CRP Verifications

• Site conducted

  Select

• Division

  Select

• Division Or Group Contacted

• Conducted on

  Date

• Completed By

  Sign

• Document Number

Fit For Duty

• Is the physical, emotional and/or mental condition of the employee such that they are capable of performing their duties in a safe and competent manner?

  Yes

  No

  N/A

• Does the employee know what to do if they or a co-worker have "fit for duty" concerns?

  Yes

  No

  N/A

Training & Risk Assessment

• Is the employee trained, competent, capable, and comfortable with the task they are performing?

  Yes

  No

  N/A

• Have employees considered alternative approaches to reduce exposure to hazards

  Yes

  No

  N/A

• What alternatives have been considered?

• Has a Risk/Hazard Assessment been conducted and any controls implemented to minimize risk prior to commencement of work?

  Yes

  No

  N/A

• What controls are being used to minimize risk?

• Do employees periodically re-assess work activities to identify new hazards or for any additional required controls?

  Yes

  No

  N/A

• If immediate correction is not possible, have the hazards been isolated and communicated to all affected personnel?

  Yes

  No

  N/A

• How have hazards been isolated and communicated?

Standard Work Practices

• Is the employee following established job instructions, practices, and procedures?

  Yes

  No

  N/A

• What instructions, practices, or procedures are being followed?

• Is the employee obeying all signs, barriers, using the right tools/equipment and wearing PPE for the task at hand?

  Yes

  No

  N/A

• Are signs and barriers being obeyed?

  Yes

  No

  N/A

• Are the tools being used right for the job?

  Yes

  No

  N/A

• Is the employee wearing the correct PPE for the task?

  Yes

  No

  N/A

• Does the employee know what to do in case of emergency?

  Yes

  No

  N/A

• What are the emergency notification procedures?

• What is your primary escape plan/path from the work area?

• Where is your closest refuge chamber?

Stop Work Authority

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to using Stop Unsafe Work Authority

  Sign

Safety Devices

• Do the tires and wheels appear to be free of damage or wear and properly functioning? (proper inflation, lug nuts intact and secure)

  Yes

  No

  N/A

• Can the operator confirm that the vehicle brakes and all steering systems are fully functional?

  Yes

  No

  N/A

• Did the employee complete a pre-operational exam where all safety critical items were checked and found to be functioning properly prior to operating equipment?

  Yes

  No

  N/A

• What items were found to be defective?

• Have all seatbelts been inspected for damage (tears, cuts, frays, etc.), and determined to be in good operable condition and worn correctly?

  Yes

  No

  N/A

• What defects or issues were found with the seatbelts?

Vehicle / Pedestrian Segregation

• Has interaction between vehicles and pedestrians been minimized by physical barriers, designated walkways/travel ways, work area exclusion zones?

  Yes

  No

  N/A

• What additional measures can be taken to minimize vehicle and pedestrian interaction?

• In parking areas and other congested traffic areas, are berms installed and maintained to minimize vehicle interactions?

  Yes

  No

  N/A

• What areas of concern were identified?

• Are vehicles operating at the appropriate speed and required separation distance?

  Yes

  No

  N/A

• Do employee(s) avoid entering equipment blind spots unless positive communication is established?

  Yes

  No

  N/A

• If approaching equipment, equipment is shut down, secured from movement i.e. park brake, chocks in place and blades/buckets are lowered into the ground?

  Yes

  No

  N/A

Berms

• Are effective berms in place to prevent vehicles from falling over edges? (i.e. dumps, stopes, travel ways, etc.)

  Yes

  No

  N/A

• What deficiencies have been identified?

Stable Parking & Secured Loads

• Are correct parking procedures being followed?

  Yes

  No

  N/A

• Are the park & service brakes set?

  Yes

  No

  N/A

• Is the vehicle or equipment chocked/blocked against movement?

  Yes

  No

  N/A

• Are implements (buckets/blades/rippers/etc.) lowered to the ground?

  Yes

  No

  N/A

• Are loads and loose items that could become a hazard or risk secured?

  Yes

  No

  N/A

• What deficiencies have been identified?

Communication

• Is positive communication made when passing equipment or when entering exclusion zones?

  Yes

  No

  N/A

Engineered Fire Detection & Suppression System

• Has the employee inspected the fire suppression system, fire extinguisher(s) and conducted a self-check on the fire suppression system prior to operation?

  Yes

  No

  N/A

• Was the fire suppression or extinguisher found to be in usable condition?

  Yes

  No

  N/A

• Does the operator know how to activate/use the fire suppression system and activation points / fire extinguisher?

  Yes

  No

  N/A
Stop Work Authority

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to using Stop Unsafe Work Authority

  Sign

Energy Isolation

• Are the employee(s) using an appropriate lock out device and tags for the task being performed, per standard?

  Yes

  No

  N/A

• What deficiencies were observed?

  Yes

  No

  N/A

• Have all energy sources been identified and isolated?

  Yes

  No

  N/A

• What types of energy sources were identified and isolated?

  Select Electrical Mechanical Hydraulic Pneumatic Chemical Kinetic Other

  • Electrical
  • Mechanical
  • Hydraulic
  • Pneumatic
  • Chemical
  • Kinetic
  • Other

• What other types of energy sources were identified?

• Have all energy sources been drained of stored energy?

  Yes

  No

  N/A

• What "Try" steps did were used to verify a Zero Energy State?

• Has the operator verified isolation effectiveness (LOTOTO ZERO ENERGY STATE) prior to starting work?

  Yes

  No

  N/A

Arc Flash Protection

• Are all PPE and tools rated, certified as necessary for the work to be conducted?

  Yes

  No

  N/A

• What Arc Flash PPE is being used for the job?

• What deficiencies were observed?

• Are exclusion zones established to prevent unauthorized access to electrical work areas?

  Yes

  No

  N/A

Barricades / Exclusion Zones

• Are proper clearance distances maintained when working around live energy sources and are spotters established as required?

  Yes

  No

  N/A

• Are guards, barriers and barricades properly installed to prevent exposure to uncontrolled release of energy?

  Yes

  No

  N/A

• Have all guards and safety systems been restored when the work is completed?

  Yes

  No

  N/A
Stop Work Authority

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to utilizing their Stop Unsafe Work Authority

  Sign

Work Area Setup

• Are all objects, tools, and equipment secured to prevent them from falling below?

  Yes

  No

  N/A

• Are exclusion zones established on lower levels to prevent individuals from being struck by falling objects?

  Yes

  No

  N/A

• What methods and/or materials are being used to establish exclusion zones?

• Is there a physical barrier or barricade in place that will mitigate the risk of falling over an edge?

  Yes

  No

  N/A

• What type of barrier or barricade is being used?

Fall Protection System

• Have all key components of the fall protection system been certified for use by a competent person?

  Yes

  No

  N/A

• Have the key components bee inspected by the worker prior to use and deemed suitable for use? Anchorage, Connecting Device, Body Harness

  Yes

  No

  N/A

• Anchorage points are adequate?

  Yes

  No

  N/A

• Harnesses are in good condition?

  Yes

  No

  N/A

• Connecting devices are functional?

  Yes

  No

  N/A

• Is the proper fall protection system being used for the task?

  Yes

  No

  N/A

• What type of fall protection system is being used?

  Fall Prevention

  Fall Protection

• What type of Fall Prevention system is being used?

• Properly fitted/adjusted full body harness

  Yes

  No

  N/A

• Proper lanyard length to prevent working edge exposure

  Yes

  No

  N/A

• Proper anchorage point capable of restraining the employee

  Yes

  No

  N/A

• What type of Fall Protection system is being used?

• Properly fitted/adjusted full body harness

  Yes

  No

  N/A

• Proper lanyard length to prevent contact with the next lowest working surface

  Yes

  No

  N/A

• Properly maintained shock absorbing lanyard or decelerator (SRL)

  Yes

  No

  N/A

• Adequate anchorage point to support the employee

  Yes

  No

  N/A

• Is the anchorage point rated for the selected fall protection system and are all connection points correctly latched?

  Yes

  No

  N/A

• What defects or issues were found with the Anchorage?

• What defects or issues were found with the Connection Points?

Work Platform

• Are work platforms tagged correctly, inspected, certified, maintained, and in proper working condition suitable for the task?

  Yes

  No

  N/A

• Has the platform been properly tagged to indicate its capacity raiting?

  Yes

  No

  N/A

• Has the platform been inspected and certified?

  Yes

  No

  N/A

• Is the platform maintained in good condition without defects?

  Yes

  No

  N/A

• What defects or issues were found with the platform?

• Is the platform suitable for the task?

  Yes

  No

  N/A

• Why is the platform not suitable for the task being performed?

• Is the aerial lift or elevated work platform equipped with properly maintained floors, guardrails, and toe-boards to prevent items from falling to lower levels?

  Yes

  No

  N/A

• Are the floors maintained in good condition?

  Yes

  No

  N/A

• What defects or issues were found with the floors?

• Are the guardrails maintained in good condition?

  Yes

  No

  N/A

• What defects or issues were found with the guardrails?

• Are the toe-boards maintained in good condition?

  Yes

  No

  N/A

• What defects or issues were found with the toe-boards?

• Are workers on the mobile work platform properly protected with a fall prevention or fall arrest system?

  Yes

  No

  N/A

• What defects or issues were found with the workers fall arrest/prevent system?

• Are weather and terrain conditions acceptable to keep the working platform stable?

  Yes

  No

  N/A

• Is there risk of the platform sinking in soft ground?

  Yes

  No

  N/A

• Is the platform working near energized electrical lines?

  Yes

  No

  N/A

• Is the platform on level ground or has it been leveled appropriately and secured?

  Yes

  No

  N/A

• Do the workers have good visibility of their surroundings: work task and ground below?

  Yes

  No

  N/A

• Is the area and work properly illuminated?

  Yes

  No

  N/A

• Do weather conditions (rain, snow, etc.) create a hazard to workers?

  Yes

  No

  N/A

• Is the windspeed acceptable for the platform and work performed?

  Yes

  No

  N/A

• Is the platform free of overloading and in good order?

  Yes

  No

  N/A

• Is the platform being overloaded (workers + supplies + tools) beyond its designed capacity?

  Yes

  No

  N/A

• Is the floor of the platform clean, orderly, and free of tripping hazards?

  Yes

  No

  N/A

Emergency Procedures

• Do workers have means to summon help or self rescue?

  Yes

  No

  N/A

• What communication or rescue methods do workers have?

• Do workers have adequate means to summon help?

  Yes

  No

  N/A

• What defects or issues were found with the worker's communication?

• Do workers have adequate means of performing self rescue?

  Yes

  No

  N/A

• What defects or issues were found with the self rescue plan?

• Is a fall protection plan and rescue plan in place, communicated to all affected personnel, and do employees know what to do if rescue is required?

  Yes

  No

  N/A

• What steps do the workers plan to take to communicate emergencies and provide rescue if required?

• Has a fall protection and rescue plan been prepared for the work performed?

  Yes

  No

  N/A

• Has the plan been communicated to affected personnel?

  Yes

  No

  N/A

• Has a rescue plan been prepared and is it adequate?

  Yes

  No

  N/A

• What defects or issues were found with the rescue plan?

• Has a rescue plan been developed for the work being perfomed?

  Yes

  No

  N/A
Stop Work Authority

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to utilizing their Stop Unsafe Work Authority

  Sign

Competent & Capable

• Are the employees engaged in the lifting operation qualified and competent?

  Yes

  No

  N/A

• Are employees qualitied to perform their assigned tasks?

  Yes

  No

  N/A

• Are employees competent to inspect lifting equipment and rigging?

  Yes

  No

  N/A

• What defects or issues were found with the worker's qualifications and/or competency?

Lift Plan

• Has a risk assessment or lift plan been conducted and documented?

  Yes

  No

  N/A

• What risks were identified?

• Has a workplace inspection been conducted and documented?

  Yes

  No

  N/A

• Were any hazards identified?

• Have all hazards been mitigated?

  Yes

  No

  N/A

• Has the rigging equipment been correctly attached/slung to the load?

  Yes

  No

  N/A

• What deficiencies were observed?

• Has the lift been communicated to all affected personnel?

