE

DDPICKUPNANDD AUTOMOBILE D SIDE SWIPED HEAD ON DREAR END

DD TRUCK DD OTHER (Specify) D BROADSIDED ROLL OVER D BACKING (1) FRONT SEAT D D D

D OTHER (Specify) (2) REAR SEAT D D D

8. PROPERTY MATERIAL INVOLVED

a. NAME OF ITEM b. OWNERSHIP c. AMOUNT OF DAMAGE

(1)

(2)

(3)

9. VESSEUFLOATI NG PLANT ACCIDENT (Fill in line and cotTespondence code number in box from list - see help menu)

a. ACTIVITY AT TIME OF ACCIDENT (CODE) a. ACTIVITY AT TIME OF ACCIDENT (CODE)

#I I #I I

10. ACCIDENT DESCRIPTION (Use additional paper, if necessary, see attached page 4.)

11. CAUSAL FACTOR(s) (Read instructions before completing)

a. (Explain YES answers in item 13) YES NO

DESIGN: Was design of facility, workplace or equipment a factor? D D

INSPECTION/MAINTENANCE: Were inspection & maintenance procedures a factor? D D

PERSON'S PHYSICAL CONDITION: In your opinion, was the physical condition of the person a factor? D D OPERATING PROCEDURES: Were operating procedures a factor? D D

JOB PRACTICES: Were any job safetylhealth practices not followed when the accident occurred? D D

HUMAN FACTORS: Did any human factors such as, size or strength of person, etc., contribute to accident? 0 0 ENVIRONMENTAL FACTORS: Did heat, cold, dust. sun, glare, etc., contribute to the accident? 0 0 CHEMICAL AND PHYSICAL AGENT FACTORS: Did exposure to chemical agents, such as dust, fUmes, mists, vapors or physical agents, such

D 0 as, noise, radiation, etc., contribute to accident?

OFFICE FACTORS: Did office setting such as, lifting office furniture, carrying, stooping, etc., contribute to the accident? D D SUPPORT FACTORS: Were inappropriate tools/resources proVided to properly perform the actiVity/task? D D

PERSONAL PROTECTIVE EQUIPMENT: Did the improper selection, use or maintenance of personal protective equipment contribute to the D D accident?

DRUGS/ALCOHOL: In your opinion, was drugs or alcohol a factor to the accident? D D

b. WAS A WRITIEN JOB/ACTIVITY HAZARD ANALYSIS COMPLETED FOR TASK BEING PERFORMED AT TIME OF ACCIDENT? (/fyes, D D attach a copy.)

12. TRAINING

a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK? b. TYPE OF TRAINING c. DATE OF MOST RECENT FORMAL

TRAINING (YYYYMMDD)

DYES ONO D CLASSROOM D ON JOB

13. FULLY EXPLAIN WHAT ALLOWED OR CAUSED THE ACCIDENT; I NC LU DE DIRECT AND INDIRECT CAUSES (See instruction tor definition of di"ect and indirect causes.) (Use additional paper, if necessary)

a. DIRECT CAUSE(sJ (Attach additional sheets as needed, See page 4)

b. INDIRECT CAUSE(s) (Attach additional sheets as needed, See page 5) Exhibit F

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 2of13

14. ACTION(s) TAKEN, ANTICIPATED OR RECOMMENDED TO ELIMINATE CAUSE(s)

DESCRIBE FULLY (Attach additional sheets as necessary, See page 5)

15. DATES FOR ACTIONS IDENTIFIED IN BLOCK 14.

a. BEGINNING (YYYYMMDD) I b. ANTICIPATED COMPLETION (YYYYMMDD)

c. DATE SIGNED d. TITLE OF SUPERVISOR COMPLETING REPORT e. CORPS SIGNATURE, SUPERVISOR COMPLETING REPORT

(YYYYMMDD)

c. DATE SIGNED d. TITLE OF SUPERVISOR COMPLETING REPORT e. CONTRACTOR SIGNATURE, SUPERVISOR COMPLETING REPORT

(YYYYMMDD)

f. ORGANIZATION IDENTIFIER (Division, Branch, Section, etc.,) g. OFFICE SYMBOL

16. MANAGEMENT REVIEW (1st)

a. D CONCUR b. D NONCONCUR c. COMMENTS

DATE (YYYYMMDD) TITLE SIGNATURE

17. MANAGEMENT REVIEW (2nd- Chief Operations, Construction, Engineering, etc.,)

a. D CONCUR b. D NONCONCUR c. COMMENTS

DATE (YYYYMMDD) TITLE SIGNATURE

18. SAFETY AND OCCUPATIONAL HEALTH OFFICE REVIEW

a. D CONCUR b. D NONCONCUR c. ADDITIONAL ACTIONS/COMMENTS

DATE (YYYYMMDD) TITLE SIGNATURE

19. COMMAND APPROVAL

COMMENIS

DATE (YYYYMMDD) COMMANDER SIGNATURE Exhibit F

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 3of13 Pages

10. ACCIDENT DESCRIPTION (Continuation)

13a. DIRECT CAUSE(s) (Continuation)

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 4of13 Pages

13b. INDIRECT CAUSE(s) (Continuation)

14. ACTION(s) TAKEN, ANTICIPATED, OR RECOMMENDED TO ELIMINATE CAUSE(s) (Continuation)

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 5of 13 Pages

GENERAL Complete a separate report for each person who was injured, caused, or contributed to the accident (excluding uninjured personnel and witnesses).

Use of this form for reporting USAGE employee first-aid type injuries not submitted to the Office of Workers' Compensation Programs (OWCP,I shall be at the discretion of the FOA commander. Please type or print legibly. Appropriate items shall be marked with an "X" in box( es). If additional space is needed, provide the information on a separate sheet and attach to the completed form. Ensure that these instructions are forwarded with the completed report to the designated management reviewers indicated in sections 16 and 17.

INSTRUCTIONS FOR SECTION 1 - ACCIDENT CLASSIFICATION

(Mark All Boxes That Are Applicable)

a. GOVERNMENT. Mark "CIVILIAN" box if accident involved government civilian employee; mark "MILITARY'' box if accident involved U.S. military personnel.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in any government ciVilian employee injury, illness, or fatality that requires the submission of OWCP Forms CA-1 (injury), CA-2 (illness) or CA-6 (fatality) to OWCP; mark if accident resulted in military personnel lost-time or fatal injury or illness.

(2) PROPERTY DAMAGE- Mark the appropriate box if accident resulted in any damage of $1000 or more to government property (including motor vehicles).

(3) VEHICLE INVOLVED- Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are marked.

(4) DIVING ACTIVITY- Mark ifthe accident involved an in-house USACE diving actMty.

b. CONTRACTOR.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in any contractor lost-time injury/illness or fatality.

(2) PROPERTY DAMAGE - Mark the appropriate box if accident resulte.d in any damage of $1000 or more to contractor property (including motor vehicles).

(3) VEHICLE INVOLVED- Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are marked.

(4) DIVING ACTIVITY - Mark if the accident involved a USAGE Contractor diving activity.

c. PUBLIC.

(1) INJURY /ILLNESS/FATALITY - Mark. if accident resulted in public fatality or permanent total disability. (The "OTHER" box will be marked when requested by the FOA to report an unusual non-fatal public accident that could result in claims against the government or as otherwise directed by the FOA Commander).

( (2) VOi D SPACE - Make no entry.

(3) VEHICLE INVOLVED- Mark if accident resulted in a fatality to a member of the public and involved a motor vehicle, regardless of whether "INJURY/ILLNESS/ FATALITY" is marked.

(4) VOID SPACE- Make no entry.

INSTRUCTIONS FOR SECTION 2 • PERSONAL DATA

a. NAME- (MANDATORY FOR GOVERNMENT ACCIDENTS. OPTIONAL AT THE DISCRETION OF THE FOA COMMANDER FOR CONTRACTOR AND PUBLIC ACCIDENTS). Enter last name, first name, middle initial of person involved.

b. AGE- Enter age.

c. SEX- Mark appropriate box.

d. SOCIAL SECURITY NUMBER - (FOR GOVERNMENT PERSONNEL ONLY) Enter the social security number (or other personal identification number if no social security number issued).

e. GRADE - (FOR GOVERNMENT PERSONNEL ONLY) Enter pay grade. Example: 0-6; E-7; WG-8; WS-12; GS-11; etc.

f. JOB SERIES/TITLE- For government civilian employees enter the pay plan, full series number, and job title, e.g., GS-0810/Clvil Engineer. For military personnel enter the primary military occupational SPecialty (PMOS), e.g., 15A30or11G50. For contractor employees enter the job title assigned to the injured person, e.g., carpenter, laborer, surveyor, etc.

g. DUTY STATUS- Mark the appropriate box.

(1) ON DUTY - Person was at duty station during duty hours or person was away from duty station during duty hours but on official business at time of the accident.

