Solicitation Amend 01 Cleveland W912P423B0001.pdf

AlVIENDMENT OF SOLICITA TION/MODIF1CATION OF CONIRACT

I. CON'IRACTID CODE PAGEOF PAGES

1 I 2

3. EFFECilVE DA'lE 4. REQUIS11K)N/PUR CHASE REQ. NO. 5. PROJECTNO (lfappliubla) 2. AMENDMEN11MODIFICA'IlON NO.

01 08-Fet>-2023

6.ISSUEDBY CODE W912P4 7. ADMINIS'lERED BY (lfothartlun itam6) CODE I

U.S.ARMY B�GINEER OISTRICT,BUFFALO

See Item 6 17i6N IAGARASTREET

BUFFALO I-N 142J7-3199

8. N AME AND ADDRESSOFCO\'TRACTOR (No., Street, County, 9:ate andZip Code) X 9 A. Al\.iENDME!\'T OF S:XICTT AT ION N O.

W912P423B0001

X

9B. DA TED (� E ITEM 11)

1�an-2023

I 0A. MOD. OF Co:\'TRACT/ORDER N O .

I OB. DATED (� E ITEl\•i 13)

CODE IFACILITY CODE

11. THIS ITEM O!\'L Y APPLIES TO Al\•iE!\1DME!\'TS OF S:XICTT ATIONS [i!The.abovenuttb.ered solicitation is .anend.ed as set D'!'th in Item 14. The hour.and datespeci.6.ed D'!'reoeipt ofO&r □ is extend.ed, 0 is not extended.

Ofi.t'irust .acknowledge receipt of this amendmfflt prior to the hour md datespaciied in the so licitation or .s anend.ed by one of the DU owing netho d s:

(.a)By conpleting Item S .and 15, .and ratuming _1_copi..s of the Jnlffldnent; (o)Bya cknowledging receipt of this anendnent on ,ea.ch copyoftheofusubnitted;

o-r(c)Bysepar.ate letterM tele-gramwhich induda a ra&renoe to thesolicib.tion .and Jmffldttent nunbers. FAil..URE OF YOUR ACKNO\VLEDG MENT'IO BE RECEIVED A TIHEP LACEDES IGNA'lED FOR 1HE RECEIPTOFOFFERS P RKJR 101HE HOUR AN D DA 1ESPECIFIED MAY RESULTIN

REJEC'IION OF YOUR OFFER. lfbyvirtue of this a.n-endment youdaira to ch.ange anofiralrudysubmittad, such change miybe mideby telegamodet:ter, provided ea:h telegam01'1ettermik� reirenoe to the solicitation and this a.n-endnent,and is raceived pri01'to the �g hour and dJtespecifai.

12. ACCO UNI'INGAi'\'D APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIF1CA TIONSOF Co:\'TRACTS'ORDERS.

IT MODIFIES THE CONTRACT/ORDER NO. AS DEs:RIBED IN ITEM 14.

A. THISCHA .. '<CE ORDER ISISSt;"EDPUR&JA .. '<T TO (�edfy authority) THE CHA .. '1GES�T FORTH DI ITE.\,i 14 ARE '.\l.:\DE lc\THE CO)ffRACT ORDER >10. DIITE'.\i I0A.

B. THE ABOVE :\'U'.\iBERED CO>ITRACT ,CRDER IS '.\.fODIFIED TO REFLECT THE . .:\D'.\IDIISIRATIVE CliA>IGES (such as ch anges in p aying office, appropriation date, etc.) �T FORTI! IN ITEM 14, Pt;R&:A:ll' TO TIIE A t;THORITY OF FAR43.103(B).

C. THIS &JPPLEl\,iENTAL AGREEl\iE>IT ISE>ITERED DITO Pt;RSUANT TO A t;THORITY OF:

D. OTHER (�edfy type of modificati on and authority)

E. IMPORTA .. '<T Contractor □ is no t, □ is required to si� this doament and ret um copies to the is.-uing office.---

14. DEs::RJPTIO>I OF Al\,iEND'.\iENI'/MODillCATION (Organized by t;CF section he adings, indudingsolidtationrcontract subject matter

,.Jiere feasible.)

Arrendment 01.

1. Update NAICS 237990-Siz.e Standard for 0-edge projects from $32,500,000.00 to $37,000,000.00.

2. Answers toquesfions from Contractors questions posted on FR)JNET are attached.

3. Updated to Rans and Specifications.of project.

E,-.oept as provided hera:in, .all tems and conditions ofthedoc:ument ra&renoed inltem9A or l0A, .as heratobrechangad, ramains un changai and in full Dfoeand e.fict.

