Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Is a contractor being audited?

  • Which contractor company?

Prework Aspects

  • Foundational aspects applicable to all Fatal Risks that address: housekeeping, workplace exams, FLRA, training confirmation, and emergency protocols.

  • Is the work area housekeeping in good order? (i.e., clear walkways and organized tools/materials)

  • Has a workplace exam been conducted?

  • Have all hazards been identified, corrected, or communicated?

  • Has the employee conducted a Field Level Risk Assessment (FLRA) or Team Risk Assessment (TRA)?

  • Has the employee received training? (i.e., task training, procedure or guidelines)

  • Can the employee explain the proper emergency shut down, summoning for help and evacuation procedures? 

Critical Control Verification

  • Critical Controls: Actions and conditions that must be in place and functioning 100% of the time, without fail, to protect people when working in potentially significant risk situations.

    Instructions: For each critical control, select Controlled, AtRisk, or NA (Not Applicable or not observed). See Assessment below for definitions. If something is marked AtRisk, immediately Pause the work until the missing protections are put in place. Write the corrective action taken in the notes box below

Competency

  • Has the worker been trained and authorized, and does the worker understand the components of Fall of Ground activity?

  • Is the worker familiar with the FRA and critical controls?

Ground Control

  • Have identified ground control hazards and mitigations been communicated from geotechnical to supervisors and frontline operations in between shifts?

  • Is an adequate length scaling bar immediately available to workers?

  • Does it appear that scaling/sounding has been 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?

  • Are employees working in supported ground?

Barriers/Barricades and Exclusion Zones

  • Are restricted areas demarcated and signed?

  • Are employees not entering equipment blind spots unless positive communication is established, equipment is shut down, brake set and any blades/buckets/etc. are lowered to the ground?

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

Engineered Support System

  • Has the correct ground support been installed per the site’s Ground Control Management Plan?

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

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

Geotechnical Inspection and Monitoring Systems

  • Is the work being performed within the design limits? (e.g., cut sheets)

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

Emergency Procedures

  • Do the employees understand the emergency procedures? (e.g., seismic, primary/secondary escape, and refuge locations)

  • Are up-to-date escape and evacuation maps available and communicated?

  • When was the last drill and what had we learn from it?

  • CONTROLLED The presence of this control is verified and effective

  • ATRISK This control is missing or ineffective

  • NA / NO Not Applicable to this exposure situation or Not Observed

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.