Attachment_2_-_17-R-0002_-_Scope_of_Work_(Apendix_D).pdf

Activity Hazard Analysis (AHA) Activity/Work Task: Scaffolding Erection Overall Risk Assessment Code (RAC) (Use highest code) M

Project Location: 1010 W. Snow Blind Street, Ft. Nowhere, Alaska Risk Assessment Code (RAC) Matrix Contract Number: W921CM-09-M0001

Severity Probability

Date Prepared: Frequent Likely Occasional Seldom Unlikely

Prepared by (Name/Title): Someone Else, SO Specialist Catastrophic E E H H M Critical E H H M L

Reviewed by (Name/Title): Super Safetyman/SOH Manager Marginal H M M L L Negligible M L L L L

Notes: (Field Notes, Review Comments, etc.)

Crane set-up and use are on a separate AHA.

Step 1: Review each “Hazard” with identified safety “Controls” and determine RAC (See above)

“Probability” is the likelihood to cause an incident, near miss, or accident and identified as: Frequent, Likely, Occasional, Seldom or Unlikely. RAC Chart “Severity” is the outcome/degree if an incident, near miss, or accident did occur and identified as: Catastrophic, Critical, Marginal, or Negligible

E = Extremely High Risk H = High Risk

Step 2: Identify the RAC (Probability/Severity) as E, H, M, or L for each “Hazard” on AHA. Annotate the overall highest RAC at the top of AHA.

M = Moderate Risk L = Low Risk

Job Steps Hazards Controls RAC General Safety Requirements all Steps

Exposure to Cold or Hot Weather

Dehydration

**Add additional potential hazards for general on site safety requirements. **

The above hazards are not all inclusive and the Site Safety and Health Officer including the Quality Assurance Representative (QAR) shall review the AHAs

Minimum Personal Protective Equipment Dress:

• Long Pants

• Shirts with Sleeves

• Hardhat

• Safety Shoes (Steel/Composite Toe Preferred)

• Safety Glasses (Potential Eye Hazard Areas)

Weather:

• Wear appropriate clothing for hot or cold weather.

(List specific clothing or refer to Company quick sheet, SOPs, plan, etc. for specific details)

• Sun block

• Lip balm

Dehydration:

• Drink at least ½ liter of water an hour.

• Refer to Company quick sheet, SOPs, plan, etc. for specific details on heat stress signs and symptoms.

L

1.. Set-Up

1. Back Strain from uploading or moving scaffold components.

2. Lacerations on hands

3. Scaffold failure due to damaged scaffolding components.

4. Struck by mechanized equipment.

**See above “Notes box”**

5. Loss of load.

6. Stuck by suspended loads or material.

7. Electrical Shock

8. Scaffold failure due to improper set-up

1a. Utilize proper lifting techniques.

1b. Size up load before lifting.

1c. Ask for help when lifting heavy items more than 50 lbs.

2. Wear leather gloves.

3a. INSPECT all scaffolding components defects or damage such as cracks, excessive rust, metal fatigue, unauthorized repairs, bent tubing or frame, etc.

• Frames

• Tubing

• Base Plates

• Locking Pins

• Access Ladder

• Planking (Wood or Metal)

• Cross Braces

3b. REMOVE damaged or defective scaffold components immediately.

3c. Attach tag or label “DO NOT USE” on scaffold component.

4a. ALWAYS maintain eye contact with operator of equipment.

4b. NEVER stand behind (Blind Spots) equipment.

4c. NEVER stand near unloading or moving of scaffold components.

4d. ONLY qualified operators shall operate equipment.

5a. Secure loads from displacement with ropes, cables, chains, etc.

before movement.

5b. Ensure load to be lifted is secured, balanced, etc.

5c. Keep hands, fingers, or other body parts away from pinch points.

6a. NEVER stand underneath suspended loads.

6b. Use taglines to control loads when elevated.

7a. Check above for overhead power lines.

7b. NEVER erect scaffolding within 10 ft (3 m) of overhead power lines.

Refer to EM 385-1-1, Table 11-1 for Minimum Clearance from Energized Overhead Electrical Lines 7c. NEVER string or hang temporary power cords, wires, etc. on metal scaffolding. Consult with Safety Officer.

8a. Inspect ground conditions (level and firm).

8b. Stable base is necessary for proper scaffold assembly.

8c. Scaffold shall be tied into structure when the scaffold height exceeds four times the minimum scaffold base dimension.

M

2. Assembly of Scaffolding 1 Fall from Elevated Heights

2. Scaffold Failure

3. Back Strain

4. Lacerations on hands

1a. 100 percent fall protection required during assembly.

1b. Personnel shall not be exposed to unprotected sides or falls greater than 6 ft (1.8 m).

1c. Scaffolding shall not exceed 14 inches (35.5 cm) from the planking to the face of the building or structure.

1d. Scaffolding more than 14 inches (35.5 cm) from the planking to the face of the building or structure shall be guardrails and/or the use of personal fall protection.

1e. Personnel shall be tied off to a vertical lifeline with a rope grab during assembly of scaffolding.

1f. Vertical lifeline shall be secured to an anchor point of at least 5,000 lbs (2,267.9 kg) per individual.

Develop a site specific Fall Protection Plan IAW EM 385-1-1, para 21.C.01 and refer to EM 385-1-1, Section 21.

2a. See diagram below and refer EM 385-1-1, Section 22 for specific requirements (i.e., toe boards, guard rails, safe access, etc.)

2b. Scaffolding shall be assembled on mud sills and base plates.

2c. Mud sills shall be at least 2 times the size of the base plates to disperse total weight of scaffolding.

2d. Scaffolding shall be plumb and level.

2e. Working levels shall be fully decked and/or planked.

2f. Planking shall extend over the end supports not less than 6 in (30.4 cm), 2g. Planking shall be secured, supported, or braced to prevent excessive spring or deflection and secured to prevent loosening, tipping, or displacement. Use of tie wire, cleats, etc. are options.

2h. Planking shall overlapped at least 12 inches (30.4 cm) or secured from movement.

2i. Scaffold shall be capable of supporting without failure at least 4 times the maximum anticipated loads.

2j. Scaffolding shall be all required cross, horizontal, or diagonal braces to secure vertical members laterally.

2k. Scaffolding shall be rigid.

3a. Utilize proper lifting techniques.

3b. Size up load before lifting.

3c. Ask for help when lifting heavy items more than 50 lbs.

4. Wear leather gloves.

2. Assembly of Scaffolding (Diagram)

3. Use of Scaffolding

1. Scaffold Failure

2. Falls from Heights

3. Slips, Trips, or Fall

1a. DO NOT overload more than 4 times the maximum load rating.

1b. DO NOT attached hoists or other material lifting devices without Safety Officer approval.

1c. Scaffolding shall be tied into building whenever height of the scaffold exceeds 4 times the minimal base. Refer to EM 385-1-1, para 22.B.09 for additional guidance.

1d. Scaffold usage shall cease during high winds or severe inclement weather conditions.

2a. Guardrails shall be used as primary fall protection. Guard rails shall installed IAW EM 385-1-1, para 21.B.02.

2b. Securing of personal fall protection devices to scaffolding is prohibited.

2c. Personnel shall have fall protection whenever above 6 ft (1.8 m).

2d. Climbing of braces or cross bracing is prohibited.

2e. Safe access (ladder) shall be provided.

2f. Personnel shall not stand on mid rails.

2g. Ladders shall extend at least 3 ft (0.9 m) past the work area.

3. Walking surfaces on and around scaffolding shall be clear of debris.

3. Use of Scaffolding

4. Disassembling of Scaffolding

1 Fall from Elevated Heights

The scaffold checklist is not all inclusive of the safety requirements for the assembly, use, and disassembly of scaffolding. Competent Person onsite for work platform safety shall review EM 385-1-1 Safety and Health Requirements Manual, Host Nation safety laws, contract specifications, manufacture specifications, etc. as additional guidance or information for work platform safety.

1a. 100 percent fall protection required during disassembly.

1b. Personnel shall not be exposed to unprotected sides or falls greater than 6 ft (1.8 m).

1c. Personnel shall be tied off to a vertical lifeline with a rope grab during assembly of scaffolding.

1d. Vertical lifeline shall be secured to an anchor point of at least 5,000 lbs (2,267.9 kg) per individual.

Develop a site specific Fall Protection Plan IAW EM 385-1-1, para 21.C.01 and refer to EM 385-1-1, Section 21.

4. Disassembling of Scaffolding

2. Back Strain

3. Lacerations on hands

2a. Utilize proper lifting techniques.

2b. Size up load before lifting.

2c. Ask for help when lifting heavy items more than 50 lbs.

3. Wear leather gloves.

Equipment to be Used Training Requirements/Competent or Qualified Personnel name(s) Inspection Requirements

Scaffold components Hammers Mud sills Full body harness Lanyard Lifeline Fall protection anchor points Float Crane Electric Hand Tools (Battery type) Portable Generator 5 Ma GFCIs Power Cords Ladders First Aid Kit

Competent/Qualified Personnel:

Mr. Someone Else – CP/Scaffolding Mr. Supersafety Man – QP/First Aid and CPR Mr. Work Man – QP/First Aid and CPR Mr. Fall Safety – CP/Fall Protection Mr. Shocker Cord – QP/Electrical Mr. Lift Boom – QP/Crane Operator

Training Requirements:

Scaffold Assembly Fall Protection Inspection of Work Platforms Heat or Cold Hazards Daily/Monthly safety toolbox meetings

Inspect scaffold components prior to use

Inspect scaffold daily (Use Checklist)

Inspect level and plumb of scaffoldings during erection and daily when in use.

Daily Housekeeping of work areas and scaffolding

Inspect PPE to include fall protection harnesses and lanyards prior to use.

Inspect fall protection anchor points.

Inspect crane IAW manufacture instructions.

Inspect power cord sets prior to use.

Inspect temporary power panel box, circuit breakers, grounding, etc. at least monthly.

Inspect first aid kit at least monthly.

Daily site safety inspections by SSHO and CQC.

Monthly Record of Work-Related Injuries/Illnesses & Exposure USACE PRIME CONTRACTOR US Army Corps of Engineers

Month May, 2009

In accordance with the provisions of EM 385-1-1, Section 01 Program Management, Paragraph 01.D Accident Reporting and Recording, sub-paragraphs 01.D.05, you (the Prime Contractor) shall provide a monthly record of all exposure and accident experience incidental to the work (this includes exposure and accident experience of the Prime Contractor and its sub-contractor(s)). As a minimum, these records shall include exposure work hours and a record or occupational injuries and illneses that include the data elements listed below.

Definitional criteria for each data element is found in 29 CFR Part 1904. If the maintenance of OSHA 300 Logs are required by OSHA, most of this information can be obtained from those logs. If data on log provided below is revised after it is submitted to USACE, Contractor shall provide a revised report to the GDA. You must complete the USACE ENG Form 3394, Report of Accident Investigation Report for all recordable accidents. If you're not sure whether a case is recordable, call your local Safety and Occupational Health Office for help.

USACE Command

Contractor Name

Contract Number

Project Title

City & State

USACE Office

Los Angeles District

Freeman's Funny Farm

W912PP-07-C-0010

RMS Training Contract

Litchfield Park, AZ 85340

Flagstaff Project Office

Totals:

Exposure Hours

Month:

Year To Date:

12,899 hours

59,665 hours

Certification of Record

Date:Signature:

Name of Person Submitting Record: Kevin Walker

Contractor

Labor Classification

P rim e/ S ub co nt ra ct or

Age

G en de r

Date Employee began work

Date of Injury or onset of illness

Where the event occured

Describe the injury or illness Death

Days Away From Work

Job Transfer or restriction

Other record-able cases

On Job transfer or restriction

(days)

Away from work

(days)

In ju ry

S ki n D is or de r

R es pi ra to ry

C on di tio n

P oi so ni ng

H ea rin g

Lo ss

A ll ot he r ill ne ss es

Number of Days

No accidents reported

0 0 0 0 0 0 0 0 0 0 0 0 e5eccjad Text Box SAMPLE FORM From USACE RMS/QCS System

Month May, 2009

Contractor

Trade

P or S

Current Period

Year to Date

Death Cases

Days Away from Work

Cases

Transfer or Restriction

Cases

Other Reportable

Cases

Days Away from Work

Job Transfer

Days Injuries

Skin Disorder

Respiratory Conditions

Poisoning Hearing

Loss All Other Illnesses

Lost Time Frequency

Rate

Contractor

DART

Rate

Contractor Day

Count

Exposure Hours Number of Cases Number of Days Number of Injuries / Illnesses Rates

Freeman's Funny Farm Prime Contractor

P 1,359 6,886 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

ATL, Inc.

Materials Testing

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Aero Automatic Sprinkler Co.

Fire Protection-Systems

S 306 848 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Aero Construction Co Fencing

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Affordable Fire & Safety Fire Protection-Systems

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

American Fence Fencing

S 0 282 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Arizona Custom Millwork Cabinetry/Casework

S 650 832 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Benham Enterprises, Inc; DBA: Tucson Restaurant Equipment &

Furnishings S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Bureau of Indian Aff S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Bureau of Indian Affairs S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Charles Court Constr Specialities

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Claridge Products & Equipment Specialities

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Commercial Enterprises Insulation-Buildings

S 4,258 25,993 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Concrete Structures, Inc Concrete

S 1,259 2,516 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Contract Decor, Inc.

Furnishings

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Core Slab - Albuquer Concrete

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Coreslab Structures - PHX Concrete

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Cornell Metro PHX Doors, Steel

S 6 6 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Dial Mechanical Plumbing

S 150 2,332 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0 e5eccjad

Month May, 2009

Contractor

Trade

P or S

Current Period

Year to Date

Death Cases

Days Away from Work

Cases

Transfer or Restriction

Cases

Other Reportable

Cases

Days Away from Work

Job Transfer

Days Injuries

Skin Disorder

Respiratory Conditions

Poisoning Hearing

Loss All Other Illnesses

Lost Time Frequency

Rate

Contractor

DART

Rate

Contractor Day

Count

Exposure Hours Number of Cases Number of Days Number of Injuries / Illnesses Rates

Exterior Systems Furnishings

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

FCI Constructors, In Prime Contractor

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Falcon Contracting Pavement Marking

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Farwest Pump Plumbing

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Frank Redmond and As Food Service Equipment

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

G & G Enterprises Masonry

S 0 87 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Hark Drilling Concrete

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Howard Electrical Electrical

S 1,488 7,587 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Hufcor/Arizona, Inc.

Furnishings

S 0 238 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

J.E.P., Inc.

Specialities

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

KTI Tile, Inc.

Ceramic Tile

S 1,380 2,320 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Kadee Industries, Inc.

Furnishings

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Kebko Architectural Signage Signage Interior/Exterior

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

L.PH Bolander & Sons Furnishings

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

M & K Mechanical

HVAC

S 450 3,422 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Maggart & Associates Cathodic Protection

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Mudslingers Concrete

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Nations Gas Technologies Plumbing

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Norcon Industries Furnishings

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0 e5eccjad

Month May, 2009

Contractor

Trade

P or S

Current Period

Year to Date

Death Cases

Days Away from Work

Cases

Transfer or Restriction

Cases

Other Reportable

Cases

Days Away from Work

Job Transfer

Days Injuries

Skin Disorder

Respiratory Conditions

Poisoning Hearing

Loss All Other Illnesses

Lost Time Frequency

Rate

Contractor

DART

Rate

Contractor Day

Count

Exposure Hours Number of Cases Number of Days Number of Injuries / Illnesses Rates

Northland Surveying Surveying

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Otis Elevator Elevator/Conveying Equip

S 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

PDI Pest Control Pest/Termite Control

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Partitions & Accessories Toilet Partitions/Access

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Pena Acoustics Acoustic Ceiling

S 339 648 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Phoenix Fabricators, Inc.

Tanks/Tank Covers

S 0 40 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Power Line Technolog Electric Special Systems

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Progressive Roofing Roofing

S 0 2,012 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

R. E. Nelson Earthwork

S 272 1,083 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

RTR Paving Asphalt Paving

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Rigid Building Syste Pre-Engineered Buildings

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Robert Cohen Co., LL Floor Coverings

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

S & H Steel Steel Joists/Decks

S 244 641 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

San Juan Glass Windows/Glazing

S 0 504 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Sky Design Concepts Windows/Glazing

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Steel Dor of Phoenix Doors, Steel

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Sunstate Installations, Inc.

Furnishings

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

TAB Technology, Inc.

Mechanical

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Tri-Hurst Construction Pre-Engineered Buildings

S 0 460 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0 e5eccjad

Month May, 2009

Contractor

Trade

P or S

Current Period

Year to Date

Death Cases

Days Away from Work

Cases

Transfer or Restriction

Cases

Other Reportable

Cases

Days Away from Work

Job Transfer

Days Injuries

Skin Disorder

Respiratory Conditions

Poisoning Hearing

Loss All Other Illnesses

Lost Time Frequency

Rate

Contractor

DART

Rate

Contractor Day

Count

Exposure Hours Number of Cases Number of Days Number of Injuries / Illnesses Rates

USACE

Sub-Contractor

S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

VWR International LL Cabinetry/Casework

S 0 51 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Western Technologies QC Testing Lab

S 66 200 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Wholesale Floors Floor Coverings

S 672 672 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.0 0.0

Totals:

12,899 59,665 0 0 0 0 0 0 0 0 0 0 0 0 e5eccjad

Month Year

City

Describe The Case

(B1) (B2) (B3) (C) (D) (F)

Classify the caseIdentify the person

State

Contract Number

USACE Command

Project Title

Check the "injury" column or choose

Contractor Name

Monthly Record of Work-Related Injuries/Illnesses & Exposure

In accordance with the provisions of EM 385-1-1, Section 01 Program Management, Paragraph 01.D Accident Reporting and Recording, sub-paragraphs 01.D.05, you (the Prime Contractor) shall provide a monthly record of all exposure and accident experience incidental to the work (this includes exposure and accident experience of the Prime Contractor and its sub-contractor(s). As a minimum , these records shall include exposure work hours and a record of occupational injuries and illnesses that include the data elements listed below. Definitional criteria for each data element is found in 29 CFR Part 1904. If the maintenance of OSHA 300 Logs are required by OSHA, most of this information can be obtained from those logs. If data on log provided below is revised after it is submitted to USACE, Contractor shall provide a revised report to the GDA. You must complete the USACE ENG Form 3394, Report of Accident Investigation Report for all recordable accidents. If you're not sure whether a case is recordable, call your local Safety and Occupational Health Office for help.