!SA. N Al\•iE AND TITLE OF SIG\'ER (Type or print) 16A. NAl\•iE Ai'\'D TITLE OF CO!\'TRACTINGOFF1CER (Type or print)

TEL: EMAIL:

!SB. CO!\'TRACTOR/OFFEROR !SC. DA TE SIGNED 16B. UNITED SI'ATESOF Al\•iERICA 16C. DATE SIGNED

BY

(S�ature of person authorized to :i�) (S�ature of Contracting Officer)

EXCEPTION TO go 30

APPROVEDBYO IRM 11-84

30-105-04 SI' Ai'1DARD FORl\•i 30 (Rev. I 0-83) P rescri bed by ffiJ'.

FAR (48 CFR) 53.243

W912P423B0001

SECTION SF 30 BLOCK 14 CONTINUATION PAGE

SUMMARY OF CHANGES

SECTION 00 21 13 - INSTRUCTIONS TO BIDDERS

The following have been modified:

52.252-3 ALTERATIONS IN SOLICITATION (APR 1984)

Portions of this solicitation are altered as follows:

0001 Amendment 01.

1. Update NAICS 237990-Size Standard for Dredge projects from $32,500,000.00 to $37,000,000.00.

2. Answers to questions from Contractors questions posted on PROJNET are attached.

3. Update to Plans and Specifications:

1. Specifications

a. Section 01 35 13

(1) Paragraph 3.2.2b .has been updated

2. Plans

a. Sheet C-101

(1) Notes 2.B has been been deleted.

(End of Summary of Changes)

AMENDMENT NO. 1

CLEVELAND, OHIO

CLEVELAND HARBOR

DREDGING

FY23

CONTRACTOR QUESTIONS,

GOVERNMENT REPLIES,

UPDATED PLANS,

AND SPECIFICATIONS

06 FEBRUARY 2023

CONTRACTOR QUESTIONS AND GOVERNMENT RESPONSES

1.) The buckeye pipeline is located at approximately station 29+25/29 +50, per Buckeye

Pipeline contact no dredging is allowed 50 feet upstream or down stream of this pipeline, has dredging in this location been approved by pipeline owner. What is the depth of this pipeline?

Response: The Contractor will be responsible for dredging within the contract limits in accordance with the contract documents (including but not limited to: Section 01 35 13, paragraphs 1.3.5 and 1.3.10d, and Section 35 20 23, paragraph 3.1.2).

2.) Based on plans and specifications will dredging be required under all bridges and over any/all underground pipelines? Have all utilities depths and offset of structures been identified in plans?

Response: Known utilities are shown on the drawings. The Contractor will be responsible for dredging within the contract limits in accordance with the contract documents (including but not limited to: Section 01 35 13, paragraphs 1.3.5 and 1.3.10d, and Section 35 20 23, paragraph 3.1.2).

3.) Size Standard for Dredging is shown as $32,500,0 00 – this was increase d to $37,000,

000.00 per the federal registry. Located at following link. https: //www.federalregis ter.gov/documents/ 2022/11/1 7/2022-24 595/small -business -size-standards-adjustment-of-monetary-based- size-standards-disadvantage -thresholds. Will this solicitation be modified to the updated size standard?

Response: This will be addressed via amendment, with the solicitation revised to include the $37M threshold.

4.) Option A Station 29+00 to 31+00 – this dredge area would be limited to 30+00 to 31+00 with lower overhead clearance, the buckeye pipeline location has a dredging restrict ion from 29+00 to 30+00. Is the intent to only dredge 30+00 to 31+00?

Response: The Contractor will be responsible for dredging within the contract limits in accordance with the contract documents (including but not limited to: Section 01 35 13, paragraphs 1.3.5 and 1.3.10d, and Section 35 20 23, paragraph 3.1.2).

5.) SHT C-101, Note 2.B States Stations 28 – 39 are a separate bid item on the bid form?

Please clarify bid form?

Response: This will be addressed via amendment, with the drawing revised to delete this note.

6.) Dredging Safety Personnel Requirements –

Please provide clarification on the SSHO and CDSO. Specification state minimum one

SSHO for Primary Shift, but also states one per shift and an addition al CDSO is required for the material placement site, does the placement site not fall under one dredge project site, paragraph 1.6.1.4. 1.c? If the CDSO (Non-Operating) is required at the material placemen t site is this per shift also? Is intent to have 4 non-working SSHO/CDS O for this contract?

3538313 Response: Each shift will be required to have a SSHO (for the entire project) and CDSO (at the material placement site) in accordance with Section 01 35 26, paragraph 1.6.1.4.

7.) If site improvements are made to allow access to Government Furnished CDF, will improvements be required to be removed upon completion of contract?

Response: The Contractor will be required to remove CDF improvements in accordance with Section 01 35 13, paragraph 3.2.2b. Note that this specification section is now revised via amendment.

8.) SHT C-104, Note 2. Begin Material Placement along Pts EX9 and EX10, are there any restrictions of where placement is required to start along these points? North to South?

Response: There are no restrictions on where sediment placement starts along the noted points.

The following changes have been made to the bid form, specifications, and plans.

They are shown on the following pages.

1. Specifications

a. Section 01 35 13

(1) Paragraph 3.2.2b .has been updated

2. Plans

a. Sheet C-101

(1) Notes 2.B has been been deleted.

FY23 CLEVELAND HARBOR DREDGE AMENDMNET NO. 1

3.2.2 Additional Requirements for Mechanical Placement of Dredged Sediment

a. Before any work begins at CDF 10B, complete a Joint Pre-Condition Survey of the area. The Contracting Officer or their representative will attend. Record the condition of all roads, structures, utilities, etc, in detail and photographed as directed by the Contracting Officer. Submit the results of the survey within 2 days of completion of the survey.

Include all information (written and photographic) from the survey in one document, and submit one hard copy and one electronic copy of the report.

The Government will respond within 2 days, providing either acceptance of the report or requesting more information to be entered. If more information is required, the Contractor has 2 days to re-submit the report and the Government will respond within 2 days. This process will continue until Government acceptance of the report. A hard copy and electronic copy is reqruired for every time the survey is submittes. No work will be allowed on-site until the report is approved.

b. The Contractor may make improvements to CDF10B to facilitate the placement of material. Perform all work on the improvements and the actual improvements in accordance with all FAA requirements as stated and shown on the contract drawings. Remove any materials used for improvements that were not in the CDF at the start of the Dredging, at the end of the dredging. The contractor may, at their own risk, leave all improvements in place and all equipment on-site between the Spring and Fall dredging, providing that all FAA requirements are met.

(1) Daily coordination of activities with Burke Lakefront Airport personnel

(2) Placement operations will be as directed by the Contracting Officer .

(3) Complete the work in conformance with the Contractor's approved Material Placement Plan. Joint Contractor/Government inspections will be performed periodically throughout the work (at the Government's discretion) to evaluate and document contract compliance.

(4) Place all dredged material into the CDF without the addition of water.

(5) Conduct operations (and provide temporary site facilities as necessary) to prevent dredged sediment and runoff/discharge water from contacting the lake, shoreline and/or property outside the CDF any time the dredged material is moved/relocated/transported. Provisions may include but not be limited to:

(a) Roadway improvements/modifications and wheel washing station for trucking operations.

(b) Aprons, tarps or other protective systems to prevent spillage of sediment or water at the scow unloading area.

(6) For all cranes, conveyors, or other equipment and structures, comply with the adjacent Burke Lakefront Airport, FAA requirements (e.g., marking/lighting of equipment, radio communication with airport, potential lowering of equipment during airplane arrival/departure, etc.)

(7) Return perimeter roadways and CDF berms to their original

SECTION 01 35 13 Page 1031 02/06/23

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APP Checklist

CONTRACTOR ACCIDENT PREVENTION PLAN (APP) CHECKLIST

(EM 385-1-1, Appendix - A, dated 30 Nov 2014)

Minimum Basic Outline for APP The APP is the Contractor Safety and Health Program Document. The following Site Specific Areas will be addressed:

NOTE: 1. Contractor will complete Checklist and Submit with their APP.

NOTE: 2. Contractor APP WILL be submitted in format below.

NOTE: 3. Safety Office will review Contractor APP and return to PM /COR.

NOTE: 4. Contractor APP's ARE NOT APPROVED by the USACE, only found as Acceptable or Non-Acceptable.

Safety Office Review Status: ACCEPTED BY/DATE: NOT ACCEPTED BY/DATE:

Contractor Name: _______________________________________________________

Contract No: _________________________________

Project Title & Location: Included? Location

Page(s) Yes No N/A

ALL CHECKLIST ITEMS WILL BE COMPLETED!

1. SIGNATURE SHEET. Title, signature, and phone number of the following:

a. Plan Preparer (qualified person, Competent Person such as corporate safety staff person, QC).

b. Plan Approval by company/corporate officers authorized to obligate the company (e.g. owner company president, regional vice president etc.)

c. Plan Concurrence (e.g. Chief of Operations, Corporate Chief of Safety, Corporate Industrial Hygienist, project manager or superintendent, project safety professional, project QC). Provide concurrence of other applicable corporate and project personnel (Contractor).

2. BACKGROUND INFORMATION. List the following:

a. Contractor;

b. Contract number;

c. Project name;

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

equipment to be used; anticipated high risk activities

e. Major phases of work anticipated and activities that will require an AHA

3. STATEMENT OF SAFETY AND HEALTH POLICY. Provide a copy of your current corporate/company Safety & 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 for his own employees, all sub-contractors and all others on the worksite.

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. Per EM 385-1-1 01.A.17, the SSHO is required to have as a minimum the OSHA 30-hour Construction Safety course and construction industry safety experience; and must be on-site at all times when work is 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 and details of the employers Risk Management Process (i.e.AHAs)

e. Requirements for activity specific AHAs to be submitted and accepted at preparatory meetings, prior to work being performed;

f. Requirements that no work by the Contractor shall be performed unless a designated CP/SSHO is present at the job site;

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

h. Lines of authority;

i. 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.

7. SAFETY AND HEALTH 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. MISHAP REPORTING AND INVESTIGATION. 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/incidents as soon as possible but not more than 4 hours afterwards to the Contracting Officer/Representative (KO/COR). The contractor shall thoroughly investigate the incident/accident per Section 01.D and, if applicable, submit the findings of the investigation along with appropriate corrective actions to the KO/COR in the prescribed format as soon as possible. Implement corrective actions as soon as reasonably possible and provide notice to the KO/COR when corrective actions are completed;

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

b. Emergency Plans (01.E);

c. Site Sanitation/ Housekeeping Plan (Section 02.B);

d. Medical Support Agreement (03.A.01; 03.A.03);

e. Blood Borne Pathogen Program (03.A.05);

f. Exposure Control Plan (03.A.05);

g. Automatic External Defibrillator (AED) Program (03.B.04);

h. Site Layout Plan (04.A);

i. Access / Haul Road Plan (04.B);

j. Hearing Conservation Program (05.C);

k. Respiratory Protection Plan (05.G);

l. Health Hazard Control Program (06.A);

m. Hazard Communication Program (06.B.01);

n. Process Safety Management Plan (06.B.04);

o. Lead Compliance Plan (06.C.02 & specifications);

p. Asbestos Abatement Plan (06.C.03 & specifications);

q. Radiation Safety Program (06.F);

r. Abrasive Blasting Procedures (06.I.01);

s. Heat Stress Monitoring Plan (HSMP) (06.J.02);

t. Cold Stress Monitoring Plan (CSMP) (06.J.04);

u. Indoor Air Quality Management Plan (06.L);

v. Mold Remediation Plan (06.L.04);

w. Chromium (VI) Exposure Evaluation (06.M);

x. Crystalline Silica Evaluation (06.N.02) ;

y. Lighting Plan for Night Operations (07.A.06);

z. Traffic Control Plan (08.C.05);

aa. Fire Prevention Plan (09.A.01);

bb. Wild Land Fire Management Plan (09.L);

cc. Arc Flash Hazard Analysis (11.B);

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

ee. Hazardous Energy Control Program & Procedures (12.A.01);

ff. Standard Pre-Lift Plan – Load Handling Equipment (16.A.03);

gg. Critical Lift Plan – Load Handling Equipment (16.H);

hh. Naval Architecture Analysis – Load Handling Equipment (Floating) (16.L);

ii. Floating Plant Inspection and Certification (19.A.01);

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

kk. Emergency Plan for Marine Activities (19.A.04);

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

mm. Float Plan for Launches, Motorboats, and Skiffs (19.F.04);

nn. Fall Protection & Prevention Plan (21.D);

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

pp. Rope Access Work Plan (24.H2);

qq. Excavation / Trenching Plan (25.A.01);

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

ss. Compressed Air Work Plan for Underground Construction (26.D.01);

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

uu. Precast Concrete Plan (27.D.01);

vv. Lift Slab Plans (27.E);

ww. Masonry Bracing Plan (27.F.01);

xx. Steel Erection Plan (28.B);

yy. Explosives Safety Site Plan (ESSP) (29.A);

zz. Blasting Safety Plan (29.A; 26.J);

aaa. Dive Operations Plan (30.A.14 & 30.A.16);

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

ccc. Emergency Management Plan for Diving (30.A.18);

ddd. Tree Felling and Maintenance Program (31.A.01);

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

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

ggg. Site Safety and Health Plan for HTRW (33.B);

hhh. Confined Space Entry Procedures (34.A.05);

iii. Confined Space Program (34.A.06);

10. RISK MANAGEMENT PROCESSES. Detailed project-specific hazards and controls shall be provided by an Activity Hazard Analysis (01.A.14, 01.A.15) for each major phase/activity of work.

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U.S. ARMY CORPS OF ENGINEERS, BUFFALO DISTRICT

ACTIVITY HAZARDS ANALYSIS (AHA)

For use of this form, see EM 385-1-1; the proponent agency is CELRB-SO.

