Type of work to be completed // Scope
Job Number ( If available / created yet)
1. Is barricading and or signage required protecting facilities, personnel or equipment ?
- electrical dangers posted - eye protection
- hard hat area - no smoking
- authorized personnel - other
2. Will work involve live systems or energized equipment?
3. Is lockout / tag-out of energized equipment required?
4. Will work involve falls greater than 6 feet or greater?
5. Are ladders, mechanical / electrical work platforms (MEWP) , scaffolds or work platforms needed to perform task?
6. Will the task involve the use of chemicals or be adjacent to process piping / equipment containing chemicals?
6a. Have material data safety sheets been provided to crew?
- container labeling
- proper chemical use
6b. Has a chemical approval request been completed for the use of the chemicals ?
6c. Does the work require disposal of chemicals?
6d. Will the work generate odors?
6e. Are chemicals stored properly ( double containment) ?
6f. Have personnel been trained in use and proper disposal of ppe?
7. Does this require the demolition of electrical / mechanical or chemical systems or equipment?
8. Does this work involve removing floor tile and or ceiling tiles?
9. Will weather conditions affect the completion of this task?
10. Does this work require awkward positions or static postures?
11. Can this work be assembled at waist height as opposed to overhead or below grade?
12. Is adequate material handling equipment available to move/ lift materials? (( forklift, pallet jack, chain fall, cable hoist)) ?
13. Will work involve employee exposure to hazardous noise levels ( exceeding 85 DBA)?
- aisle ways, walkways - removal procedures
- nails - debris containers
- removal procedures - overall neat appearance
- materials tools, equipment
15. Fire Prevention
A. Extinguishers on site
B. storage of containers/ labeling
C. Compressed gas cylinders
D. Contaminated rag storage
E. welding/ cutting
16. Site Security
- fencing / lockable gates , doors
- locks/ lock box
A. Fire detection and or smoke detectors?
B. electrical systems ?
C. Plumbing systems ?
D. Roofing systems ?
E. Flooring systems?
G. Ceiling systems?
H. Doors and door frames?
I. Production tools?
J. Other security / Life safety systems ?
Hot work permit
At height work permit
Confined space permit
Critical lift plan
Mechanical Electrical Work Platforms ( MEWP) permits
Foot / Toe
Others / Misc.
Butyl / Chemical gloves
Mechanics / General purpose
1. Has work area been walked by crew to identify safety and or impact concerns ?
2. Is the area safe to work in?
3. Has the work been coordinated with other trades in the area?
4. All tools and equipment in safe / good condition
* including extension cords, slings , hand tools etc...
5. All necessary training for this task has been completed?
6. All new employees familiarized with work area?
7. Sufficient personnel have been assigned to the task / tasks safely?
8. Emergency exits and equipment have been identified?
( phones, fire extinguishers, eyewash, etc..)
9. Contingency plans have been developed for unexpected events ?
( medical emergencies, and or equipment failure)
10. Certified first aid / CPR personnel on site along with First Aid Kits ?
- contents of kit
- kit available?
- trained employees
IF WORK CONDITIONS OR ACTIVITIES CHANGE , WORK MUST STOP!
UNTIL TASK PLAN IS REVISED AND REVIEWED BY CREW
PLEASE POST A COPY IN WORK AREA
BELFOR office assignment ( location)
System Owner (( If Required)) ( loss contact representative)
Regional Safety Manager