CHC Safety Work Contact and JSA Audit

• Conducted on

  Date

• Prepared by

• Location
  Address

• Task Description

• Contract Supervisor

At risk behaviours judged to be of fatality potential shall result in an injury free event case in the incident reporting system (EHSIMS). The Observation Team is responsible for ensuring that this is completed

Observation Team:

• Number of people in Observation team

• Number of people contacted:

• Please take a photo of the task being undertaken.

  Media

Personal Protective Equipment

• Head, Foot, Eye / Face, Body

  Yes

  No

  N/A

• Mandatory PPE is worn by work group

  Yes

  No

  N/A

• Hand - Available and used as required by JSA

  Yes

  No

  N/A

• Respiratory - Available and used as required by JSA

  Yes

  No

  N/A

• Hearing - Available and used where mandatory

  Yes

  No

  N/A

Procedure Related

• Tag / Lock / Isolation - Personal Danger Tag is attached correctly

  Yes

  No

  N/A

• Secure Work - Crew agrees with Contents of SWI & JSA

  Yes

  No

  N/A

• Job Prep Hazard - SWI & JSA available and being used

  Yes

  No

  N/A

• Chemical Usage - MSDS readily available

  Yes

  No

  N/A

Working Environment Category 3

• Housekeeping / Storage - Work area free of housekeeping hazards

  Yes

  No

  N/A

• Barricades / Exclusion Zones - Reason for installation is on attached tag

  Yes

  No

  N/A

• Facility condition / Working conditions - Aware of housekeeping responsibilities

  Yes

  No

  N/A

Tools and Equipment

• Selection - Adequate and suitable for task being performed

  Yes

  No

  N/A

• Condition - In good order and checked prior to use

  Yes

  No

  N/A

• Use - Able to explain safety features / controls

  Yes

  No

  N/A

Body use and Position

• Line of Fire - Defensive working positions adopted

  Yes

  No

  N/A

• Pinch Points - Mechanical aids available and used

  Yes

  No

  N/A

• Lifting / Pushing / Pulling / Carrying - Able to explain correct lifting techniques

  Yes

  No

  N/A

• Walking / Climbing - Aware of hazards on floors, stairs and wet surfaces

  Yes

  No

  N/A

• Stable/Secure/Extended - Correct body position during task performance

  Yes

  No

  N/A

Mobile Equipment

• Condition - Pre-Start Checks completed daily

  Yes

  No

  N/A

• Enter / Exit - Three points of contact used

  Yes

  No

  N/A

• Pedestrian Segregation - 50m Rule, radio or eye contact used

  Yes

  No

  N/A

JSA Audit

• Is the JSA readily available at the workface for any persons entering the work area?

  Yes

  No

  N/A

• Has the JSA been reviewed/updated and signed onto today?

  Yes

  No

  N/A

• Have all personnel engaged in the task signed onto the JSA?

  Yes

  No

  N/A

• Has the JSA been reviewed and signed by the CHC Supervisor?

  Yes

  No

  N/A

• Has the JSA been signed off by the client representative?

  Yes

  No

  N/A

• Does the workgroup have a clear understanding of the task and associated hazards?

  Yes

  No

  N/A

• Does the JSA identify ‘Permit To Work’ requirements associated with the task?

  Yes

  No

  N/A

• Is an exclusion zone erected as per site requirements and are all entry points signed posted?

  Yes

  No

  N/A

• Does the JSA adequately reflect the task being performed?

  Yes

  No

  N/A

• Has the task been appropriately Risk Assessed?

  Yes

  No

  N/A

• Are the JSA task steps being followed by the work group?

  Yes

  No

  N/A

• Have all potential hazards been identified (detail major hazards that have not been accounted for)?

  Yes

  No

  N/A

• Is the workgroup wearing all the required PPE for the task?

  Yes

  No

  N/A

• Have STOP points been identified in the JSA?

  Yes

  No

  N/A

• Is the workgroup working with the correct ergonomics techniques in place?

  Yes

  No

  N/A

• Have the critical controls been documented and implemented?

  Yes

  No

  N/A

• Did you need to STOP the task or implement any corrective actions? YES / NO (detail actions above)

  Yes

  No

  N/A

• Are there any follow-up actions required? YES / NO Details:-

  Yes

  No

Sign off

• Name

  Sign

• Additional personnel involved

  Sign