CELRB FORM 385-02 AHA, 2020

PREVIOUS EDITIONS ARE OBSOLETE.

Page of

FREQUENT

LIKELY

OCCASIONAL

SELDOM

UNLIKELY

E

H

M

L

OVERALL RISK ASSESSMENT CODE (RAC) (Use Highest Code)

SEVERITY

PROBABILITY

NEGLIGIBLE

RISK ASSESSMENT CODE (RAC) MATRIX

CRITICAL

“Severity” is the outcome/degree if an incident, near miss, or accident did occur.

CATASTROPHIC

“Probability” is the likelihood to cause an incident, near miss, or accident.

MARGINAL

NOTES:

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

Step 2: Identify the RAC for each “Hazard” on AHA. Annotate the overall highest RAC at the top of AHA.

Risk Code: E (Extremely High Risk), H (High Risk), M (Moderate Risk), or L (Low Risk)

Step 3: Identify any equipment, training, and inspection requirements.

Step 4: Identify the names of the Competent Person(CP)/Qualified Person(QP) required for a particular activity specified in EM 385-1-1/OSHA and provide proof of their competency/qualification.

JOB STEPS

Break down the job into individual steps, e.g., mobilization, erect forms, erect scaffolding, install reinforcement bar, remove forms, demobilization.

HAZARDS

Identify the hazards, what are the man, machine, and environmental hazard factors of an operation. Note: include hazards that could potentially change the risk, such as weather, changing site conditions, abnormal operating procedures, etc. Do a change analysis when site conditions change.

Controls (Actions to Eliminate or Minimize Hazards)

List the controls needed to eliminate or reduce the risks. Controls can be in the form of educational controls (training), physical controls (barriers, guards, signs, etc.), Administrative Controls, Personal Protective Equipment, or Engineering Controls. Risk avoidance is another alternative, are there ways to do the job differently so that risks aren't encountered.

RAC

EQUIPMENT

List equipment needed for the job.

TRAINING REQUIREMENTS

List any specialized training or certifications needed for the job.

INSPECTION REQUIREMENTS

List any inspection requirements, before, during, or after the job is completed.

1.0 darwin.chen@usace.army.mil

2011-11-29

Forms Design Team

Darwin Chen

Activity Hazards Analysis

2011-11-29

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Contractor No: _______________________________________ Month and Year: ______________________________________

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ENG FORM 3394, AUG 2021 PREVIOUS EDITIONS ARE OBSOLETE. Page of

U.S. Army Corps of Engineers (USACE)

MISHAP NOTIFICATION AND INVESTIGATION

For use of this form, see instructions in the attachments and USACE ER 385-1-99; the proponent agency is CESO.

Requirement Control Symbol

RCS-CESO-21-0001

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority 10 U.S.C. 7013, Secretary of the Army; 5 U.S.C. 7902, Safety Programs; Public Law 91-596, Occupational Safety and Health Act of 1970; DoD Instruction 6055.1, DoD Safety and Occupational Health Program; Army Regulations 385-10, Army Safety Program;

DoD Instruction 6055 .07, Mishap Notification, Investigation, Reporting, and Record Keeping; and E.O. 9397 (SSN), as amended.

Principal Purpose Information collected is to provide the USACE leaders, soldiers, families and civilians in injury, illness, and loss data to effectively manage its safety and occupational health program.

Routine Uses In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b) as follows: To the Department of Labor, the Federal Aviation Agency, the National Transportation Safety Board, and to Federal, State, and local agencies and applicable civilian organizations, such as the National Safety Council, for use in a combined effort of accident prevention. In some cases, data must also be disclosed to an employee's representative under the provisions of 29 CFR

1960.29. Records will be made available consistent with applicable laws and regulations. Information will be withheld from the public only if authorized by 5 U.S.C. Section 552 (Freedom of Information Act (FOIA), 5 U.S.C. 552a (Privacy Act)), or other statutory or regulatory authority.

Disclosure Failure to provide all the required information on the report may result in the rejection of report submission.

1. WHO IS REPORTING MISHAP

a. Name: b. Phone number:

c. Email address: d. Signature:

e. Report type:

1. Near Miss Report. (No injury/illness, or property damage. Complete all fields with underlined text.) Date:

2. Initial Accident Report. (For accident notification within 24 hrs, Complete all fields with underlined text.) Date:

3. Final Accident Report. (For reporting findings from accident investigation, complete full form.) Date:

f. Mishap Type. (Check all that apply)

Fatality Injury/Illness Property Damage Near Miss

g. Were any of the following items associated with the mishap ? (If yes, check all that apply)Yes No

Electrical and/or Hazardous Energy Working at Heights Diving

Load Handling Equipment or Rigging

Occupational Health Exposure

2. WHO WAS INVOLVED IN THIS MISHAP?

a. Name:

b. Personnel Classification: c. Time employee began work:

d. Gender: e. Date of birth (for Government personnel only): f. Age:

g. Date hired: h. Primary language:

i. Is individual a supervisor? Yes No j. Duty status at time of mishap: k. Years experience in job:

l. What was individual doing when mishap occurred? (Select activity from the drop downs below.)

