Information
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Document No.
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Operating Company
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Project Name / Job Number
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Conducted on
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Prepared by
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Location
Safety Program Administration
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Appropriate Signage in Place
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Safety Policy & Standard Operating Procedure Manual Onsite & Updated
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Site Specific MSDS available for all chemicals
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Legal compliance (General Register available, Equipment fitness certificates...etc)
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Pre-job safety moment Performed (Green area, Tool box..etc)
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Topic Covered:
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JSA Completed Prior to Hazardous/Non-routine Tasks
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Site Specific Emergency Action Plan
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Applicable Permits Onsite (Trench/Excavation, Scaffold/Falsework, etc.,)
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Safety Inspections Performed (Planned or spot..etc)
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Other;
First Aid
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Trained Person(s) Onsite
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First Aid Kit and Supplies Adequate in Size and Maintained
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Eye Wash Station(s) in Place
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Other;
Machinery Safety
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Guards in Place
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Grounded System
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GFCI Protection (Test Operation)
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Hazardous energy isolation and securing is done in a reasonable manner when engaging with machinery hazards
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Emergency Stops (where applicable)
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Damaged Outlets
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Other;
Air Compressors
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Belts and Pulleys Guarded
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Pressure Gauge Working
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Pressure Relief Valve Operational
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Hose Connections Secured
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Pressure Reduced at Operation
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Hoses in Good Condition
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Other;
Fire Extinguishers
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Readily Accessible/Mounted
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Proper Type and Size Available
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Proper Maintenance/Tagged
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Inspected Monthly/Annually
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Employees Trained Annually on Usage
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Other;
Flammable Liquids (Gasoline) / Chemical Handling
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Stored in Approved Containers/Cabinets
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Containers Properly Labeled (Identity, Hazard Warnings)
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Spill Containment and Cleanup Supplies
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Oxygen Cylinders Separated from Fuel Gas Cylinders or Combustible Materials
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Fire Extinguisher Available Near Storage Areas
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Hydrants are Clear
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Signs Posted NO SMOKING "Flammable Materials"
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Hazardous Chemicals in Secondary Containment, Proper Disposal
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Storage Area Bermed for Spill
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Other;
Power Cords / Extension Cords / Electrical Hazards
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Cords Protected From Damage
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Grounding Pin Present
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Damaged Insulation Exposed Wiring
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Plug Ends & Insulation Connected
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Cords Protected From Damage
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Other;
Hand and Power Tools
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All Mechanical Safeguards In Place as per Manufacturer
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User Properly Trained
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Tools Are in Good Condition
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Correct Tool Being Used For The Job
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Tools are Stored Neatly When Not In Use
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Materials Properly Supported
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Other;
Ladders and Stairways
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Ladders Inspected and Maintained
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Ladders Proper Length & Secured to Prevent Slipping, Sliding or Falling
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Extension Ladders Extend 36" Above Landing
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Extension Ladder Base Positioned 1/4 of the Vertical Distance
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Area Around Base and Top of Ladder Clear and Unobstructed
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Proper Maintenance and Storage
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Stepladders Fully Opened
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Job Made Ladders Constructed as Per Cal OSHA Regulations
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Metal Ladders Not Being Used Around Electrical Hazards
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Evidence of Unsafe Use of Ladders (Zero Tolerance Item)
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Other;
Material Handling & Storage
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Proper Lifting Techniques Being Used
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Stacks on Firm Footing & Not Too High
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Lay Down Areas Neat & Organized
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Passage Ways are Clear
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Other;
Personal Protective Equipment
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Head Protection Hard Hat
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Safety Glasses
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Full Face Shield
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Hearing Protection
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Appropriate Hand Protection (Abrasion, Cut, Puncture, Chemical)
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Foot Protection
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Respiratory Protection
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ANSI Class II or III High Visibility Garment or similar (Vest, Shirt, or Jacket)
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Other;
Fall Protection
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Full Body Harness
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Appropriate Connecting Device (Lanyard above 18', SRL below 18')
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Engineered Vertical or Horizontal Life Line
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Guard Rails in Place and Secure, Top Rail 42"-45" Mid Rail at 1/2 the Distance
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Controlled Access Zone Established
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Appropriate Anchorage (5000 lb. Capacity)
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Warning Line Established
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Competent Trained Person(s) Onsite
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Employees Properly Trained
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Equipment in Good Condition and Inspected Semi Annually
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Rescue Plan In Place
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All Personnel Protected Against Fall Height Greater Than 6' (Zero Tolerance Item)
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Other;
Aerial Lifts
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Equipped with Outriggers
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Guard Rails in Good Condition
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Full Body Harness and Fall Restraint in Use
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Safety Chain Present and Connected
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Employees Properly Trained
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Employees Standing on Floor of Lift
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Documented Daily Inspection Completed
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Other;
Industrial Trucks
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Roll Over Protective System (ROPS)
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Documented Daily Inspection Performed
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Back-up Alarm and Horn Operational
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Fire Extinguisher
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Operator Trained and Authorized to Use
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Seatbelt Being Worn
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Other;
Cranes / Boom Trucks
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Annual and Daily Inspections Complete
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Fire Extinguisher in Cab & Inspected
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Boom Angle Indicator and Load Charts Visible
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Proper Hand Signals in Use & Posted
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Swing Radius Barricaded
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Rigging Inspected Prior to Use & in Good Condition, All Tags Legible & Attached
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Rigging Properly Stored When Not In Use
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Seat Belt Being Used
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Qualified Rigger in Use
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Qualified Signal Person in Use
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Power Lines Deactivated, Removed or at a Minimum Safe Distance, Spotter in Use w/in 20'
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Tag Line(s) in Use For Load Control
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Equipment is Firmly Supported
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OutRiggers In Use
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Pre-Lift Meeting Conducted
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Critical Lift Plan Reviewed
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Operator Certified and Medical Card Current
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Other;
General House Keeping
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Orderly Storage of Material
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Orderly Storage of Equipmen
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Trash and Debris Picked Up
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Adequate Supply of Trash Receptacles
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Banding Material and Wire
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Protruding nails Removed or Bent Over
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Restrooms Clean and Supplies Adequate
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Hand Wash Stations Supplied & Stocked
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Dust Protection Observed
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Lighting is Adequate
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Other;
Heat Illness Prevention
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Cool Drinking Water Supplied & Nearby
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Disposable Cups & Trash Receptacles Provided
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Adequate Shade Provided & Comfortable Seating
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Employees Properly Trained
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High Heat Requirements In Effect (95 degrees +)
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Un-acclimatized Employees Monitored
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Other;
Confined Space
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Permit Completed
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Verify Atmospheric Monitor Onsite & Calibrated w/in Last 30 Days
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Continuos Monitoring Required and Documented every 30 Minutes
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Ventilation of Space Adequate
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Pre-Task JSA Completed and Reviewed Prior to Entry
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Rescue Procedures in Place & Reviewed Prior to Entry
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Employees Involved Trained on Responsibilities (Supervisor, Attendant, Entrant)
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Other;
Heavy Equipment and Vehicles
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Operator Trained on Equipment Being Used
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Seatbelt Worn at All Times
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Inspection and Maintenance Logs Completed
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Safety Devices Functioning Properly (Brakes, Lights, Mirrors, Horn, Etc.,)
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Back-up Alarm Installed and Audible
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All moving parts guarded
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Wheels Chocked on All Mobile Equipment When Standing Alone
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Fire Extinguisher Present and Inspection Tag Current
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Other;
Traffic Control
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Traffic paths secures by reasonable equipment (Cones, hard barricade, tapes...etc)
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Flaggers Are Trained & Wearing ANSI Class II or III High Visibility Garment
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Workers Exposed To Vehicular Traffic Wearing ANSI Class II or III High Visibility Garment
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Pre-Warning Signs In Place (Road Work Ahead, Flagger Ahead, Etc,.)
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Sign Board(s) In Place To Warn of Lane Closure
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Approved Traffic Plan In Place and Followed
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Public (other employees) Protected from Work
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Spotter Used For Moving Of Equipment Near Or Through Traffic
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Other;
Welding and Cutting
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Equipment Is In Good Condition
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Welders and Helpers Are Wearing Proper PPE
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Adjacent Workers Protected By Screens or Shields
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Electrical Equipment Is Grounded
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All Cables Are Protected And In Good Condition
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Fire Extinguisher Of Proper Type And Size In The Work Area
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Flammable Materials Removed From Work Area Or Protected
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Compressed Gas Cylinders Secured In Upright Position And Protective Caps In Place
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Backflow Preventer On Leads From Oxygen and Acetylene Cylinders
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Gas Lines Are Protected And In Good Condition
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Hot Work Permit Completed When Required
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Trained Fire Watch In Place (Min. Of 30 Minutes After Welding Task Completed)
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Other:
Corrective Actions Taken / Inspection Summary
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Notes:
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All "Corrective Action" items are to be corrected at the jobsite within 24 hours. If corrective action is not possible, the item shall be brought to the immediate attention of the Safety Director.
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Project Supervision:
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Safety Specialist: