Information
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Document No.
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Client
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Conducted on
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Prepared by
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Project Name
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Location
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Personnel
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Location
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Date
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Contractor Crew Name
AUI Crew Name -
Type of work being performed
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Work order documentation complete?
- YES
- NO
- N.A.
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Procedures / Maps / Drawings reviewed?
- YES
- NO
- N.A.
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Locates valid and complete
- YES
- NO
- N.A.
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Add media
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Hazard assessment completed and signed by all personnel
- YES
- NO
- N.A.
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Work plan review completed
- YES
- NO
- N.A.
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Add media
PPE
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Safety foot wear
- YES
- NO
- N.A.
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F.R. Coveralls
- YES
- NO
- N.A.
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Hard hat
- YES
- NO
- N.A.
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Hand protection
- YES
- NO
- N.A.
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Eye protection
- YES
- NO
- N.A.
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Condition of P.P.E.
- YES
- NO
- N.A.
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First aid kit
- YES
- NO
- N.A.
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Spill kit
- YES
- NO
- N.A.
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Fire extinguisher Available / Certified
- YES
- NO
- N.A.
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Road signage
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Proper sign placement
- YES
- NO
- N.A.
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Traffic control person certified
- YES
- NO
- N.A.
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Traffic cones
- YES
- NO
- N.A.
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Barricades
- YES
- NO
- N.A.
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Chock blocks used
- YES
- NO
- N.A.
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Excavating
Excavation
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Facilities exposed prior to excavation
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Spotter and fire extinguisher around live lines
- YES
- NO
- N.A.
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Safe entry and exit for workers
- YES
- NO
- N.A.
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Shoring / Sloping Excavations > 1.5 deep Follow OH&S Part 32
- YES
- NO
- N.A.
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Traffic and pedestrian protected from trenches
- YES
- NO
- N.A.
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Proper depth achieved
- YES
- NO
- N.A.
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Spoil pile to ditch 1 M
- YES
- NO
- N.A.
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Soil separation
- YES
- NO
- N.A.
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Directional drilling
Directional drilling
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Buried facilities non destructively exposed
- YES
- NO
- N.A.
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Weak link
- YES
- NO
- N.A.
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Adequate size reamer
- YES
- NO
- N.A.
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Crossing facilities at sight hole
- YES
- NO
- N.A.
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Double tracer wire
- YES
- NO
- N.A.
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Required depth Achieved
- YES
- NO
- N.A.
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Pipe free of damage after bore completed
- YES
- NO
- N.A.
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Creek crossing
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Plan of work reviewed and signed
- YES
- NO
- N.A.
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Spill kit
- YES
- NO
- N.A.
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Pictures of creek taken
- YES
- NO
- N.A.
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Water samples taken
- YES
- NO
- N.A.
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Proper set back from banks
- YES
- NO
- N.A.
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Monitor for fraction out
- YES
- NO
- N.A.
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Pipe squeeze
Pipe squeezing
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Static control
- YES
- NO
- N.A.
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1/2" per minute or slower squeeze and release rate
- YES
- NO
- N.A.
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Squeeze points marked
- YES
- NO
- N.A.
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Add media
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Hydro Excavation
Hydro excavation
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Water pressure < 2000 psi (13790 Kpa) Water temp < 180 F (82 C)
- YES
- NO
- N.A.
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PPE Utilized
- YES
- NO
- N.A.
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Continuous wand motion
- YES
- NO
- N.A.
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Adequate protection of holes
- YES
- NO
- N.A.
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Power company orientation
- YES
- NO
- N.A.
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Welding
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AUI Certified welder
- YES
- NO
- N.A.
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Reviewed procedure with welder
- YES
- NO
- N.A.
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Condition of pipe inspected
- YES
- NO
- N.A.
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Preheat completed
- YES
- NO
- N.A.
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Correct electrodes used
- YES
- NO
- N.A.
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PPE Utilized
- YES
- NO
- N.A.
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Manned fire extinguisher
- YES
- NO
- N.A.
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Steel line stopping
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Reviewed procedure
- YES
- NO
- N.A.
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Proper tool and fitting selection
- YES
- NO
- N.A.
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Fitting properly tested
- YES
- NO
- N.A.
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Center punch used
- YES
- NO
- N.A.
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Dry fit test run
- YES
- NO
- N.A.
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Mark depth of travel
- YES
- NO
- N.A.
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Tooling assembled correctly
- YES
- NO
- N.A.
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Handles removed when not in use
- YES
- NO
- N.A.
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Proper compression of rubber stopper Number of turns
- YES
- NO
- N.A.
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Purge isolated section
- YES
- NO
- N.A.
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No leaks on completion plug
- YES
- NO
- N.A.
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Denso / polyken tape completed properly
- YES
- NO
- N.A.
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Add media
P.E. Fusions
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Add type of fusion
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Static protection utilized
- YES
- NO
- N.A.
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Fusion temp to manufactures specs
- YES
- NO
- N.A.
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Proper tooling used ( E.F. Clamps)
- YES
- NO
- N.A.
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Proper pipe prep
- YES
- NO
- N.A.
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Pyrometers / temp stick utilized
- YES
- NO
- N.A.
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Cord condition and size appropriate
- YES
- NO
- N.A.
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Bell hole clear of garbage
- YES
- NO
- N.A.
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Fuser info
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Pressure testing
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Stabilize time appropriate <100m - 10 min 100-500m- 15 min >500 m - 30 min
- YES
- NO
- N.A.
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Valves open and plugged
- YES
- NO
- N.A.
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Available joints soap tested
- YES
- NO
- N.A.
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Backfill
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Trench free from foreign objects
- YES
- NO
- N.A.
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Tracer wire maximum separation of 15 cm
- YES
- NO
- N.A.
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Proper pipe shading
- YES
- NO
- N.A.
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Back fill follows municipal requirements & or AUI requirements
- YES
- NO
- N.A.
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Vibratory tampers used
- YES
- NO
- N.A.
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Site securement
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Equipment on site secured and parked appropriately
- YES
- NO
- N.A.
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Excavations snow fenced and barricaded
- YES
- NO
- N.A.
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Pipe ends capped
- YES
- NO
- N.A.
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Material secure
- YES
- NO
- N.A.
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Flashing barricades working
- YES
- NO
- N.A.
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Follow up
Follow up
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Complete by:
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Hazard Risk Rating
A: Hazards have the potential for causing immediate and serious injury or damage
B: Hazards are less severe, but still have potential for causing injury or damage
C: Hazards/deficiencies that have potential to cause minor injury or damage -
Category:
1. Environmental
2. Safety
3. Procedures
4. Equipment -
Hazard Risk and Category classification
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Accepted by:
