270115 Site Start. Risk Ass't . Feedback inc Customer Satisfaction R&M STW(East)

• STW east R&M

General information

• SAP Order nr

• Maygurney order nr

• Start date / time on site

  Date

• Description of works

  Select pipe / rising main repair up to 1.5 m deep pipe / rising main repair over 1.5 m deep internal repair to manhole interceptor removal manhole replacement manhole construction flood mitigation works schedule 13 exceptional works

  • pipe / rising main repair up to 1.5 m deep
  • pipe / rising main repair over 1.5 m deep
  • internal repair to manhole
  • interceptor removal
  • manhole replacement
  • manhole construction
  • flood mitigation works
  • schedule 13 exceptional works

• Any additional information available

  yes

  no

• Location of works

  highway

  private

  other

• Works in highway

  yes

  no

• Road category (details from schedulers / TMA team)

  footway

  cat 1

  cat 2

  cat 3

  cat 4

• Traffic management used

  Select chapter 8 give and take lane closure 2 way lights 3 way lights 4 way lights stop / go road closure footpath closure

  • chapter 8
  • give and take
  • lane closure
  • 2 way lights
  • 3 way lights
  • 4 way lights
  • stop / go
  • road closure
  • footpath closure

• Is TMA a road closure

  yes

  no

• Duration of closure ?

• Has diversion route been agreed with highway authority ?

  yes

  no

• Contact supervisor for guidance

• Location of diversion route

  rural

  town

  urban minor

  urban major

  traffic sensitive

• Is the route suitable for the increased traffic volumes and size of vehicle ?

  yes

  no

• Contact supervisor for guidance

• Are there site specifics ,eg school,bus stops,hospital,industrial estate,pedestrianised area,play park,etc. that will be affected by the increased traffic volume or type of vehicle using route

  yes

  no

• Contact supervisor for guidance

• Impact of works on highway user

  none

  minor

  average

  major

Risks to signing ,lighting and guarding

• Weather

  Select wind ( ensure sand bags in place to secure) other (supply details)

  • wind ( ensure sand bags in place to secure)
  • other (supply details)

• Traffic

  Select Traffic too large for diversion route traffic speed traffic volumes

  • Traffic too large for diversion route
  • traffic speed
  • traffic volumes

• Vandalism

  Select local school pub night club other (give details)

  • local school
  • pub
  • night club
  • other (give details)

• Other factors

• Is TMA remotely controlled STOP / GO board operation

  yes

  no

• Reason stop / go selected

  Select highway authority specified location suited to manual control stop / go maintains traffic flow efficiency stop / go safest option remotely operated stop / go boards cannot be used

  • highway authority specified
  • location suited to manual control
  • stop / go maintains traffic flow efficiency
  • stop / go safest option
  • remotely operated stop / go boards cannot be used

• 1. Correct SLG available on site

  yes

  no

• 2. Distance between stop / go boards is less than 200m

  yes

  no

• 3. Daylight hours and good visibility?

  yes

  no

• 4. Unobstructed view of both approaches ?

  yes

  no

• 5. Operator is no more than 100m from each board ?

  yes

  no

• 6. Traffic flow is less than 800 vehicles per hour ?

  yes

  no

• Are all answers 1. to 6. yes ?

  yes

  no

• Do not use boards . Contact supervisor

• Is TMA manually controlled STOP / GO board operation

  yes

  no

• Reason manual stop / go selected

  Select highway authority specified location suited to manual control stop / go maintains traffic flow efficiency stop / go safest option remotely operated stop / go boards cannot be used

  • highway authority specified
  • location suited to manual control
  • stop / go maintains traffic flow efficiency
  • stop / go safest option
  • remotely operated stop / go boards cannot be used

• 1. Correct SLG available on site

  yes

  no

• 2. Distance between stop / go boards is less than 200m

  yes

  no

• 3. Both boards are fully illuminated during hours of darkness ?

  yes

  no

• 4. Where operator's are not in direct line of sight, 2 way radios are in use ?

  yes

  no

• 5. Operator is in a position of safety - not in the safety zone ?

  yes

  no

• 6. Traffic flows do not exceed maximum flows stated in table on page 60 of the red book ?

  yes

  no

• 7. For a single operated stop / go board , the site is less than 20m in length?

  yes

  no

• Are all answers 1. to 7. yes ?

  yes

  no

• Do not use boards . Contact supervisor

• Is TMA a footpath closure

  yes

  no

• Duration of closure ?

• Location of works

  rural

  town

  urban minor

  urban major

  traffic sensitive

• Have all alternatives to closing the foot way been considered ?

  yes

  no

• Has the work been planned to avoid peak / traffic sensitive times ?

  yes

  no

• Contact supervisor for guidance

• Describe control measures

  Select pedestrian walkway of correct width pedestrian ramps correct signage for pedestrians

  • pedestrian walkway of correct width
  • pedestrian ramps
  • correct signage for pedestrians

• Describe monitoring arrangements when site unattended

  Select visual ,PHOTO and physical check of SLG before leaving site out of hours site visit planned site visits by supervisor

  • visual ,PHOTO and physical check of SLG before leaving site
  • out of hours site visit
  • planned site visits by supervisor

• Impact of works on highway user

  none

  minor

  average

  major

• Are the works under a permit scheme ?

  yes

  no

• Are the permit conditions in place ?

  yes

  no

• Contact supervisor for guidance

• Will the highway be temporarily obstructed for short periods

  yes

  no

• Control measures in place

  Select banksman directing pedestrians as required correct additional signage on site and used barriers moved and replaced as required

  • banksman directing pedestrians as required
  • correct additional signage on site and used
  • barriers moved and replaced as required

• Are there site specifics ,eg. Commuter route,school,bus stop,hospital,industrial estate,farm,pedestrians,play-park, etc.

  yes

  no

• Control measures in place

  Select banksman directing pedestrians as required correct additional signage on site and used barriers moved and replaced as required

  • banksman directing pedestrians as required
  • correct additional signage on site and used
  • barriers moved and replaced as required

• Will pedestrians,cyclists,horse riders be affected by the works? Do they have safe access through the works at all times ?

  yes

  no

• Control measures in place

  Select banksman directing pedestrians as required correct additional signage on site and used barriers moved and replaced as required

  • banksman directing pedestrians as required
  • correct additional signage on site and used
  • barriers moved and replaced as required

• Will the site layout change during the works ?

  yes

  no

• Risks during changeover

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Control measures in place

  Select banksman directing pedestrians as required correct additional signage on site and used barriers moved and replaced as required

  • banksman directing pedestrians as required
  • correct additional signage on site and used
  • barriers moved and replaced as required

Risks to signing ,lighting and guarding

• Weather

  Select wind ( ensure sand bags in place to secure) other (supply details)

  • wind ( ensure sand bags in place to secure)
  • other (supply details)

• Traffic

  Select Traffic too large for diversion route traffic speed traffic volumes

  • Traffic too large for diversion route
  • traffic speed
  • traffic volumes

• Vandalism

  Select local school pub night club other (give details)

  • local school
  • pub
  • night club
  • other (give details)

• Other factors

• Control measures frequency of site inspection / visit

  Select next working day daily twice daily every 6 hours every 3 hours continuous

  • next working day
  • daily
  • twice daily
  • every 6 hours
  • every 3 hours
  • continuous

• Any additional information available

  yes

  no

• PTD Required before start on works

  yes

  no

• PTD Signed

  yes

  no

• DO NOT START WORKS CALL SUPERVISOR FEEDBACK WITH PHOTO TO PROVE ATTENDANCE

• Grid ref X

• Grid ref Y

• Address

• Postcode

• County

  Select Derbyshire Nottinghamshire Leicestershire Warwickshire Worcestershire Gloucestershire

  • Derbyshire
  • Nottinghamshire
  • Leicestershire
  • Warwickshire
  • Worcestershire
  • Gloucestershire

Daily risk assessment

• Is this first job of working day

  yes

  no

• COMPLETE VAN CHECKS BEFORE MOVING ON

• Items checked and in working order / fit for use

  Select oil water fire extinguisher first aid kit hand cleaning facilities gloves tyre / wheel check tow bar lights

  • oil
  • water
  • fire extinguisher
  • first aid kit
  • hand cleaning facilities
  • gloves
  • tyre / wheel check
  • tow bar
  • lights

• Are any items requiring attention

  yes

  no

• Items requiring attention

  Select oil water fire extinguisher first aid kit hand cleaning facilities gloves tyre / wheel check tow bar lights

  • oil
  • water
  • fire extinguisher
  • first aid kit
  • hand cleaning facilities
  • gloves
  • tyre / wheel check
  • tow bar
  • lights

• Details of requirements and actions taken

• Is vehicle safe to operate

  yes

  no

• DO NOT USE VEHICLE CONTACT MANAGEMENT FOR GUIDANCE AND INSTRUCTION

• Do works involve use of plant and tools ?

  yes

  no

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• Are any items defective in any way

  yes

  no

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• ISOLATE IN STORE CABIN , RAISE DEFECT WITH MANAGER AND COLLECT REPLACEMENT

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• ISOLATE IN STORE CABIN , RAISE DEFECT WITH MANAGER AND COLLECT REPLACEMENT

• Plant used

  Select P. power saw D. hand held breaker GD. gas detector TR. trench rammer K. kango breaker HB. hydraulic breaker ERB. electric road breaker G. generator M. microwave SP. submersible pump PP. petrol pump TRP. tripod and winch TP. plant trailer TT. tipping trailer RR. road roller T. transit van LS. lifting sling CS. chain sling DC. drop chain DL. d link GR 4" grinder LB line burner WP wackier plate MD mini excavator RT ratchet straps extension lead FE fire extinguisher gauge

  • P. power saw
  • D. hand held breaker
  • GD. gas detector
  • TR. trench rammer
  • K. kango breaker
  • HB. hydraulic breaker
  • ERB. electric road breaker
  • G. generator
  • M. microwave
  • SP. submersible pump
  • PP. petrol pump
  • TRP. tripod and winch
  • TP. plant trailer
  • TT. tipping trailer
  • RR. road roller
  • T. transit van
  • LS. lifting sling
  • CS. chain sling
  • DC. drop chain
  • DL. d link
  • GR 4" grinder
  • LB line burner
  • WP wackier plate
  • MD mini excavator
  • RT ratchet straps
  • extension lead
  • FE fire extinguisher gauge

• Plant nr

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13

• ISOLATE IN STORE CABIN , RAISE DEFECT WITH MANAGER AND COLLECT REPLACEMENT

• Do works involve working at height

  yes

  no

• Control measures required

  Select drag box / sheets extended 1m above ground level covers / fencing in place around open manholes 1m fencing to be used as additional edge protection fall prevention measures required ( harness and winch / fall arrest device)

  • drag box / sheets extended 1m above ground level
  • covers / fencing in place around open manholes
  • 1m fencing to be used as additional edge protection
  • fall prevention measures required ( harness and winch / fall arrest device)

• Do works involve excavation<br>

  yes

  no

• Control measures required

  Select trench support as required / in place excavation battered / stepped back to safe angle of repose excavation to be inspected prior to each entry by competent person

  • trench support as required / in place
  • excavation battered / stepped back to safe angle of repose
  • excavation to be inspected prior to each entry by competent person

Pre excavation checklist

• Risk assessments suitable for work

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Public utility records available

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Pre or construction drawings available

  yes

  no

  n/a

• CAT and genny function check completed

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• CAT And genny in calibration

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• CAT and genny survey completed to mark services complete with photo to confirm

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Suitable insulated tools available

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• No mechanical dig or use of picks, bars / spikes within 500 mm of known services

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• PPE worn as per risk assessment

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Signing / lighting / guarding to company standards

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Are measures to protect public suitable

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

Permit to dig

• CAT serial number

• Genny serial number

• Operatives trained and competent with use of CAT and genny

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Can operatives read and understand service drawings

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Are operatives aware of safe digging techniques

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Has risk assessment been completed