(2) TDY - Person was on official business, away from the duty station and with travel orders at time of accident. Line-of-duty investigation required.

(3) OFF DUTY - Person was not on official business at time of accident.

h EMPLOYMENT STATUS - (FOR GOVERNMENT PERSONNEL ONLY) Mark the most appropriate box. If "OTHER''" ' ' .• " e employment status . ofthe person. Exhibit F

ENG FORM 3394/NST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 6of13 Pages

INSTRUCTION FOR SECTION 3 - GENERAL INFORMATION

a. DATE OF ACCIDENT - Enter the month, day, and year of accident.

b. TIME OF ACCIDENT- Enter the local time of accident in military time. Example: 1430 hrs (not 2:30 p.m.).

c. EXACT LOCATION OF ACCIDENT- Enter facts needed to locate the accident scene. (installation/project name, building number, street, direction and distance from closest landmark, etc).

d. CONTRACTOR NAME

(1) PRIME - Enter the exact name (title offirni) of the prime contractor.

(2) SUBCONTRACTOR - Enter the name of any subcontractor involved in the accident.

e. CONTRACT NUMBER- Mark the appropriate box to identify if contract is civil works, military, or other: if "OTHER" is marked. specify contract appropriation on line provided. Enter complete contract number of prime contract, e.g., DACW 09-85-C-0100.

f. TYPE OF CONTRACT - Mark appropriate box. NE means architecUengineer. If "OTHER" is marked. specify type of contract on line provided.

g. HAZARDOUSffOXIC WASTE ACTIVITY (HT'vV) - Mark the box to identify the HTW activity being performed atlhe lime of the accident. For Superfund. DERP.

and Installation Restoration Program (/RP) HTW activities include accidents that occurred during inventory, predesign, design, and construction. For the purpose of accident reporting, DERP Formerly Used DoD Site (FUDS) activities and IRP activities will be treated separately. For Civil Works O&M HTW activities mark the "OTHER" box.

INSTRUCTIONS FOR SECTION 4 - CONSTRUCTION ACTIVITIES

a. CONSTRUCTION ACTIVITY - Select the most appropriate construction activity being performed at time of accident from the 1.ist below. Enter the activity name and place the corresponding code number identified in the box.

CONSTRUCTION ACTIVITY LIST 13. CARPENTRY

14. ELECTRICAL

1. MOBILIZATION 15. SCAFFOLDING/ACCESS

2. SITE PREPARATION 16. MECHANICAL

3. EXCAVATIONffRENCHING 17. PAINTING

4. GRADING (EARTHWORK) 18. EQUIPMENT/MAINTENANCE

5. PIPING/UTILITIES 19. TUNNELING

6. FOUNDATION 20. WAREHOUSING/STORAGE

7. FORMING 21. PAVING

8. CONCRETE PLACEMENT 22. FENCING

9. STEEL ERECTION 23. SIGNING

10. ROOFING 24. LANDSCAPING/IRRIGATION

11. FRAMING 25. INSULATION

12. MASONRY 26. DEMOLITION

b. TYPE OF CONSTRUCTION EQUIPMENT - Select the equipment involved in the accident from the list below. Enter the name and place the corresponding code number identified in the box. If equipment is not included below, use code 24, "OTHER". and write in specific type of equipment.

CONSTRUCTION EQUIPMENT 12. DUMP TRUCK (HIGHWAY)

13. DUMP TRUCK (OFF HIGHWAY)

1. GRADER 14. TRUCK (OTHER)

2. DRAGLINE 15. FORKLIFT

3. CRANE (ON VESSEL/BARGE) 16. BACKHOE

4. CRANE (TRACKED) 17. FRONT-END LOADER

5. CRANE (RUBBER TIRE) 18. PILE DRIVER

6. CRANE (VEHICLE MOUNTED) 19. TRACTOR (UTILITY)

7. CRANE (TOWER) 20. MANLIFT

8. SHOVEL 21. DOZER

9. SCRAPER 22. DRILL RIG

10. PUMP TRUCK (CONCRETE) 23. COMPACTORNIBRATORY ROLLER

11. TRUCK (CONCRETE/TRANSIT MIXER) 24. OTHER

INSTRUCTIONS FOR SECTION 5 - INJURY/ILLNESS INFORMATION

a. SEVERITY OF INJURY/ILLNESS - Reference paragraph 2-10 of USACE Supplement 1 to AR 385-40 and enter code and description from list below.

NOi

FAT

PTL

PPR

LWD

NLW

RFA

NRI

NO INJURY

FATALITY

PERMANENT TOTAL DISABILITY

PERMANENT PARTIAL DISABILITY

LOST WORKDAY CASE INVOLVING DAYS AWAY FROM WORK

RECORDABLE CASE WITHOUT LOST WORKDAYS

RECORDABLE FIRST AID CASE

NON-RECORDABLE INJURY

b. ESTIMATED DAYS LOST- Enter the estimated number of workdays the person will lose from work.

ENG FORM 3394/NST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE.

Page 7 of 13 Pages

c. ESTIMATED DAYS HOSPITALIZED - Enter the estimated number of workdays the person will be hospitalized.

d. 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.

e. BODY PART AFFECTED- Select the most appropriate primary and when applicable, secondary body part affected from the list below. Enter body part name on line and place the corresponding code letters identifying that body part in the box.

GENERAL BODY AREA CODE BODY PART NAME HEAD, EXTERNAL H1 EYE EXTERNAL

H2 BOTH EYES EXTERNAL

ARM/WRIST AB ARM AND WRIST H3 EAR EXTERNAL

AS ARMOR WRIST H4 BOTH EARS EXTERNAL

HC CHIN

TRUNK, EXTERNAL B1 SINGLE BREAST HF FACE

MUSCULATURE B2 BOTH BREASTS HK NECK/THROAT

B3 SINGLE TESTICLE HM MOUTH/LIPS

B4 BOTH TESTICLES HN NOSE

BA ABDOMEN HS SCALP

BC CHEST

BL LOWER BACK KNEE KB BOTH KNEES

BP PENIS KS KNEE

BS SIDE LEG, HIP, ANKLE, LB BOTH LEGS/HIPS/ ANKLES/

BU UPPER BACK BUTIOCKS

BW WAIST BUTIOCK LS SINGLE LEG/HIP/ ANKLE/BUTTOCK

BZ TRUNK OTHER

HAND MB BOTH HANDS

HEAD, INTERNAL C1 SINGLE EAR INTERNAL MS SINGLE HAND

C2 BOTH EARS INTERNAL

C3 SINGLE EYE INTERNAL FOOT PB BOTH FEET

C4 BOTH EYES INTERNAL PS SINGLE FOOT

CB BRAIN

cc CRANIAL BONES TRUNK, BONES R1 SINGLE COLLAR BONE co TEETH R2 BOTH COLLAR BONES

CJ JAW R3 SHOULDER BLADE

CL THROAT, LARYNX R4 BOTH SHOULDER BLADES

CM MOUTH RB RIB

CN NOSE RS STERNUM (BREAST BONE)

CR THROAT, OTHER RV VERTEBRAE (SPINE; DISC)

CT TONGUE RZ TRUNK BONES OTHER

CZ HEAD OTHER INTERNAL

SHOULDER SB BOTH SHOULDERS

ELBOW EB BOTH ELBOWS SS SINGLE SHOULDER

ES SINGLE ELBOW

THUMB TB BOTH THUMBS

FINGER F1 FIRST FINGER TS SINGLE THUMB

F2 BOTH FIRST FINGERS

F3 SECOND FINGER TRUNK, INTERNAL V1 LUNG, SINGLE

F4 BOTH SECOND FINGERS ORGANS V2 LUNGS, BOTH

F5 THIRD FINGER V3 KIDNEY, SINGLE

F6 BOTH THIRD FINGERS V4 KIDNEYS, BOTH

F7 FOURTH FINGER VH HEART

F8 BOTH FOURTH FINGERS VL LIVER

TOE G1 GREAT TOE VR REPRODUCTIVE ORGANS

G2 BOTH GREAT TOES vs STOMACH G3 TOE OTHER w INTESTINES G4 TOES OTHER vz TRUNK, INTERNAL; OTHER

f. NATURE OF INJURY/ILLNESS - Select the most appropriate nature of injury/illness from the list below. This nature of injury/illness shall correspond to the primary body part selected in 5e, above. Enter the nature of injury/illness name on the line and place the corresponding CODE letters in the box provided.

• The injury or condition selected below must be caused by a specific incident or event which occurred during a single work day or shift.

GENERAL NATURE TU BURN, SCALD, SUNBURN

CATEGORY CODE NATURE OF INJURY NAME Tl TRAUMATIC SKIN DISEASES/

*TRAUMATIC INJURY OR

DISABILITY

GENERAL NATURE