USACE PRIME CONTRACTOR

(A) (E)

US Army Corps of Engineers

Enter the number of days the injured or ill worker Using these categories, check ONLY the most

USACE Office Overseeing Work

(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)

0 0 0 0 0 0 0 0 0 0 0 0 Type of Contract (Choose One):

Construction Opn & Main. Civil Works Eng. Services Military Programs Dredging Other Rsch. & Dev.

Emerg. Opns.

Other

Date of injury or onset of illness

On job transfer or restriction (days)

Away from work (days)

In ju ryOther record-able cases

Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill (e.g. Second degree burns on right forearm from acetylene torch) j y one type of illness:

Certification of Record Name of Person Submit. RecordFUDS

(mo./day)

FUSRAP

IRP

Year to Date

Days away from work

Signature

Pr im e or

S ub

(P o r S

Company Name Ag e

G en de r Where the event occurred (e.g. Loading dock north end)Date

Employee Began

Work on Job

Covered by Contract

Job Title (e.g., Welder)

Sk in

D is or de r

R es pi ra to ry

C on di tio n

Po is on in g

H ea rin g

Lo ss

(M)

Job transfer or restriction j was:

Remained at work g g , serious result for each case:

Al l o th er

Ill ne ss es

Date

Exposure Hours Month

___ of ___Page

Death

Ordinance/Expl. Cleanup Environmental Other

For Government Use Only TYPE OF WORK ACTIVITY (Choose One):

Environmental Remed.

Superfund

Year

US Army Corps of Engineers

Establishment information

Establishment name

Street

Number of Cases City State Zip

Industry description (e.g., Manufacture of motor truck trailers) Total number of deaths Total number of cases with days away from work

Total number of cases with job transfer or restriction

Total number of other recordable cases

Standard Industrial Classification (SIC), if known (e.g., SIC 3715) 0 0 0 0

(G) (H) (I) (J) or

Number of Days

Total days of job transfer or restriction

Total days away from work

0 0

(K) (L)

Employment information

Total number of…

(M) Annual average number of employees

(1) Injury

(4) Poisoning

(2) Skin Disorder

(5) Hearing Loss

0 Total hours worked by all employees last year

(3) Respiratory Condition 0 (6) All other illnesses 0

Using the Record, count the individual entries you made for each category. Then write the totals below, making sure you've added the entries from every page of the record. If you had no cases write "0". This summary is a cummulative record of the injury/illness experience for the year

Injury and Illness Types

North American Industrial Classification (NAICS) if known (e.g. 336212)

USACE Summary of Contractor Work-Related Injuries and Illnesses Review the Record o verify that the entries are complete & accurate before completing this summary

Month Submitted

Form 16-1

FORM 16-1

Certificate of Compliance for LHE and Rigging

This form is applicable to all Contractor Load Handling Equipment (LHE) and Rigging Gear being brought onto the project site and applies to all cranes, derricks and any other hoisting equipment used to lift suspended loads.

This certificate shall be signed by an official of the company that provides LHE/cranes and rigging gear for any application under this contract.

Contracting Officer’s Point of Contact:

(Government Designated Representative)

Phone #:

Prime Contractor/Phone #:

Contract Number:

SSHO/QC:

Phone #:

LHE Manufacturer/Type/Capacity:

LHE Operator(s) Name(s):

I certify that:

1. The above noted LHE and all rigging gear conform to the EM 385-1-1, applicable OSHA regulations (host country regulations in foreign countries) and applicable ASME standards.

2. The operator(s) noted above has been trained, qualified and designated in accordance with the requirements in Section 16, EM 385-1-1 for the operation of the above noted LHE.

3. The operator(s) noted above has been trained not to bypass safety devices during LHE operations.

4. The operator(s), rigger(s) and company official (staff) are aware that immediate notification to the GDA of any incident or accident involving this equipment is required.

Company Official Signature:

Date:

Company Official Name/Title:

Post on Crane/LHE.

(In Cab and Contractor’s Office for each LHE brought onto USACE Project/Property)

CESO Form A-02 MAR 15

Form A-02 U.S. Army Corps of Engineers

Accident Prevention Plan Checklist

Date of Inspection

Location (Plant or Facility) Contract Number

Contractor Name Project Name

Inspector Name (Print) Inspector Signature

This checklist serves as a guide only, it does not replace or eliminate the need to comply with the requirements set forth in Engineering Manual 385-1-1, Safety and Health Requirements Manual, dated 30 Nov 2014. The references included in this checklist correspond to the applicable sections of EM 385-1-1.

Item Description Yes No N/A Remarks (Any NO or N/A item)

a. Signature sheet

1. Includes the name, title, signature, telephone number, and qualifications of the Plan Preparer (Qualified person, i.e. corporate safety staff person, QC)

2. Includes the name, title, signature, telephone number, and qualifications of the Plan Approver (e.g. owner, company president, regional vice president) (HTRW activities require approval of a Certified Industrial Hygienist, a Certified Safety Professional may approve the plan for operations involving UST removal where contaminants are known to be petroleum, oils, or lubricants).

3. Includes the name(s), title(s), signature(s), telephone number(s), and qualifications for Plan Concurrence (provide concurrence of other applicable corporate and project personnel (contractor)) (e.g. Chief of Operations, Corporate Chief of Safety, Corporate Industrial Hygienist, project manager or superintendent, project safety professional, project QC.)

b. Background information

1. Includes the Contractor Name.

2. Includes the Contract Number.

3. Includes the Project Name.

4a. Includes the Brief Project Description.

4b. Includes a Discription of the Work to be Performed.

4c. Includes the Location of the Project (map).

4d. Includes the Equipment to be Used.

4e. Includes the Anticipated High Risk Activities.

5. Includes the Major Phases of Work Anticipated.

(Within these major phases of work identified, activities [includes Definable features of Work (DFOWs) and tasks] to be performed that will require an AHA shall be specifically highlighted. This information can then be used by QC, QA and Safety personnel to track AHA submittals. The AHAs for these activities, tasks of DFOWs are NOT submitted at this time (AHAs created/submitted at this time would not be activity-specific as they are intended to be). > See Sections 01.A.14 and 01.A.15.)

Accident Prevention Plan Checklist (cont’d)

Item Description Yes No N/A Remarks (Any NO or N/A item)

c. Statement of Safety and Health Policy.

1. Provide a copy of current corporate/company Safety and Health Policy Statement, detailing commitment to providing a safe and healthful workplace for all employees. (In addition to the corporate policy statement, a copy of the corporate safety program may provide a portion of the information required by the accident prevention plan.)

2. Includes Contractor’s written safety program goals.

3. Includes Contractor’s written safety program objectives.

4. Includes the Contractor Accident Experience (Copy of OSHA 300 Forms, or equivalent documentation).

d. Responsibilities and Lines of Authority.

1. Includes statement of the employer’s ultimate responsibility for the implementation of his SOH program for his own employees, all sub-contractors and all others on the worksite (includes the strict enforcement of the program).

2. Includes the identification and accountability of personnel responsible for safety and health at both the corporate and project level – including their resumes. Qualifications shall be in accordance with Section 01.A.17. (Only official OSHA 30-Hour cards will be accepted or, if equivalent training is provided, appropriate instructor qualifications.)

3. Includes equivalent training to the OSHA 30-Hour classes is being presented as qualification, the training shall cover, as a minimum, the areas discussed in Appendix A, Section 3.d.3.(a-d).

4. Includes the names of Competent (CP) and/or Qualified Person(s) (QP) and proof of competency/qualification to meet specific OSHA CP/QP requirements. (Must include copies of proof of CP/QP).

5. Includes requirements and details of the employer’s Risk Management Process. (USACE uses the Activity Hazard Analysis (AHA) as part of a total risk management process. Contractors and other individual employer’s may use the AHAs or their own version [Job Safety Analyses (JSAs), Job Hazard Analyses (JHAs), or similar Risk Management assessment tools]. These documents are considered equivalent to, and acceptable substitutes for, the USACE’s AHA provided the data collected is the same as that required by the AHA.)

6. Includes requirements for initial activity-specific AHAs to be submitted and accepted at preparatory meetings, prior to work being performed;

7. Includes requirements that no work by the Contractor shall be performed unless a designated Competent Person/SSHO is present on the job site.

8. Includes policies and procedures regarding non-compliance with safety requirements (to include disciplinary actions for violation of safety requirements).

9. Lines of authority.

10. Includes written company procedures for holding managers and supervisors accountable for safety.

Item Description Yes No N/A Remarks (Any NO or N/A item)

e. Subcontractors and Suppliers.

1. Includes the list of subcontractors and suppliers.

(If not known at the time of initial APP submittal, the contractor shall include the following statement in their initial APP: “The subcontractors for the following DFOWs/activities are not known at this time, but additional information will be submitted to the APP for acceptance prior to the start of any activities listed”)

2. Includes safety responsibilities of subcontractors and suppliers.

f. Training

1. Includes requirements for new hire SOH orientation training at the time of initial hire of each new employee.

2. Includes 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.

3. Includes procedures for periodic safety and health training for supervisors and employees.

4. Includes the requirements for emergency response training.

g. Safety and Health Inspections

1. Includes specific assignment of responsibilities for a minimum daily jobsite SOH inspection during periods of work activity.

1a. Includes the name(s) of individual(s) responsible for conducting safety inspections. (e.g., PM, safety professional, QC, supervisors, employees)

1b. Includes proof of inspector's training / qualifications.

1c. Indicates when inspections will be conducted.

1d. Indicates procedures for documentation. (Furnished sample forms upon which inspections will be recorded.)

1e. Indicates deficiency tracking system and follow-up procedures.

2. Includes any external inspections / certifications which may be required. (e.g., US Coast Guard)

h. Mishap Reporting and Investigation

1. The plan identifies how, when, and who shall complete the Exposure data (man-hours worked).

2a. The plan identifies how, when, and who shall complete mishap investigations, reports, and logs. (The contractor shall report, thoroughly investigate, and analyze all mishaps occurring incidentally to an operation, project or facility for which this manual is applicable.)

2b. The plan identifies how, when, and who shall make immediate notification of major mishaps. (Mishaps shall be reported as soon as possible but not more than 24 hours afterwards to the KO/COR.)

2c. Includes how, when, and who will provide notice to the KO/COR when corrective actions are completed. (Implement corrective actions as soon as reasonably possible.)

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

(1)Include a project-specific compliance plan, as applicable to the work being performed, and as identified below. The plans shall incorporate project-wide procedures to control hazards to which the employees of all project employers may be exposed.

(2) These procedures shall be coordinated with all project employers and shall include project-specific, project-wide emergency response and evacuation procedures, PPE requirements, recordkeeping and reporting requirements, and training requirements.

(3) The plans shall be prepared prior to the start of any work activities on the job site (as much as the information can be known at that point in time). The plans shall be updated throughout the life of the project to include changes in personnel, equipment, conditions, etc. Additional revisions shall be incorporated as necessary to reflect changing site conditions, construction methods, personnel roles and responsibilities and construction schedules.

(4) No activity (DFOW) shall be started on site until the APP is revised and submitted to the GDA for acceptance, with the site-specific plans, programs and procedures required to complete the project.

