BNS - Grout Audit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

PPE

• Are Safety Glasses being worn?

  Yes

  No

  N/A

• Are Safety Vests and/or High Vis Clothing being worn?

  Yes

  No

  N/A

• Is Hearing Protection required?

  Yes

  No

  N/A

• Are steel toed boots being used?

  Yes

  No

  N/A

• Are Hard Hats being used?

  Yes

  No

  N/A

• Are Gloves being used?

  Yes

  No

  N/A

• Are respirators required?

  Yes

  No

  N/A

• Are Face Shields Required?

  Yes

  No

  N/A

Equipment

• Is a Tripod required for the project?

  Yes

  No

  N/A

• Has the Tripod been inspected for the project?

  Yes

  No

  N/A

• Have all Retractable lifelines been inspected?

  Yes

  No

  N/A

• What is the Condition of the Retractable?

  New

  Great

  Good

  Fair

  Poor

• Have all Winches been inspected?

  Yes

  No

  N/A

• What is the condition of the winch?

  New

  Great

  Good

  Fair

  Poor

• Have all Body Harnesses been inspected?

  Yes

  No

  N/A

• What is the condition of the Harnesses?

  Yes

  No

  N/A

• Are Air Monitors available for the project?

  Yes

  No

  N/A

• Are all Air Monitors Calibrated?

  Yes

  No

  N/A

• Have all Air Monitors been Bump Tested?

  Yes

  No

  N/A

• Is Manhole barrier readily available?

  Yes

  No

  N/A

• Has Manhole barrier been mounted and secured?

  Yes

  No

  N/A

• Is Radio communication being used for this project?

  Yes

  No

  N/A

• Are all radios charged and properly functioning?

  Yes

  No

  N/A

• Have all electrical cables and Cords been inspected?

  Yes

  No

  N/A

Documentation

• Are MSDS on hand and available?

  Yes

  No

  N/A

• Have chemicals been approved by P.M. and Site Coodinators?

  Yes

  No

  N/A

• Is correct P.P.E. being worn when handling Chemicals?

  Yes

  No

  N/A

• Is eye wash and first aid kits readily available?

  Yes

  No

  N/A

• Are fire extinguishers available and accessible?

  Yes

  No

  N/A

• Is spill kit readily available; Specified for grout spill?

  Yes

  No

  N/A

• Are all Equipment operators properly trained?

  Yes

  No

  N/A

• Has checklist for grout packer been completed?

  Yes

  No

  N/A

• Is Confined Space entry required?

  Yes

  No

  N/A

• Are all confined space entrants properly trained?

  Yes

  No

  N/A

• Is Confined Space entry Permitted or Non-Permitted?

  Yes

  No

  N/A

• Is all Confined Space entry forms completed, signed, and Submitted?

  Yes

  No

  N/A

Procedures

• Is man hole blocked and barricaded from any unauthorized entrants?

  Yes

  No

  N/A

• Is lock-out/Tag-out required for this project?

  Yes

  No

  N/A

• Does everyone know the LOTO procedure?

  Yes

  No

  N/A

• Is a rescue team on hand or has been notified of the project?

  Yes

  No

  N/A

• Is there an emergency contact number?

  Yes

  No

  N/A

• What is the emergency contact number?

  Yes

  No

  N/A

• Does the project require traffic control?

  Yes

  No

  N/A

• Are the proper personnel trained for traffic control?

  Yes

  No

  N/A

• Is the proper signage readily available for traffic control?

  Yes

  No

  N/A

• Is proper housekeeping being conducted? (ex. No Slip, Trip, or Fall Hazards)

  Yes

  No

  N/A

• Has pipe been Jetted and Televised?

  Yes

  No

  N/A

• Has Jetter Truck been inspected?

  Yes

  No

  N/A

• Has Grout rig been inspected?

  Yes

  No

  N/A

• Is Containment installed under all required vehicles?

  Yes

  No

  N/A

• Have all cables and cords been inspected for frays/damage?

  Yes

  No

  N/A

• Have all tools been inspected and in proper working use?

  Yes

  No

  N/A

• Has Grout packer been assembled and safe to operate?

  Yes

  No

  N/A

• Has an initial reading (Top, Middle, Bottom) of the pipe been conducted with Air monitor?

  Yes

  No

  N/A

• What time was the grouting started?

  Yes

  No

  N/A

• What time was the grouting finished?

  Yes

  No

  N/A

• Was the attendant taking constant readings?

  Yes

  No

  N/A

• Were there any injuries (Cuts and Abrasions) during the task?

  Yes

  No

  N/A

• Was the site properly cleaned after completion of project?

  Yes

  No

  N/A

• Have all documents including permit been signed off and delivered to customer?

  Yes

  No

  N/A