1. General activities: 2. Vehicle/Equipment/Vessel:

3. Sports/Recreation: 4. Other not listed:

m. Did individual utilize all OSHA/EM 385-1-1 required Personal Protective Equipment (PPE) for activity? Yes No N/A

If no, identify missing PPE:

n. Was a Personal Flotation Device used? Yes No N/A o. Was a seat belt used? Yes No N/A

ENG FORM 3394, AUG 2021 Page of

p. Government personnel only:

4. Center/Division/Lab: 5. District:

1. Prime Contractor name:

q. Contractor personnel only:

2. Contract number: 3. Contract type: 4. Funding type:

Other not listed:

r. If mishap occurred on a contractor site, provide the following:

1. Employer/Contractor name:

3. Grade:2. Rank:

2. Individual's occupation/trade:

1. Job series:

h. If treatment was given away from the work-site, where was it given? (For Government Personnel Only)

j. Estimated days away from work: k. Estimated days of restricted/transferred duty:

Was OSHA notified? If yes, how many nights? Yes Noi. Was employee hospitalized as an in-patient? Yes No

Country:Zip:State: City:

Address:

Treatment facility name:

g. Was employee treated in an emergency room ? Yes No N/Af. Was treatment given away from work site? Yes No

Source of injury/illness: Cause of injury/illness:

Primary body part affected:

c. Identify body part(s) affected by injury/illness:

b. Type of Injury/Illness:a. Severity of injury/illness?

Secondary body part affected:

d. Identify cause and source of injury/illness:

If yes, provide name of physician or health care professional provider?

e. Was employee treated by a physician or health care professional provider? Yes No

Note: OSHA requires reporting all work-related fatalities within 8 hours and in-patient hospitalizations, amputations and loss of an eye within 24 hours to OSHA.

3. WHAT TYPE OF INJURY/ILLNESS OCCURRED?

4. WHAT HAPPENED?

a. What was the primary activity occurring at the time of the mishap?

Other, not listed:

b. What happened? Provide a detailed description of the mishap. (Do not include any personally identifiable information (name, etc.).)

Note: Provide supporting photos, charts, diagrams, etc. with this report.

c. What other organizations or agencies have been notified about this mishap?

b. USACE Office/Program/Project name:

a. List all property/material involved in the mishap. (Include damaged and undamaged property.)

i. Type of item:

Item A Item B Item C

ii. Name of item(s):

iv. Ownership of item:

v. Dollar cost of damage:

a. Date the mishap occurred: b. Time mishap occurred:

c. What day did mishap occur on? d. What period of day did mishap occur?

a. Did the mishap occur on a military Base/Post? Yes No

c. Select the location type most closely associated with the mishap:

d. Identify exact location where mishap occurred:

e. Latitude: f. Longitude:

iii. Collision type:

Country:Zip:State: City:

Address:

5. WHAT TYPE OF PROPERTY/MATERIAL WAS INVOLVED?

6. WHEN DID THE MISHAP OCCUR?

7. WHERE DID THE MISHAP OCCUR?

8. WHY DID THE MISHAP OCCUR? (Recommend completing this section for Near Misses.)

A. Performance Causal Factors

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

If yes, select the error that contributed most to the mishap:

1. Did a problem with resources contribute to this mishap occurring?

1. Did a problem with performance contribute to this mishap occurring? Yes No

Yes No

B. Support Causal Factors

C. Standards/Policy/Planning Causal Factors

1. Did an organizational standard/policy/or plan contribute to this mishap occurring?

2. Was a written Activity Hazard Analysis (AHA) or equivalent completed and accepted by Government Designated Authority (GDA) for task(s) being performed at time of mishap? (If yes, attach a copy to this report)

If yes, was the AHA available and used by worker?

3. Was a written work plan (critical lift plan, fall protection plan, etc.) required, completed and accepted by the GDA for task(s) being performed at time of mishap?

If yes, was the plan available and used by worker?