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• water mains present

  yes

  no

• Has utility been marked and location photographed

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Gas mains present

  yes

  no

• Has utility been marked and location photographed

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Electric mains present

  yes

  no

• Has utility been marked and location photographed

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Street lighting present

  yes

  no

• Has utility been marked and location photographed

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Telecom cables / ducts present

  yes

  no

• Has utility been marked and location photographed

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Other fibre optic cables / ducts present

  yes

  no

• Has utility been marked and location photographed

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Overhead services / obstructions present

  yes

  no

• Are protection measures required

  yes

  no

• Protection measures required

  Select goalposts erected sleeving installed by utility company additional Banksman position to control operations

  • goalposts erected
  • sleeving installed by utility company
  • additional Banksman position to control operations

• Are protection measures in place

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• IF EXCAVATION OVER 1.2 m DEEP OR GROUND CONDITIONS DICTATE NON STANDARD APPROACH AND THE FOLLOWING ITEMS NOT IN PLACE OR CARRIED OUT NO WORKS TO PROCEED
  
  1. Ensure excavation assessment / inspection report is completed as part of works records
  
  2. Ensure adequate trench support or benching is in place
  
  3. Ensure adequate edge protection is in place

Excavation assessment / inspection report

• Excavation risk score A

  1

  2

  3

• Nature of ground. B

  1

  2

  3

• Ground water presence. C

  1

  2

  3

• Surcharge (side loading) possibility. D

  1

  2

  3

• Personnel entering excavation. E

  1

  2

  3

• Total risk score A + B + C + D + E

• Total risk score range

  up to 5

  6 to 7

  8 to 15

• Site team to review need for excavation support Monitor conditions as work progresses

• Advice required from competent person on need for excavation support / benching Monitor conditions as works progress

• Excavation support required Monitor conditions as works progress

• Can works be carried out safely ( if NO then name person informed and any actions taken)

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Responsible person

  Sign

• CAT SURVEY RECORD

  Media

• Is it necessary to enter a confined space<br>

  yes

  no

Confined space - permit to enter

• Reason to enter

  Select sewer repair interceptor removal internal manhole repair manhole construction man entry for inspection man entry to remove object man entry to assist other contractor flood mitigation exceptional sewer relay exceptional rising main relay exceptional manhole cover replacement

  • sewer repair
  • interceptor removal
  • internal manhole repair
  • manhole construction
  • man entry for inspection
  • man entry to remove object
  • man entry to assist other contractor
  • flood mitigation
  • exceptional sewer relay
  • exceptional rising main relay
  • exceptional manhole cover replacement

• Known and potential hazards

  Select gases services sewage flooding

  • gases
  • services
  • sewage
  • flooding

• Are all operatives confined space trained

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Have all operatives and any subcontractors received pre entry briefing on specific hazards an control methods

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Is a non entry rescue procedure in place

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Entry date

  Date

• Equipment requirement checklist

  Select full body harness tripod / hoist signing and guarding ladder fall protection ventilation fan or air mover fire extinguisher self contained breathing apparatus air purifier

  • full body harness
  • tripod / hoist
  • signing and guarding
  • ladder
  • fall protection
  • ventilation fan or air mover
  • fire extinguisher
  • self contained breathing apparatus
  • air purifier

• PPE Requirement checklist

  Select gloves leather gloves impervious gloves chemical gloves (needle stick protection ) goggles face mask general work boots Wellington boots head protection gas monitor

  • gloves leather
  • gloves impervious
  • gloves chemical
  • gloves (needle stick protection )
  • goggles
  • face mask
  • general work boots
  • Wellington boots
  • head protection
  • gas monitor

• Electrical isolation of work area required

  yes

  no

• Has isolation been completed

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Are specialist communication systems required

  yes

  no

• Has communication been established

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Is additional lighting required

  yes

  no

• Has lighting been established

  yes

  no

• DO NOT START WORKS SPEAK TO SUPERVISOR

• Responsible person

  Sign

• Pre entry set up record

  Media

• Are slips and trips possible

  yes

  no

• Control measures required

  Select all debris and materials to be cleared from designated walkways agreed area in place for material storage all spillages to be cleared immediately

  • all debris and materials to be cleared from designated walkways
  • agreed area in place for material storage
  • all spillages to be cleared immediately

• Are public in close proximity of works

  yes

  no

• Control measures required

  Select all areas protected with double fencing fencing double clipped and placed to ensure it does not enter public areas resident letters distributed courtesy boards displayed

  • all areas protected with double fencing
  • fencing double clipped and placed to ensure it does not enter public areas
  • resident letters distributed
  • courtesy boards displayed

• Overhead services (including sheathed / protected cables)

  yes

  no

• Control measures required

  Select apparatus owner required to attend site (if within 6m of overhead cables) goalposts / bunting required height restrictions in place on plant

  • apparatus owner required to attend site (if within 6m of overhead cables)
  • goalposts / bunting required
  • height restrictions in place on plant

• Underground services

  yes

  no

• Control measures required

  Select cable drawings on site calibrated cable avoidance tools used to locate services prior to digging apparatus owner required to attend site

  • cable drawings on site
  • calibrated cable avoidance tools used to locate services prior to digging
  • apparatus owner required to attend site

• Works on the highway

  yes

  no

• Control measures required

  Select traffic management in place to highways requirement & chapter 8 NRSWA Trained personnel on site

  • traffic management in place to highways requirement & chapter 8
  • NRSWA Trained personnel on site

• Substance spillage

  yes

  no

• Control measures required

  Select spill kit on site environment agency contact details in file drip trays used

  • spill kit on site
  • environment agency contact details in file
  • drip trays used

• Use of hazardous substances

  yes

  no

• Control measures required

  Select COSHH assessments on site with suitable and sufficient PPE Correct fuel storage in place Area assessed and clear of syringes / suspected asbestos containing materials

  • COSHH assessments on site with suitable and sufficient PPE
  • Correct fuel storage in place
  • Area assessed and clear of syringes / suspected asbestos containing materials

• Works near water

  yes

  no

• Control measures required

  Select Life vest required (if within 2m of watercourse) life ring in place Edge protection in place Safety line required downstream Enviro - tags in place to monitor for contamination

  • Life vest required (if within 2m of watercourse)
  • life ring in place
  • Edge protection in place
  • Safety line required downstream
  • Enviro - tags in place to monitor for contamination

• Plant operation

  yes

  no

• Control measures required

  Select Trained personnel on site Plant inspected before use Banksman required for reversing operations / plant movements Quick hitch inspected and register completed

  • Trained personnel on site
  • Plant inspected before use
  • Banksman required for reversing operations / plant movements
  • Quick hitch inspected and register completed

• Works on live electrical equipment

  yes

  no

• Control measures required

  Select Trained personnel in place All live equipment isolated Permit to isolate issued prior to works commencing

  • Trained personnel in place
  • All live equipment isolated
  • Permit to isolate issued prior to works commencing

• Does work involve use of gas burner or asphalt mixer

  yes

  no

HOT WORK PERMIT CHECKLIST All items must be in place

• Ensure all items are in place

  Select trained person uninvolved with works to provide continuous watch combustible materials removed from work area floor area cleared of debris equipment for hot work has been checked and is in good repair gas cylinders properly secured

  • trained person uninvolved with works to provide continuous watch
  • combustible materials removed from work area
  • floor area cleared of debris
  • equipment for hot work has been checked and is in good repair
  • gas cylinders properly secured

• The following operatives have read , understand and agree to follow procedures of work detailed in this assessment

  Sign

• Have there been any visitors to site

  yes

  no

• All visitors to sign that they have read and understood the briefing

• Visitor 1

  Sign

• Visitor 2

  Sign

• Visitor 3

  Sign

• Have there been any client instructions given

  yes

  no

• Instructions given

• Pre start photos

  Media

WORK FEEDBACK

• Were any other utilities services encountered in excavation ?

  Yes

  No

  N/A

• Gas

  yes

  no

• Depth

• Number

• Water

  yes

  no

• Depth

• Number

• Electric LV

  yes

  no

• Depth

• Number

• Electric HV

  yes

  no

• Depth

• Number

• Street lighting

  yes

  no

• Depth

• Number

• Sewerage

  yes

  no

• Depth

• Number

• Telemetry

  yes

  no

• Depth

• Number

• BT

  yes

  no

• Depth

• Number

• Traffic signals

  yes

  no

• Depth

• Number

• Finish date / time

  Date

• Crew on site

  Select msn 1 msn 2 msn 3 msn 4 msn 5 msn 6 msn 7 msn 8 msn 9 msn 10 msn 11 msn 12

  • msn 1
  • msn 2
  • msn 3
  • msn 4
  • msn 5
  • msn 6
  • msn 7
  • msn 8
  • msn 9
  • msn 10
  • msn 11
  • msn 12

• Are works on a transferred sewer , manhole or cover

  yes

  no

• Description of works

  Select pipe / rising main repair up to 1.5 m deep pipe / rising main repair over 1.5 m deep internal repair to manhole interceptor removal manhole replacement manhole construction flood mitigation works schedule 13 exceptional works

  • pipe / rising main repair up to 1.5 m deep
  • pipe / rising main repair over 1.5 m deep
  • internal repair to manhole
  • interceptor removal
  • manhole replacement
  • manhole construction
  • flood mitigation works
  • schedule 13 exceptional works

• Is essential additional information available

  yes

  no

• Is job a manhole cover replacement

  yes

  no

• Type of damage

  Select missing cover cracked / damaged cover polished surface rocking cover cover too low cover too high surfacing defective around cover

  • missing cover
  • cracked / damaged cover
  • polished surface
  • rocking cover
  • cover too low
  • cover too high
  • surfacing defective around cover

• Manhole cover size

  Select 450 dia 600 dia 450 x 600 600 x 600 600 x 750 675 x 675 750 x 750 600 x 900 675 x 1220 900 x 900 other

  • 450 dia
  • 600 dia
  • 450 x 600
  • 600 x 600
  • 600 x 750
  • 675 x 675
  • 750 x 750
  • 600 x 900
  • 675 x 1220
  • 900 x 900
  • other

• Depth of cover

  100mm

  150mm

  200mm

  50mm

• Work type

  Replace

  Reset

• Manhole cover type

  HD D400

  MD C250

  MD B125

  LD A15

• Is job a pipe or rising main repair

  yes

  no

• Cause of damage

  Select Collapse Blockage

  • Collapse
  • Blockage

• Sewer type

  foul sewer

  surface water

• Pipe size

  Select 75 100 150 200 225 250 275 300 325 350 375 400 425 450 >450

  • 75
  • 100
  • 150
  • 200
  • 225
  • 250
  • 275
  • 300
  • 325
  • 350
  • 375
  • 400
  • 425
  • 450
  • >450

• Pipe material

  Select Clay Concrete MDPE/HDPE PVC Ductile Cast Iron Steel Fibre Glass Brick Asbestos Other N/A

  • Clay
  • Concrete
  • MDPE/HDPE
  • PVC
  • Ductile
  • Cast Iron
  • Steel
  • Fibre Glass
  • Brick
  • Asbestos
  • Other
  • N/A

• Length of repair

• Is job an interceptor removal

  yes

  no

• Location of manhole

  highway

  private

  other

• Removal type

  Internal

  External

• Is job a manhole construction

  yes

  no

• Manhole construction

  Select mono section 600 x450 mono section 750 x 600 mono section 1200 x 750 cast in situ 900 Pcc ring 1050 Pcc ring 1200 Pcc ring 1500 Pcc ring 1800 Pcc ring 2100 Pcc ring 2400 Pcc ring other

  • mono section 600 x450
  • mono section 750 x 600
  • mono section 1200 x 750
  • cast in situ
  • 900 Pcc ring
  • 1050 Pcc ring
  • 1200 Pcc ring
  • 1500 Pcc ring
  • 1800 Pcc ring
  • 2100 Pcc ring
  • 2400 Pcc ring
  • other

• Is job an internal repair

  yes

  no

• Repairs carried out

  Select re channel re bench pointing brickwork missing

  • re channel
  • re bench
  • pointing
  • brickwork missing

• Is job a flood mitigation job

  yes

  no

• Type of mitigation installed

  Select internal non return valve non return valve in new chamber sealed manhole cover vehicle floodgate pedestrian floodgate soak away and associated diversion of flows air brick replacement non return gulley installation re profile drive

  • internal non return valve
  • non return valve in new chamber
  • sealed manhole cover
  • vehicle floodgate
  • pedestrian floodgate
  • soak away and associated diversion of flows
  • air brick replacement
  • non return gulley installation
  • re profile drive

• Is job a schedule 13 item

  yes

  no

• Detail work type

  Select sewer repair interceptor removal internal manhole repair manhole construction man entry for inspection man entry to remove object man entry to assist other contractor flood mitigation exceptional sewer relay exceptional rising main relay exceptional manhole cover replacement

  • sewer repair
  • interceptor removal
  • internal manhole repair
  • manhole construction
  • man entry for inspection
  • man entry to remove object
  • man entry to assist other contractor
  • flood mitigation
  • exceptional sewer relay
  • exceptional rising main relay
  • exceptional manhole cover replacement

Reinstatement details

• Reinstatement type

  Temp

  Perm

  Unplanned Move

  Fresh Air Work

  N/A

• Length of reinstatement

• Width of reinstatement

• Thickness of surfacing

• Depth of repair carried out

• Surfacing material

  Select HRA SMA 10mm 6mm grass verge grass lawn PACO Patch hardcore Soil unmade concrete block paving

  • HRA
  • SMA
  • 10mm
  • 6mm
  • grass verge
  • grass lawn
  • PACO Patch
  • hardcore
  • Soil
  • unmade
  • concrete
  • block paving

Customer satisfaction record

• Is job on private

  yes

  no

• Is customer available to answer a few questions regarding works carried out

  yes

  no

• Was a pre start visit arranged ?

  Yes

  No

  N/A

• Were all appointments kept ?

  Yes

  No

  N/A

• Was the work completed on time

  Yes

  No

  N/A

• Was the work clearly explained ?

  Yes

  No

  N/A

• We're all staff polite and courteous at all times ?

  Yes

  No

  N/A

• Was the work carried out safely ?

  Yes

  No

  N/A

• Is all the area we have worked in left in good order ?

  Yes

  No

  N/A

• We're any complaints dealt with promptly ?

  Yes

  No

  N/A

• Would you recommend this company ?

  Yes

  No

  N/A

• How would you rate the overall performance where 1 is poor 10 is excellent

• Any other comments you would like recording

• I confirm that the afore mentioned works were carried out with our full agreement and to our satisfaction

  Sign

• Reason for not signing

  not at home

  no time

  refuses request

• Additional information

Waste disposal details

• Was any waste disposed of offsite

  yes

  no

• Method of waste disposal

  grab lorry

  on site skip

  skip in yard

  direct into lorry

  reused on site

Tankering / Overpumping details

• Was any Tankering or Overpumping carried out

  yes

  no

• Tanker type 1

• Tanker size

  Select 2000 gal 3000 gal 4000 gal

  • 2000 gal
  • 3000 gal
  • 4000 gal

• Nr of tankers

  Select 1 2 3 4 5 6 7 8 9 10 11

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11

• Hrs used

• Tanker type 2

• Tanker size

  Select 2000 gal 3000 gal 4000 gal

  • 2000 gal
  • 3000 gal
  • 4000 gal

• Nr of tankers

  Select 1 2 3 4 5 6 7 8 9 10 11

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11

• Hrs used

• Tanker type 3

• Tanker size

  Select 2000 gal 3000 gal 4000 gal

  • 2000 gal
  • 3000 gal
  • 4000 gal

• Nr of tankers

  Select 1 2 3 4 5 6 7 8 9 10 11

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11

• Hrs used

• Pump 1 type

• Pump size

  4"

  6"

  8"

• Nr of pumps

  Select 1 2 3 4 5 6 7 8 9 10 11

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11

• Hrs used

• Pump 2 type

• Pump size

  4"

  6"

  8"

• Nr of pumps

  Select 1 2 3 4 5 6 7 8 9 10 11

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11

• Hrs used

• Pump 3 type

• Pump size

  4"

  6"

  8"

• Nr of pumps

  Select 1 2 3 4 5 6 7 8 9 10 11

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11

• Hrs used

Location plan / photos / sketch ( as required)

• Site address
  Address

• Location and general feedback photos

  Media

• Draw sketch plan (if needed)

  Drawing