  Yes

  No

  N/A

• Has a designated signaler, rigger(s), and operated been assigned?

  Yes

  No

  N/A

• Name of the designated Operator

• Name of the designated Signaler

• Name(s) of the designated Rigger(s)

• Are tag lines utilized to control the load while the lift is in progress and free from posing additional hazards?

  Yes

  No

  N/A

• Is the crane operator present during all lifting operations? (Suspended load is attended at all times)

  Yes

  No

  N/A

Mechanical Integrity Of Crane And Lifting Gear

• Has the appropriate pre-operational inspection been completed prior to work commencing?

  Yes

  No

  N/A

• Were any defects or hazardous conditions noted?

  Yes

  No

  N/A

• What deficiencies were noted on the pre-operational inspection?

• Has the equipment been certified fit for use and free from defects?

  Yes

  No

  N/A

• What deficiencies were observed?

• Is the lift capacity of the crane and lifting gear rated for the load weight?

  Yes

  No

  N/A

• What is the rated capacity of the crane (based on position and boom angle)?

• What is the weight of the load?

• Are all safety devices on the lifting equipment properly installed and correctly functioning?

  Yes

  No

  N/A

• What safety devices are installed and being used?

Exclusion Zones

• Is the exclusion zone large enough to protect people in the event of a load falling?

  Yes

  No

  N/A

• What is being used to demarcate the exclusion zone?

  Yes

  No

  N/A

• What is the approximant size of the exclusion zone?

  Yes

  No

  N/A

• What is the approximant length of the crane boom plus load?

  Yes

  No

  N/A
Stop Work Authroity

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to utilizing their Stop Unsafe Work Authority

  Sign

Confined Space Permit

• Has the Confined Space Permit been completed and implemented correctly?

  Yes

  No

  N/A

• What deficiencies were observed on the permit?

• Is the confined space watch present while the confined space is occupied?

  Yes

  No

  N/A

• Who has been designated as the space attendant?

• Is the confined space watch maintaining a register of people entering and exiting?

  Yes

  No

  N/A

• Is the confided space register accurate and completed correctly?

  Yes

  No

  N/A

• What deficiencies were observed with the confined space register?

• Are all confined space entry and exit locations guarded or barricaded and labeled to prevent unauthorized entry?

  Yes

  No

  N/A

• What deficiencies were observed in guarding, barricading, or labeling?

• Is there effective communication between the confined space watch and entrants?

  Yes

  No

  N/A

• What type of communication system is being used?

• What deficiencies were observed?

• Has a risk assessment been conducted and have proper controls been established for each risk identified?

  Yes

  No

  N/A

• What risks were identified and what controls were put in place?

• Was a risk assessment completed adequatly?

  Yes

  No

  N/A

• What deficiencies were observed?

  Yes

  No

  N/A

• Have each of the identified risks been properly controlled?

  Yes

  No

  N/A

• What deficiencies were observed?

• Is the work area clear of materials that could fall and cause a fatal event?

  Yes

  No

  N/A

• What hazards were observed in the work area?

Atmospheric Testing & Monitoring

• Has the appropriate gas monitor been selected, daily bump tested conducted and have valid calibration for use based on the identified hazards?

  Yes

  No

  N/A

• Is the appropriate gas monitor with the correct gas sensors being used?

  Yes

  No

  N/A

• What deficiencies were observed?

• Was a daily bump test conducted before use?

  Yes

  No

  N/A

• Does the gas monitor have a valid calibration?

  Yes

  No

  N/A

• What is the date of the last valid calibration?

  Date

• What type of gas monitor is being used?

• What gases are being monitored?

• When was the last calibration of the gas monitor?

  Date

• Is the atmosphere being tested, results documented per confined space permit and appropriate controls implemented?

  Yes

  No

  N/A

• Is the atmosphere of the confined space being tested?

  Yes

  No

  N/A

• Are the atmospheric test results being correctly documented?

  Yes

  No

  N/A

• Are controls implimented to prevent an unsafe atmosphere in the confined space?

  Yes

  No

  N/A

• What deficiencies were observed?

  Yes

  No

  N/A

• What controls are being used?

Lockout/Tagout/Tryout

• Have all sources of energy been identified, isolated by all occupant's personal lock, tagged, tried out and zero energy state?

  Yes

  No

  N/A

• What hazardous energy sources have been identified?

• Have all hazardous energy sources been identified?

  Yes

  No

  N/A

• What hazardous energy sources were not identified?

• Have all the space occupants isolated hazardous energy with personal locks?

  Yes

  No

  N/A

Rescue Plan

• Do attendant and entrants have means to summon help, self-rescue and are not working alone while in confined space?

  Yes

  No

  N/A

• What rescue method is being?

• Is the rescue method appropriate for the work/space?

  Yes

  No

  N/A

• What deficiencies were observed with the proposed rescue plan?

• Do the attendant and entrants understand events that could trigger an evacuation or rescue and how to initiate emergency response?

  Yes

  No

  N/A

• What events were stated when asked?

Stop Work Authority

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to utilizing their Stop Unsafe Work Authority

  Sign

Ground Control

• Have identified ground control hazards and mitigations been communicated to supervisors and between shifts?

  Yes

  No

  N/A

• What deficiencies were observed?

• Are the highwalls scaled, free of debris and catch benches adequate?

  Yes

  No

  N/A

• What deficiencies were observed?

• Employee(s) are maintaining loading faces at a safe working height / angle and do not position themselves between mining equipment and the face

  Yes

  No

  N/A

• What deficiencies were observed?

• Is there a barrier in place to stop people, mobile equipment from entering areas where material can fall from a high wall/excavation?

  Yes

  No

  N/A

• What type of barrier is being used?

• Is the barrier adequate for the hazard, people, and equipment in the affected area?

  Yes

  No

  N/A

• What deficiencies were observed?

• What deficiencies were observed?

• Is the highwall/stockpile built and maintained to plan design?

  Yes

  No

  N/A

• What deficiencies were observed?

  Yes

  No

  N/A

• What is the designed height of the highwall/stockpile in the employee's work area?

• Employee(s) never enter restricted areas without permission?

  Yes

  No

  N/A

• Is the surface water control (i.e. storm water drains) installed and maintained according to design and clear of obstructions?

  Yes

  No

  N/A

• What deficiencies were observed?

Barriers/Barricades & Exclusion Zones

• Are restricted areas demarcated and employee(s) never enter without authorization?

  Yes

  No

  N/A

• What methods are used to demarcate restricted areas?

• What deficiencies were observed?

• Employee(s) are not entering equipment swing radius or blind spots unless positive communication is established, equipment is shut down and any blades/buckets/rippers/etc. are lowered into the ground?

  Yes

  No

  N/A

• What deficiencies were observed?

Engineered Support Systems

• Do installed trenching controls meet or exceed Excavation and Trenching Standard requirements?

  Yes

  No

  N/A

• What types of controls are being used? (i.e. shoring, sloping, benching)

  Yes

  No

  N/A

• What deficiencies were observed?

• Is a ground disturbance permit at the work site and filled out correctly?

  Yes

  No

  N/A

• What deficiencies were observed?

Geotechnical Inspection & Monitoring Systems

• Is there functioning ground displacement detection equipment in place for all areas of the pit wall where there is a risk of failure?

  Yes

  No

  N/A

• Is displacement detection equipment in place?

  Yes

  No

  N/A

• Is the displacement detection equipment functioning properly?

  Yes

  No

  N/A

Uncontrolled Ground Movement Procedures

• Do the employees understand the emergency procedures? (i.e. seismic, primary/secondary escape)

  Yes

  No

  N/A

• What are the emergency procedures for the work area?

  Yes

  No

  N/A

• What deficiencies were observed?

  Yes

  No

  N/A
Stop Work Authority

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to utilizing their Stop Unsafe Work Authority

  Sign

Ground Control

• Have identified ground control hazards and mitigations been communicated to supervisors and between shifts?

  Yes

  No

  N/A

• What ground control hazards were identified?

• What was done to mitigate the identified hazards?

• Are the highwalls scaled, free of debris and catch benches adequate?

  Yes

  No

  N/A

• What deficiencies were observed?

• Does it appear that scaling/sounding has been conducted in the active work area?

  Yes

  No

  N/A

• Is a scaling bar of adequate length available at the work location?

  Yes

  No

  N/A

• Does the work area (face, ribs, back) show marks of recent scaling/sounding?

  Yes

  No

  N/A

• What deficiencies were observed to believe scaling/sounding was not conducted in the active work area?

• Is there a barrier in place to stop people and occupied mobile equipment from entering areas where ground fall hazards exist?

  Yes

  No

  N/A

• What type of barrier is being used?

• Is the barrier adequate and in good condition?

• What deficiencies were observed?

• Employee(s) are working in supported ground?

  Yes

  No

  N/A

• What deficiencies were observed?

Barriers/Barricades & Exclusion Zones

• Are restricted areas demarcated and employee(s) never enter without authorization?

  Yes

  No

  N/A

• What methods are used to demarcate restricted areas?

• What deficiencies were observed?

  Yes

  No

  N/A

• Is there a barrier or barricade in place to prevent employees from entering areas where material can fall?

  Yes

  No

  N/A

• What type of barrier/barricade is being used?

• Is the barrier/barricade adequate?

• What deficiencies were observed?

  Yes

  No

  N/A

• Employee(s) are not entering equipment blind spots unless positive communication is established, equipment is shut down, brake set and any blades/buckets/etc. are lowered into the ground?

  Yes

  No

  N/A

• What deficiencies were observed?

  Yes

  No

  N/A

Engineered Support Systems

• Has the correct ground support been installed per the sites Ground Control Management Plan?

  Yes

  No

  N/A

• What type of ground support is being used in the work area?

• Does the employee know the required ground support for the work area?

  Yes

  No

  N/A

• What deficiencies were observed?

  Yes

  No

  N/A

• Is shotcrete/paste/backfill being installed in compliance with the Ground Control Management Plan?

  Yes

  No

  N/A

• What deficiencies were observed?

  Yes

  No

  N/A

• What are the Ground Control Management Plan requirements for the work area?

• Is there a ground support testing program in place and to standard? (i.e. pull testing)

  Yes

  No

  N/A

• Are bolts tensioned by torquing being used?

  Yes

  No

  N/A

• Are bolt torque values documented for the 1st, every 10th, and last bolt installed during the shift?

  Yes

  No

  N/A

• Are grouted bolts being used?

  Yes

  No

  N/A

• Is the torque value of the first fixture installed in the work area documented?

  Yes

  No

  N/A

• Did the first fixture withstand a torque value of at least 150 foot-punds?

  Yes

  No

  N/A

• Are non-tensioned bolts (friction bolts) being used?

  Yes

  No

  N/A

• Have pull tests been conducted in the work area?

  Yes

  No

  N/A

Geotechnical Inspection & Monitoring Systems

• Is the work being performed within the design limits?

  Yes

  No

  N/A

• What deficiencies were observed?

• If design variances are noted, have controls been implemented to mitigate the hazard?

  Yes

  No

  N/A

• What variances were noted?

• What controls were implemented to mitigate hazards?

• What variances were noted?

  Yes

  No

  N/A

• What controls were not implemented to mitigate hazards?

  Yes

  No

  N/A

Emergency Procedures

• Do the employees understand the emergency procedures?

  Yes

  No

  N/A

• What is the method of escape from the working area (primary & secondary routes)?

• Where is the nearest refuge chamber to the working area?

• What methods of communication are used to notify employees of an emergency?

• Did the employee(s) know the egress routs (primary & secondary) from their work area?

  Yes

  No

  N/A

• Did the employee(s) know the location of the nearest refuge chamber?

  Yes

  No

  N/A

• Did the employee(s) know how emergencies are communicated?

  Yes

  No

  N/A

• Are up to date escape and evacuation maps available?

  Yes

  No

  N/A

• What is the location of the nearest escape and evacuation map/plan?

  Yes

  No

  N/A

• What was the draft date of the nearest escape and evacuation map/plan?

  Date

• Do the employees know where the nearest escape and evacuation maps/plan is locatded?

  Yes

  No

  N/A

• Is the nearest map/plan out of date?

  Yes

  No

  N/A

• Date of last map/plan revision?