4. Describe action(s) taken, anticipated or

1. Did any leader/supervisory mistake/task error contribute to this mishap occurring?

1. Did any individual mistakes/task errors contribute to this mishap occurring?

4. Describe action(s) taken, anticipated or

3. Describe action(s) taken, anticipated or

1. Did any material failure contribute to this mishap occurring?

1. Did a problem with training contribute to this mishap occurring?

If yes, select type of training: Classroom On the jobCertification/License

Other, describe:

What was date of most recent training?

2. Which failure is most closely associated with the material failure/malfunction?

1. Did any physical environment contribute to this mishap occurring?

2. Was individual trained to perform the activity/task?

3. Describe action(s) taken, anticipated or

2. Did the safety climate/culture contribute to the mishap?

3. Did challenges with teamwork contribute to the mishap?

D. Training Causal Factors

E. Leader/Supervisor Causal Factors

F. Individual Causal Factors

G. Physical Environment Causal Factors

H. Material Causal Factors

I. Environmental Causal Factors

If yes, select the factor that contributed most to the mishap:

1. Did any environmental condition contribute to this mishap occurring?

recommended to eliminate hazard:

If yes, describe:

1. Did the design of the facility/building contribute to the mishap?

J. Facility/Building Design

b. Who is responsible for the corrective action plan?

a. Have all corrective action(s) to prevent mishap recurrence been completed?

c. What date will/have all corrective action(s) be/been completed by:

d. Additional information:

recommended to eliminate hazard(s):

If yes, describe the hazard(s):

1. Did a hazard(s) contribute to the mishap?

K. Existing Hazard

9. Corrective Action plan

10. Additional Information

ENG FORM 3394, AUG 2021

PREVIOUS EDITIONS ARE OBSOLETE.

ENG FORM 3394, AUG 2021

U.S. Army Corps of Engineers (USACE)

For use of this form, see instructions in the attachments and USACE ER 385-1-99; the proponent agency is CESO.

Requirement Control Symbol RCS-CESO-21-0001

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority 10 U.S.C. 7013, Secretary of the Army; 5 U.S.C. 7902, Safety Programs; Public Law 91-596, Occupational Safety and Health Act of 1970; DoD Instruction 6055.1, DoD Safety and Occupational Health Program; Army Regulations 385-10, Army Safety Program;

DoD Instruction 6055 .07, Mishap Notification, Investigation, Reporting, and Record Keeping; and E.O. 9397 (SSN), as amended.Principal Purpose Information collected is to provide the USACE leaders, soldiers, families and civilians in injury, illness, and loss data to effectively manage its safety and occupational health program.Routine Uses In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b) as follows: To the Department of Labor, the Federal Aviation Agency, the National Transportation Safety Board, and to Federal, State, and local agencies and applicable civilian organizations, such as the National Safety Council, for use in a combined effort of accident prevention. In some cases, data must also be disclosed to an employee's representative under the provisions of 29 CFR

1960.29. Records will be made available consistent with applicable laws and regulations. Information will be withheld from the public only if authorized by 5 U.S.C. Section 552 (Freedom of Information Act (FOIA), 5 U.S.C. 552a (Privacy Act)), or other statutory or regulatory authority.Disclosure Failure to provide all the required information on the report may result in the rejection of report submission.

1. WHO IS REPORTING MISHAP

e. Report type:

f. Mishap Type. (Check all that apply)

g. Were any of the following items associated with the mishap ? (If yes, check all that apply)

2. WHO WAS INVOLVED IN THIS MISHAP?

i. Is individual a supervisor?

l. What was individual doing when mishap occurred? (Select activity from the drop downs below.)

m. Did individual utilize all OSHA/EM 385-1-1 required Personal Protective Equipment (PPE) for activity?

n. Was a Personal Flotation Device used?

o. Was a seat belt used?

p. Government personnel only:

q. Contractor personnel only:

r. If mishap occurred on a contractor site, provide the following:

h. If treatment was given away from the work-site, where was it given? (For Government Personnel Only)

Was OSHA notified?

i. Was employee hospitalized as an in-patient?

g. Was employee treated in an emergency room ?

f. Was treatment given away from work site?

c. Identify body part(s) affected by injury/illness:

d. Identify cause and source of injury/illness:

e. Was employee treated by a physician or health care professional provider?

Note: OSHA requires reporting all work-related fatalities within 8 hours and in-patient hospitalizations, amputations and loss of an eye within 24 hours to OSHA.

3. WHAT TYPE OF INJURY/ILLNESS OCCURRED?

4. WHAT HAPPENED?

Note: Provide supporting photos, charts, diagrams, etc. with this report.

a. List all property/material involved in the mishap. (Include damaged and undamaged property.)

i. Type of item:

Item A

Item B

Item C

ii. Name of item(s):

iv. Ownership of item:

v. Dollar cost of damage:

a. Did the mishap occur on a military Base/Post?

iii. Collision type:

5. WHAT TYPE OF PROPERTY/MATERIAL WAS INVOLVED?

6. WHEN DID THE MISHAP OCCUR?

7. WHERE DID THE MISHAP OCCUR?

8. WHY DID THE MISHAP OCCUR? (Recommend completing this section for Near Misses.)

A. Performance Causal Factors

1. Did a problem with resources contribute to this mishap occurring?

1. Did a problem with performance contribute to this mishap occurring?

B. Support Causal Factors

C. Standards/Policy/Planning Causal Factors

1. Did an organizational standard/policy/or plan contribute to this mishap occurring?

2. Was a written Activity Hazard Analysis (AHA) or equivalent completed and accepted by Government Designated Authority (GDA) for task(s) being performed at time of mishap? (If yes, attach a copy to this report)

If yes, was the AHA available and used by worker?

3. Was a written work plan (critical lift plan, fall protection plan, etc.) required, completed and accepted by the GDA for task(s) being performed at time of mishap?

If yes, was the plan available and used by worker?

1. Did any leader/supervisory mistake/task error contribute to this mishap occurring?

1. Did any individual mistakes/task errors contribute to this mishap occurring?

1. Did any material failure contribute to this mishap occurring?

1. Did a problem with training contribute to this mishap occurring?

If yes, select type of training:

1. Did any physical environment contribute to this mishap occurring?

2. Was individual trained to perform the activity/task?

2. Did the safety climate/culture contribute to the mishap?

3. Did challenges with teamwork contribute to the mishap?

D. Training Causal Factors

E. Leader/Supervisor Causal Factors

F. Individual Causal Factors

G. Physical Environment Causal Factors

H. Material Causal Factors

I. Environmental Causal Factors

1. Did any environmental condition contribute to this mishap occurring?

1. Did the design of the facility/building contribute to the mishap?

J. Facility/Building Design

a. Have all corrective action(s) to prevent mishap recurrence been completed?

1. Did a hazard(s) contribute to the mishap?

K. Existing Hazard

9. Corrective Action plan

10. Additional Information

1.0 darwin.chen@usace.army.mil

2021-06-28

Forms Design Team

Darwin Chen

2021-07-30

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APP Checklist Site Activity Page 1 of 4

APP Checklist with Attachments

CONTRACTOR ACCIDENT PREVENTION PLAN (APP) CHECKLIST

(EM 385-1-1, Appendix - A, dated 30 Nov 2014)

Minimum Basic Outline for APP The APP is the Contractor Safety and Health Program Document. The following Site Specific Areas will be addressed:

NOTE: 1. Contractor will complete Checklist and Submit with their APP.

NOTE: 2. Contractor APP WILL be submitted in format below.

NOTE: 3. Safety Office will review Contractor APP and return to PM /COR.

NOTE: 4. Contractor APP's ARE NOT APPROVED by the USACE, only found as Acceptable or Non-Acceptable.

Safety Office Review Status: ACCEPTED BY/DATE: NOT ACCEPTED BY/DATE:

Contractor Name: _______________________________________________________

Contract No: _________________________________

ALL CHECKLIST ITEMS WILL BE COMPLETED!

1. SIGNATURE SHEET. Title, signature, and phone number of the following:

a. Plan Preparer (qualified person, Competent Person such as corporate safety staff person, QC).

b. Plan Approval by company/corporate officers authorized to obligate the company (e.g. owner company president, regional vice president etc.)

c. Plan Concurrence (e.g. Chief of Operations, Corporate Chief of Safety, Corporate Industrial Hygienist, project manager or superintendent, project safety professional, project QC). Provide concurrence of other applicable corporate and project personnel (Contractor).

2. BACKGROUND INFORMATION. List the following:

a. Contractor;

b. Contract number;

c. Project name;

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

equipment to be used; anticipated high risk activities

e. Major phases of work anticipated and activities that will require an AHA

3. STATEMENT OF SAFETY AND HEALTH POLICY. Provide a copy of your current corporate/company Safety & 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 for his own employees, all sub-contractors and all others on the worksite.

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. Per EM 385-1-1 01.A.17, the SSHO is required to have as a minimum the OSHA 30-hour Construction Safety course and construction industry safety experience; and must be on-site at all times when work is 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 and details of the employers Risk Management Process (i.e.AHAs)

APP Checklist Site Activity Page 2 of 4

e. Requirements for activity specific AHAs to be submitted and accepted at preparatory meetings, prior to work being performed;

f. Requirements that no work by the Contractor shall be performed unless a designated CP/SSHO is present at the job site;

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

h. Lines of authority;

i. 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.

7. SAFETY AND HEALTH 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…