Safety_Submittals.pdf

ACCIDENT PREVENTION PLAN

Plan Preparer (Name, Title, Phone Number, & Signature):

Plan Approver (Name, Title, Phone Number, & Signature):

Plan Concurrence (Name, Title, Phone Number, & Signature):

Project Name

Contractor Name

Contract Number

Date

EMERGENCY PHONE NUMBERS AND MEDICAL FACILITY MAP

1. Map with Highlighted Route, Address, and Directions:

2. Emergency Phone Numbers:

Contact Phone Number

SIGNATURE SHEET

Name Signature Date Company

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

b. Background Information

1. Project Description and Definable Features of Work:

2. Anticipated High Risk Activities:

3. List of Equipment/Machinery to be Used Onsite:

4. Activities Hazard Analysis have been (or will be) submitted to the GDA for all the Definable Features of Work prior to initiating each phase.

c. Statement of Safety and Health Policy

1. is committed to:

A. The safety, health, and well-being of each and every employee, to include subcontractors;

B. Requiring all employees to follow all aspects of the APP and additional company safety programs/policies;

C. Holding all managers and supervisors accountable for the safety performance and awareness of all employees under their direction;

D. Performing all aspects of this project in accordance with EM 385-1-1 and OSHA regulations;

E. Maintaining safe and healthful working conditions;

F. Providing all necessary protective equipment to ensure the safety and health of site employees, subcontractors, and the public;

G. Providing site workers with the information and training required to make them fully aware of known and suspected hazards that may be encountered;

H. Encouraging active involvement of employees at all levels, during the implementation and continuous improvement of the health and safety program.

I. Additional Safety Policy Information:

3. Contractor Safety Goals and Objectives:

4. Contractor Accident Experience (OSHA 300 forms, or equivalent) are available if requested by the GDA.

d. Responsibilities and Lines of Authority

1. The lines of authority for this project and at the corporate level are:

(include names and titles)

2. is the Site Safety and Health Officer

(SSHO). He/she is responsible for enforcing the requirements of this APP for the duration of the project. The SSHO has the authority to immediately correct all areas of noncompliance and can stop work for unsafe environments.

3. has submitted a 10 Hour OSHA card (or above), along with their related experience and other qualifications for review.

4. No work will be performed by or any subcontractors unless the SSHO (or approved Alternate SSHO) is onsite.

5. If applicable, provide a list of Competent Persons (CPs) and their area of proficiency: Submit their trainings/qualifications for review.

(Examples: Fall Protection, Excavation/Trenching, Confined Spaces, Scaffolding, Cranes/Rigging, etc.)

6. Policies and procedures regarding noncompliance with safety requirements. ‘s disciplinary actions for violation of safety requirements are:

e. Subcontractors and Suppliers:

1. requires its subcontractors to work in a responsible and safe manner. Subcontractors for this project will be required to adhere to applicable requirements set forth in the EM

385-1-1 and this APP.

2. List of Anticipated Subcontractors (Name and Roles):

f. Training:

1. The following Safety and Occupational Health topics will be briefed to employees on their first day onsite, during the initial site safety orientation:

2. All employees, including subcontractors, have reviewed this APP during the safety orientation and have signed the included signature sheet.

3. The following are mandatory trainings and certifications applicable to this project: (Examples: Crane Operators, CDL, Diver, SPRAT, etc.)

4. All site personnel have been briefed on the sites emergency response procedures. This includes but is not limited to:

A. Emergency Responsibilities, Communications, & Procedures:

B. Rally point(s):

C. Emergency Phone Numbers (Refer to Page 2 of the APP)

D. Locations of emergency equipment:

E. A map to closest medical facility is included with the APP.

F. Additional Emergency Information:

5. First Aid/CPR certificates, in accordance with EM 385-1-1 Section

03.A.02, have been submitted for two onsite employees:

a. b.

6. Safety meetings/toolbox talks will be held by the SSHO/Competent

Person: , on a weekly basis or at the beginning of each new phase of work (whichever is sooner). Minutes will be documented and will include: attendee’s names, meeting duration, and topics discussed.

g. Safety and Health Inspections:

1. Daily safety and health inspections will be performed in accordance with EM 385-1-1, Section 01.A.13. These inspections will be conducted by the SSHO/Competent Person: . All inspections must be documented and any deficiencies that cannot be immediately corrected will be tracked on the deficiency log below, or equivalent.

2. List any anticipated external inspections (EPA, OSHA, State, other

Federal Agencies, etc.):

3. Deficiency Log/Corrective Actions: Date Found Date Corrected

h. Mishap Reporting and Investigation:

1. is responsible for reporting the exposure data (man-hours worked) to the GDA no later than close of business on the 5th calendar day of the following month.

2. All accidents and near misses will be investigated by the Contractor.

All work-related recordable injuries, illnesses and property damage accidents (excluding on-the-road vehicle accidents), in which the property damage exceeds $5,000.00, will be verbally reported to the GDA within 4 hours of the incident. Serious accidents as described in EM 385-1-1 Section 01.D shall be immediately reported to the GDA.

ENG Form 3394 shall be completed and submitted to the GDA within five working days of the incident.

3. is responsible for completing the accident notifications, investigations, and reports.

i. Plans, Programs, and Procedures:

1. Additional site-specific plans (listed in EM 385-1-1, Appendix A, Section i) are required to be included as amendments to this APP.

Only the plans applicable to the work being performed are required to be submitted. A few common plans include but are not limited to:

A. Fall Protection and Prevention

B. Excavation/Trenching

C. Tree Felling and Maintenance

D. Confined Space Entry

E. Rope Access Work

F. Hazardous Energy Control (Lockout/Tagout)

G. Crane/Load Handling Equipment

H. Lead Compliance

I. Asbestos Abatement

J. Hazard Communication

Other Remarks:

Month Year

City State

USACE Office Overseeing Work:

Describe The Case

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

Project Title

Using these categories, check ONLY the most serious result for each case:

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.

Contractor Name

USACE PRIME CONTRACTOR

USACE Command

US Army Corps of Engineers

(A) (E)

Contract Number

Classify the case

Check the "injury" column or choose one type of illness:

Identify the person

Enter the number of days the injured or ill worker was:

(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

Away from work (days)

In ju ry

Death

Job transfer or restriction

Using these categories, check ONLY the most serious result for each case:

Sk in

D is or de r

R es pi ra to ry

C on di tio n

Pr im e or

S ub

(P o r S )Company Name

Al l o th er

Ill ne ss es

On job transfer or restriction (days)

Ag e

G en de r

Other record-able cases

Remained at work

Date of injury or onset of illness

Check the "injury" column or choose one type of illness:

Po is on in g

Days away from work

Signature

Certification of Record

Name of Person

Submit. Record

Job Title (e.g., Welder)

(mo./day)

H ea rin g

Lo ss

(M)

Enter the number of days the injured or ill worker was:

FUSRAP

IRP

Year to Date

Ordinance/Expl. Cleanup

Superfund

TYPE OF WORK ACTIVITY (Choose One):

For Government Use Only

Where the event occurred (e.g. Loading dock north end)Date Employee

Began Work on

Job Covered by Contract

Date

Exposure Hours

Month

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)

Environmental Remed.

___ of ___PageEnvironmental Other

FUDS

ENG FORM 3394-1-999 CAN BE FOUND AT THE FOLLOWING LINK: http://www.publications.usace.army.mil/Portals/76/Publications/EngineerForms/ ENG_FORM_3394_1999Mar.pdf?ver=2013-09-08-231303-357

Emergency Equipment:

Mandatory Training/Certs:

Emergency Communications:

Rally Points:

Equipment/Machinery: