Information

22773 EA - CULVERT INSPECTION & CLEANING CONTRACT

  • Conducted on

  • Project number

  • Prepared by

Works detail

  • Assessed priority

  • Site Address

  • Nature of Works

  • Remote CCTV Survey.

  • Confined Space Entry CCTV Assist.

  • Culvert cleaning utilising HPWJ Equipment.

  • Culvert cleaning utilising mechanical plant.

  • Confined Space Entry Assist Culvert Cleaning

  • Other.

Confined Space Classification

  • NC1<br>

  • NC2

  • NC3

  • NC4

Can works be conducted without the need to enter the Confined Space?

Confined Space Classification during work task/activities?

  • NC1

  • NC2

  • NC3

  • NC4

Self & Assisted Rescue at Confined Spaces

  • Self Rescue

  • Assisted Rescue

Specified Risks are: -

  • • Loss of consciousness arising from gas, fumes, vapours or the lack of oxygen

  • • Loss of consciousness arising from an increase in body temperature

  • • Serious injury arising from a fire or explosion

  • • Drowning from an increase in the level of liquid

  • • Asphyxiation from a free flowing solid or inability to reach a respirable atmosphere due to entrapment in a free flowing solid.

  • Approx length

  • Summary of findings

  • Silt sample required?

  • Number of men required for task

Inlet Structure

  • Photo of Inlet structure

  • Comments

  • Photo of Watercourse upstream from inlet

  • Comments

Culvert inlet

  • Height (mm)

  • Width (mm)

  • Water depth (mm)

  • Material

  • If other please detail

  • Approx silt depth at inlet (mm)

  • Additional notes

  • Overhead services

Access to Culvert

  • Type of land

  • If other please give details

  • Restrictions & contact numbers

Working area

  • Off road parking?

  • Restrictions / directions

  • Soft / uneven ground?

  • Restrictions / directions

  • Stock present?

  • Restrictions / directions

  • Traffic Management

  • Restrictions / directions

Bridges

  • Is there a bridge restricting access?

  • Location

  • Weight restriction

  • Width restriction (mm)

  • Height restriction. (mm)

Outlet structure

  • Photo of outlet structure

  • Comments

  • Photo of watercourse downstream from outlet

  • Comments

Culvert outlet

  • Height (mm)

  • Width (mm)

  • Water depth (mm)

  • Material

  • If other please detail

  • Approx silt depth at outlet (mm)

  • Additional notes

  • Overhead services

Access to culvert

  • Type of land

  • If other please give details

  • Restrictions & contact numbers

Working area

  • Off road parking?

  • Restrictions / directions

  • Soft / uneven ground?

  • Restrictions / directions

  • Live stock present?

  • Restrictions / directions

  • Traffic management

  • Restrictions / directions

Bridges

  • Is there a bridge restricting access?

  • Location

  • Weight restriction

  • Width restriction (mm)

  • Height restriction (mm)

Additional photographs

Additional photos

  • Additional photo 1

  • Note

  • Additional photo 2

  • Note

  • Additional photo 3

  • Note

  • Additional photo 4

  • Note

  • Additional photo 5

  • Note

  • Additional photo 6

  • Notes

Pollution & environmental control

Environmental & pollution control

  • Environmental or pollution Control Matters which might effect the risk Assessment .

  • Any other matters relevant to the risk Assessment ?

Sign off

Report preparation

  • Signature

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