EPSM Site Safety Inspection

• Site conducted

  Select

• Conducted on

  Date

• Conducted and Prepared by

  Select
• Location
  Address

Contractor/s

• List of Contractors Involved in inspection

  Select

Specific Work Area

• Work Area

  Select

PPE - PERSONAL PROTECTIVE EQUIPMENT

• Head Protection

  Yes

  No

  N/A

• Comment

• Eye Protection

  Yes

  No

  N/A

• Comment

• Hi Visibility Clothing

  Yes

  No

  N/A

• Comment

• Long Sleeve / Long Pants

  Yes

  No

  N/A

• Comment

• Additional Task Specific PPE

  Yes

  No

  N/A

• Comment

• PPE Satisfactory

  Pass

  Fail

  N/A

• List Reasons for Fail

PLANT & EQUIPMENT

• Plant Type

  Select

• List Type of plant

• Plant Owner

  Select

• List Contractor

• Plant & Equipment Site Inducted

  Yes

  No

  N/A

• Pre Start Checklist Completed

  Yes

  No

  N/A

• Comment

• Operator Licensed to Operate

  Yes

  No

  N/A

• Is spotter in place

  Yes

  No

  N/A

• Comment

• Plant & Equipment Condition

  Good

  Fair

  Poor

  N/A

• Plant & Equipment Satisfactory

  Pass

  Fail

  N/A

• List Reasons for Fail

SAFE WORK METHOD STATEMENTS

• Work Is High Risk Activity

  Yes

  No

  N/A

• List High Risk Activity

• If High Risk Activity, Is a Safe Work Method Statement available

  Yes

  No

  N/A

• List Contractor conducting High Risk Work

  Select

• List Contractor

• Workers Have Signed and Acknowledged SWMS

  Yes

  No

  N/A

• Are All Controls Outlined In SWMS Being Followed

  Yes

  No

  N/A

• Do SWMS Identify All Risks

  Yes

  No

  N/A

• SWMS Satisfactory

  Pass

  Fail

  N/A

• List Reasons For Fail

PERMITS

• Is there a Permit in Place

  Yes

  No

  N/A

• Contractor

  Select

• All Workers Sign and Acknowledged

  Yes

  No

  N/A

• List Permit

  Select Hotworks Isolation Working At Heights Excavation Confined Space

  • Hotworks
  • Isolation
  • Working At Heights
  • Excavation
  • Confined Space

• Dial Before You Dig

  Yes

  No

  N/A

• Fire Extinguisher Tested and Tagged

  Yes

  No

  N/A

• All Controls Listed in Permit Followed

  Yes

  No

  N/A

• Permit Expiry Date

  Date

• Permits Satisfactory

  Pass

  Fail

  N/A

• List Reasons For Fail

WORK PRACTICES

• Work Area

  Select

• Contractor

  Select

• List Contractor

• Work Area Housekeeping

  Yes

  No

  N/A

• Waste Bins Available

  Yes

  No

  N/A

• Barricading and Signage In Place

  Yes

  No

  N/A

• Chemicals and Fuels Stored Correctly

  Yes

  No

  N/A

• SDS readily accessible

  Yes

  No

  N/A

• Spill kits readily available and in good order

  Yes

  No

  N/A

• All Electrical Leads and RCD Test & Tagged

  Yes

  No

  N/A

• Lead Stands Being Used

  Yes

  No

  N/A

• Ground Conditions Clear of Obstructions

  Yes

  No

  N/A

• Overhead Services Are Clear from Obstructions

  Yes

  No

  N/A

• Lifting Equipment Visually Inspected, Tagged and In Date

  Yes

  No

  N/A

• All Workers Obtain Relevant Qualifications and Competency to Task

  Yes

  No

  N/A

• Work Practices Satisfactory

  Pass

  Fail

  N/A

• List reasons for Fail

ENVIRONMENTAL

• Work Area

  Select

• Contractor

  Select

• List Contractor

• ITEM

  Select Noise Dust Air Quality Flora & Fauna Water Quality N/A

  • Noise
  • Dust
  • Air Quality
  • Flora & Fauna
  • Water Quality
  • N/A

• Risk

  Yes

  No

  N/A

• List Risk

• What control is required

• Control to be actioned by

  Select

• Not Applicable

• Satisafactory

  Compliant

  Non-Compliant

  N/A

• List Reasons for Non-Compliant

SAFE ACTS OBSERVED

• Contractor

  Select

• List safe act observed

• Safe Act by Person/s

  Select
AT RISK BEHAVIOURS

• Contractor

  Select

• List at risk behaviour

• At risk behaviour by Person/s

  Select
CORRECTIVE ACTIONS

• Is Corrective Actions Required

  Yes

  No

  N/A

• List Corrective Action

• Corrective Action requuired by (contractor)

  Select

• Corrective Action required by (person)

  Select

• Corrective Action Due Date

  Date

EPSM SIGN OFF

• Inspection Completed by:

  Sign

• Date & Time Completed

  Date