  Date
Stop Work Authority

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to utilizing their Stop Unsafe Work Authority

  Sign

Guarding & Safety Devices

• Is guarding and/or barrier present and will it eliminate the possibility of a fatality from occurring?

  Yes

  No

  N/A

• What deficiencies were observed?

• If an authorized bypass occurs, has communication been made to all affected personnel?

  Yes

  No

  N/A

• If an authorized bypass occurs, has communication been made to all affected personnel?

  Yes

  No

  N/A

• What communication deficiency was observed?

• Is the exclusion zone demarcated with the hazard and precautionary actions identified?

  Yes

  No

  N/A

• What is being used to demarcate the exclusion zone?

• What precautionary actions were identified?

• What precautionary actions were overlooked to minimize hazardous conditions?

• Is there an authorized process in place for removal of guards when necessary in order to perform live testing?

  Yes

  No

  N/A

• Is a functioning protection device in place?

  Yes

  No

  N/A

• What protection devices are in place? (GFCI, pressure relief, etc.)

• What deficiencies were observed?

• Is the emergency shut-off device visible, accessible and properly maintained?

  Yes

  No

  N/A

• What deficiencies were observed?

  Yes

  No

  N/A

• Is the equipment in a safe unaltered state?

  Yes

  No

  N/A

• What deficiencies were observed?

• If removed, have all guards and safety systems been restored when the work is completed?

  Yes

  No

  N/A

• What deficiencies were observed?

Block Against Movement

• Are jacks and blocks designed, adequate and positioned correctly for the task?

  Yes

  No

  N/A

• What deficiencies were observed?

• During maintenance, are the articulation and bed locks in place to block against movement?

  Yes

  No

  N/A

• What deficiencies were observed?

Fire Protection & Emergency Procedures

• If applicable, has a Hot Work Permit been completed for work tasks in which fire or explosion hazards could be created?

  Yes

  No

  N/A

• What deficiencies were observed?

• Have employee(s) inspected the fire protection system and know how to activate/use the system?

  Yes

  No

  N/A

• What deficiencies were observed?

• Are the fire detection and protection system in service and operable?

  Yes

  No

  N/A

• What deficiencies were observed?

• Are the emergency notification devices properly functioning?

  Yes

  No

  N/A

• What deficiencies were observed?

Stop Work Authority

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to utilizing their Stop Unsafe Work Authority

  Sign

Identification Of Chemicals

• Do employees understand the hazards associated to the chemical(s) they are/will be handling or potentially exposed to?

  Yes

  No

  N/A

• What deficiencies were observed?

• Do employees know where to locate chemical Safety Data Sheets (SDS)?

  Yes

  No

  N/A

• What deficiencies were observed?

Handling & Storage

• Do employees know and understand the procedure to follow when explosive or unknown material is found?

  Yes

  No

  N/A

• What deficiencies were observed?

• Is the chemical compatible with the containers in which it is transferred/stored?

  Yes

  No

  N/A

• What deficiencies were observed?

• Are containers appropriately labeled?

  Yes

  No

  N/A

• What deficiencies were observed?

• Is the chemical stored appropriately to eliminate hazards?

  Yes

  No

  N/A

• What deficiencies were observed?

• Are workers following safe handling and hygiene practices?

  Yes

  No

  N/A

• What deficiencies were observed?

• Are appropriate personal protective measures being used to reduce exposure to chemicals?

  Yes

  No

  N/A

• What deficiencies were observed?

Controlled Access & Emergency Procedures

• Do employees understand controlled access areas, exclusion zones and evacuation procedures?

  Yes

  No

  N/A

• What deficiencies were observed?

• Do employees understand how to trigger appropriate emergency procedures?

  Yes

  No

  N/A

• What deficiencies were observed?

• Are personnel knowledgeable of the monitoring and alarm systems required for the area where they are working and know what to do when alarms are activated?

  Yes

  No

  N/A

• What deficiencies were observed?

Stop Work Authority

• Is the employee comfortable and committed to STOP any unsafe work and to notify their supervisor immediately?

  Yes

  No

  N/A

• This employee is committed to utilizing their Stop Unsafe Work Authority

  Sign