Item Description Yes No N/A Remarks (Any NO or N/A item)

i. Plans (Programs, Procedures, Assessments, and Evaluations) required by the Safety Manual

1. Fatigue Management Plan (01.A.20)

2. Emergency Plans (01.E):

(a) Procedures & Test (01.E.01)

(b) Spill Plans (01.E.01, 06.A.02)

(c) Fire Fighting Plan (01.E.01; 19.A)

(d) Posting of Emergency Telephone Numbers (01.E.05)

(e) Man overboard/abandon ship (19.A.04)

(f) Plan for prevention of alcohol and drug abuse (01.C.02 & Specs)

3. Site Sanitation/Housekeeping Plan (02.B)

4. Medical Support Agreement. 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 (03.A.01, 03.A.03)

5. Blood-borne Pathogen Program (03.A.05)

6. Exposure Control Plan (03.A.05)

7. Automatic External Defibrillator (AED) Program (03.B.04)

8. Site Layout Plan (04.A)

9. Access/Haul Road Plan (04.B)

10. Hearing Conservation Program (05.C)

11. Respiratory Protection Plan (05.G)

12. Health Hazard Control Program (06.A)

13. Hazard Communication Program (06.B.01)

14. Process Safety Management Plan (06.B.04)

15. Lead Compliance Plan (06.C.02 & Specifications)

16. Asbestos Abatement Plan (06.C.03 & Specifications)

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, programs, procedures (assessments and evaluations), may include but not be limited to:

Item Description Yes No N/A Remarks (Any NO or N/A item)

i. Plans (Programs, Procedures) continued.

17. Radiation Safety Program (06.F)

18. Abrasive Blasting Plan (06.I)

19. Heat Stress Monitoring Plan (HSMP) (06.J.02)

20. Cold Stress Monitoring Plan (CSMP) (06.J.04)

21. Indoor Air Quality Management Plan (06.L)

22. Mold Remediation Plan (06.L.04)

23. Chromium (VI) Exposure Evaluation (06.M)

24. Crystalline Silica Assessment (06.N.02)

25. Lighting Plan for Night Operations (07.A.06)

26. Traffic Control Plan (08.C.05)

27. Fire Prevention Plan (09.A.01)

28. Wild Land Fire Management Plan (09.L)

29. Arc Flash Hazard Analysis (11.B)

30. Assured Equipment Grounding Control Program (AEGCP), (11.D.05, Appendix E)

31. Hazardous Energy Control Program and Procedures (12.A.01)

32. Standard Pre-Lift Plan – LHE (16.A.03)

33. Critical Lift Plan – LHE (16.H)

34. Naval Architectural Analysis – LHE (Floating) (16.L)

35. Floating Plant Inspection and Certification (19.A.01)

36. Severe Weather Plan for Marine Activities (19.A.03)

37. Emergency Plan for Marine Activities (19.A.04)

38. Man Overboard/Abandon Ship Procedures (19.A.04)

39. Float Plan for Launches, Motorboats, Skiffs (19.F.04)

40. Fall Protection and Prevention Plan (21.D)

41. Demolition/Renovation Plan (to include engineering survey) (23.A)

42. Rope Access Work Plan (24.H)

43. Excavation/Trenching Plan (25.A.01)

44. Fire Prevention and Protection Plan for Underground Construction (26.D.01)

45. Compressed Air Work Plan for Underground Construction (26.I.01)

46. Erection and Removal Plan for Formwork and Shoring (27.C)

47. Precast Concrete Plan (27.D)

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, programs, procedures (assessments and evaluations), may include but not be limited to:

Item Description Yes No N/A Remarks (Any NO or N/A item)

i. Plans (Programs, Procedures) continued.

48. Lift-slab Plans (27.E)

49. Masonry Bracing Plan (27.F.01)

50. Steel Erection Plan (28.B)

51. Explosives Safety Site Plan (ESSP) (29.A)

52. Blasting Plan (29.A; 26.J)

53. Dive Operations Plan (30.A.14, 30.A.16)

54. Safe Practices Manual for Diving Activities (30.A.15)

55. Emergency Management Plan for Diving (30.A.18)

56. Tree Felling/Maintenance Program (31.A.01)

57. Aircraft/Airfield Construction Safety & Phasing Plan (CSPP) (32.A.02)

58. Aircraft/Airfield Safety Plan Compliance Document (SPCD) (32.A.02)

59. Site Safety and Health Plan (HTRW) (33.B)

60. Confined Space Entry Procedures (34.A.05)

61. Confined Space Program (34.A.06)

j. Risk Management Processes (AHAs). Detailed project-specific hazards and controls shall be provided by Activity Hazard Analysis for each activity (DFOW). No work will begin on an activity (DFOW) until the initial AHA has been accepted by the GDA addressing the project-specific hazards. (01.A.14 & 01.A.15) Note: USACE uses the Activity Hazard Analysis (AHA) as part of a total risk management process. Contractors and other individual employer’s may use the AHAs or their own version [Job Safety Analyses (JSAs), Job Hazard Analyses (JHAs), or similar Risk Management assessment tools].

These documents are considered equivalent to, and acceptable substitutes for, the USACE’s AHA provided the data collected is the same as that required by the AHA.

Remarks:

Other Remarks:

Site Safety and Health Officer (SSHO) Daily Inspection U.S. Army Corps of Engineers, Philadelphia District

Date of Inspection:

Contractor:

Contract No. or Activity:

Project Name: Inspected by (print name):

Signature:

Checklist Items Yes No N/A Remarks (Any No or N/A items) Activity Hazard Analysis (AHA)

1. Do workers/crews have in their possession a current AHA that reflects current site conditions?

2. Has each employee performing work reviewed the AHA and signed a signature log prior to the start of work?

3. Has the competent person required for an activity as specified by OSHA and EM 385-1-1 been identified on the AHA and their proof of competency/qualifications available for review?

4. Has the AHA been reviewed by the SSHO and the daily activity has been inspected to assure work is being performed consistent with the AHA? Does the AHA identify the work sequences, specific anticipated hazards, site conditions, equipment, materials, personnel and the control measures to be implemented? Are workers properly wearing required PPE?

Indoctrination and Training

5. Have all workers on site been provided SOH indoctrination prior to the start of work as well as continuous SOH training to enable them to perform their work in a safe manner? Is indoctrination training available for review?

How many workers received their indoctrination today?

6. Has a daily or weekly safety meeting been conducted with all workers on site? Attach minutes.

7. Has a safety meeting been conducted with all supervisors on site at least once a month? Attach minutes.

Fencing and Warning Signs

8. Is the project fencing erected, in good repair, and secured daily? Are warning signs of the presence of construction hazards and requiring unauthorized persons to keep out posted on fencing at least every 150 ft?

Fire Prevention

9. Has a hot work permit been issued when performing activities which generate or have the potential to generate, heat, sparks, or open flames, such as abrasive blasting, burning, brazing, cutting, grinding, power-actuated tools, hot riveting, soldering, thawing activities, welding, or any similar operation capable of initiating fires or explosions?

10. Has each hot work area been inspected at least per day (in addition to the initial inspection) while the hot work permit is in effect to ensure that it is a fire safe area?

11. Is the cylinder-regulated-hose-torch equipped with both a reverse-flow check valve and a flash arrestor, in each hose at the torch (unless otherwise indicated by the manufacture)?

12. Are cylinders containing oxygen or oxidizing gases separated from cylinders containing fuel gases by at least 20 ft or by a fire resistive partition having at least a 1 hour rating? Have welding cables and hoses been inspected?

13. Are welding and cutting cables, hoses, and other equipment clear of passageways, ladders, and stairways?

14. Are fire extinguishers distributed in accordance with NFPA 10 and readily accessible?

Electrical

15. Are live parts of wiring or equipment guarded to protect all persons from harm?

16. Are extension cords inspected daily by the user?

17. Are extension cords a minimum 14 AWG, hard or extra hard usage, and not connected to other extension cords?

18. Are outlets (permanent or temporary wiring, including portable generators) equipped with a GFCI or a portable GFCI? If equipped with a portable GFCI is it as near as practical to the receptacle outlet?

19. Are lockout/tagout procedures being followed? Are the daily inspections being conducted to insure that all the program procedures are being followed and documented? Identify competent person-

Housekeeping Yes No N/A Remarks (Any No or N/A items)

20. Are work areas and means of access safe and orderly? Are work areas free of trip and fall hazards?

21. Is the construction site kept free from the accumulation of combustible materials? Is waste material and rubbish placed in containers and promptly disposed?

Vehicles, Machinery, and Equipment

22. Has every person operating machinery and mechanized equipment been properly trained, qualified, and designated by the employer in writing to operate such equipment? Is documentation available?

23. Are all tools, belts, gears, shafts, pulleys, sprockets, spindles, drums, flywheels, chains, or other reciprocating, rotating, or moving parts guarded? Are all hot surfaces guarded or insulated to prevent injury or fire?

24. Has equipment not otherwise inspected by the State been inspected by a qualified mechanic and found in safe operating condition? Is documentation available?

25. Has all machinery and equipment (when in use) been inspected daily by the employers competent person prior to use and is in safe operating conditions? Are copies of inspections and tests available for review?

Fall Protection

26. Are workers protected from falling to a lower level by guardrails, work platforms, temporary floors, safety nets, engineered fall protection systems, personal fall arrest systems, or equivalent?

27. Has the designated competent person for fall protection inspected the site prior to workers exposure to falls?

28. Is the competent person for fall protection on site? Identify competent person-

29. Has training been provided for each employee who might be exposed to fall hazards? Is documentation available for review?

Scaffolding

30. Have workers involved in erecting, disassembling, moving, operating, and using scaffolding been trained? Is training documentation available for review?

31. Is the competent person for scaffolding on site? Identify competent person-

32. Has the competent person for scaffolding inspected the scaffolding prior to each shift? Has the competent person tagged the scaffolding safe for use?

Excavation/Trenching

33. Has the competent person for excavation/trenching inspected the excavation?

34. Is the competent person for excavation/trenching on site? Identify competent person-

35. Has the air in the excavation been tested at least prior to each shift in excavations greater than 4ft, or when oxygen deficiency or gaseous conditions are known or suspected? Is a log kept?

Confined Space

36. Has all employees entering PRCS or NPRCS been trained? Is documentation available for review?

37. Is the competent person for confined space on site? Identify competent person-

38. Has the competent person for confined space inspected the space?

Have you inspected the worksite and addressed all hazards found? (This form does not address all OSHA and EM 385-1-1 requirements.)

List features of work being performed today:

Description of deficiency Person responsible for correcting Projected resolution date Date actually resolved

5.

d. CONTRACTOR'S NAME

SIDE SWIPE

BROADSIDE

OTHER (Specify)

e. BODY PART AFFECTED

REAR END

BACKING

HEAD ON

ROLL OVER

d. ESTIMATED DAYS

RESTRICTED DUTY

b. ESTIMATED

DAYS LOST

c. ESTIMATED

DAYS HOSPIT-

ALIZED

b. TYPE OF CONSTRUCTION EQUIPMENT

SUPERFUND

IRP

b. TYPE OF COLLISION/MISHAP

a. ACTIVITY AT TIME OF ACCIDENT

g. HAZARDOUS/TOXIC WASTE

ACTIVITY

(For Safety Staff only)

REPORT NO. EROC

CODE UNITED STATES ARMY CORPS OF ENGINEERS

ACCIDENT INVESTIGATION REPORT

REQUIREMENT

CONTROL SYMBOL:

CEEC-S-8(R2)

PERSONNEL CLASSIFICATION

GOVERNMENT

INJURY/ILLNESS/FATAL PROPERTY DAMAGE MOTOR VEHICLE INVOLVED DIVING

a. Name (Last, First, MI) b. AGE c. SEX d. SOCIAL SECURITY NUMBER e. GRADE

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

a. DATE OF ACCIDENT (month/day/year)

b. TIME OF ACCIDENT (Military time)

e. CONTRACT NUMBER f. TYPE OF CONTRACT

c. EXACT LOCATION OF ACCIDENT

a. CONSTRUCTION ACTIVITY

a. SEVERITY OF ILLNESS/INJURY

g. TYPE AND SOURCE OF INJURY/ILLNESS

f. NATURE OF ILLNESS/INJURY

a. TYPE OF VEHICLE

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

(1)

(2)

(3)

a. TYPE OF VESSEL/FLOATING PLANT

b. PERSONAL FLOATATION DEVICE USED?

b. TYPE OF COLLISION c. SEAT BELTS USED NOT USED NOT AVAILABLE

(1) FRONT SEAT

(2) REAR SEAT

10. ACCIDENT DESCRIPTION (Use additional paper, if necessary)

8. PROPERTY/MATERIAL INVOLVED

9. VESSEL/FLOATING PLANT ACCIDENT (Fill in line and correspondence code number in box from list - see help menu)

7. MOTOR VEHICLE ACCIDENT

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

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

3. GENERAL INFORMATION

2. PERSONAL DATA

1. ACCIDENT CLASSIFICATION

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

CIVILIAN MILITARY

CONTRACTOR

FIRE

INVOLVED OTHER

FIRE

INVOLVED OTHER

OTHERFATAL

MALE FEMALE

ON DUTY

OFF DUTY

TDY

ARMY ACTIVE

PERMANENT

TEMPORARY

OTHER (Specify)

ARMY RESERVE

FOREIGN NATIONAL

STUDENT

VOLUNTEER

SEASONAL

CONSTRUCTION

A/E

OTHER (Specify)

SERVICE

DREDGE

DERP

OTHER (Specify)

(1) PRIME:

(2) SUBCONTRACTOR:

(CODE) (CODE)

(CODE)

(CODE)

(CODE)

(CODE)

(CODE)

(CODE)

(CODE) (CODE)

(CODE)

CIVIL WORKS

OTHER (Specify)

MILITARY

PRIMARY

SECONDARY TYPE

SOURCE

YES N/ANO

AUTOMOBILE

OTHER (Specify)

PICKUP/VAN

TRUCK

ENG FORM 3394, MAR 99 EDITION OF SEP 89 IS OBSOLETE. Page 1 of 4 pages (Proponent: CESO ) hrs

(For Use of this Form See Help Menu and USACE Suppl to AR 385-40)

PUBLIC

Version 2 a.

a.

a.

b. TYPE OF TRAINING. a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK?

b. WAS A WRITTEN JOB/ACTIVITY HAZARD ANALYSIS COMPLETED

FOR TASK BEING PERFORMED AT TIME OF ACCIDENT?

a. (CONTINUED) a. (Explain YES answers in item 13)

CAUSAL FACTOR(S) (Read Instruction Before Completing)11.

TRAINING12.

FULLY EXPLAIN WHAT ALLOWED OR CAUSED THE ACCIDENT; INCLUDE DIRECT AND INDIRECT CAUSES (See instruction for definition of direct and indirect causes.) (Use additional paper, if necessary)

13.

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

DATES FOR ACTIONS IDENTIFIED IN BLOCK 14.15.

MANAGEMENT REVIEW (1st)16.

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

SAFETY AND OCCUPATIONAL HEALTH OFFICE REVIEW18.

COMMAND APPROVAL19.

c. DATE OF MOST RECENT FORMAL TRAINING.

a. DIRECT CAUSE

b. INDIRECT CAUSE(S)

DESCRIBE FULLY:

c. SIGNATURE AND TITLE OF SUPERVISOR COMPLETING REPORT

CORPS

CONTRACTOR

d. DATE (Mo/Da/Yr) e. ORGANIZATION IDENTIFIER (Div, Br, Sect) f. OFFICE SYMBOL

SIGNATURE TITLE DATE

COMMENTS

DATE

DATE

DATECOMMANDER SIGNATURE

TITLE

TITLE

SIGNATURE

SIGNATURE

a. BEGINNING (Month/Day/Year) b. ANTICIPATED COMPLETION (Month/Day/Year)

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

INSPECTION/MAINTENANCE: Were inspection & mainten-ance procedures a factor?

PERSON'S PHYSICAL CONDITION: In your opinion, was the physical condition of the person a factor?

OPERATING PROCEDURES: Were operating procedures a factor?

JOB PRACTICES: Were any job safety/health practices not followed when the accident occurred?

HUMAN FACTORS: Did any human factors such as, size or strength of person, etc., contribute to accident?

ENVIRONMENTAL FACTORS: Did heat, cold, dust, sun, glare, etc., contribute to the accident?

OFFICE FACTORS: Did office setting such as, lifting office furniture, carrying, stooping, etc., contribute to the accident?

SUPPORT FACTORS: Were inappropriate tools/resources provided to properly perform the activity/task?

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

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

CHEMICAL AND PHYSICAL AGENT FACTORS: Did exposure to chemical agents, such as dust, fumes, mists, vapors or physical agents, such as, noise, radiation, etc., contribute to accident?

CONCUR b. NON CONCUR c. COMMENTS

CONCUR b. NON CONCUR c. COMMENTS

CONCUR b. NON CONCUR c. ADDITIONAL ACTIONS/COMMENTS

Page 2 of 4 pages

YES (If yes, attach a copy.) NO

NOYES ON JOBCLASSROOM (Month) (Day) (Year)

YES NO YES NO

*U.S. GOVERNMENT PRINTING OFFICE: 1993-0-791-757

ACCIDENT DESCRIPTION (Continuation)

DIRECT CAUSE (Continuation)

10.

13a.

Page 3 of 4 pages

INDIRECT CAUSES (Continuation)

ACTION(S) TAKEN, ANTICIPATED, OR RECOMMENDED TO ELIMINATE CAUSE(S) (Continuation)

13b.

14.

Page 4 of 4 pages

PROGRESS PAYMENT CHECKLIST (Payment # )

Project Name / Contract No. __________________________________________________________________________

In accordance with FAR 52.232-5 “Payments”, progress payments may only be made in full for satisfactory progress during the payment period.