Title Page

  • Document No.

  • Audit Title

  • Date of Observation

  • Employee

  • Observer

  • Date Completed

  • Description

General Information

  • Status

  • Length of Observation

  • Crew Observation

  • Announced / Unannounced

  • Business Hours / After Hours

Did performers conduct/participate in and effective pre-job brief (PJB)? (KTL)

  • PJB Form Completed

  • Circuit ID

  • Closest Emergency Medical Facility

  • Employee in Charge (EIC) / Designated Crew Member (DCM)

  • PJB Participation (Crew and/or Traffic Control

  • Potential Hostile Situations

  • Correct Job Scope

  • Hazard Recognition and Mitigation Planned

  • Voltage and MAD Identified (CESR)

  • Roles/Tasks Identfied

  • Address Location Description

  • Post-Job Brief

Safety (attributes noted as CESR are also KTL)

  • Adheres to MAD (CESR)

  • Followed Insulate and Isolate Guidelines (CESR)

  • Designated Observer Identified/Documented on PJB (CESR)

  • Lines/Equipment Isolated - Tested

  • Mobile Equipment Appropriately Grounded and/or Barricaded (CESR)

  • Job Site Left in Orderly Safe Condition

  • Body Mechanics / Ergonomics

  • Designated Observer Effective and Engaged During All Critical Tasks (CESR)

  • Lines/Equipment Isolated - Grounded (CESR)

  • Proper Hydration Work Practices, Including PJB Hydration Discussion and Use of Hydration Monitor

Are performers inspecting and utilizing appropriate PPE and clothing for the tasks? (KTL)

  • Eye Protection

  • Foot Protection

  • Chaps Utilized Properly

  • No Jewelry

  • Rubber Hose Inspection (CESR)

  • Blanket Inspections (CESR)

  • Hearing Protection

  • FR Clothing (CESR)

  • Head Protection

  • Work Gloves

  • Rubber Gloves (CESR)

  • Sleeves (CESR)

Has crew adhered to work, drop and fell zone precautions for falling objects/line of fire? (KTL)

  • Public and Crew Protected

  • Avoided "Line of Fire" During Work Task(s)

  • Proper Drop Zone

  • Proper Fell Zone

  • Proper Construction Work Zone

Was appropriate fall protection properly utilized? (KTL)

  • Fall Protection Used Properly and Per Manufacturer's Recommendations

  • Fall Protection Equipment in Good Condition

  • Harness and Lanyard FR-Rated As Appropriate (CESR)

  • Three-Points of Contact Maintained

  • Lanyard Clipped in Properly

Vehicles, Heavy Machinery and Other Related Equipment

  • Outriggers Engaged Properly

  • Wheels Chocked (KTL)

  • Seatbelts Worn and/or in Good Condition (KTL)

  • Dielectric Boom Testing In Date

  • Utilizes Proper Towing Equipment and Procedures

  • DOT Vehicle Pre-Post Inspection Up-To-Date

  • Specialized Safety Devices (e.g. Audible Alarms)

  • Properly Positions and Operates Vehicles and Equipment (KTL)

Are state and local traffic control zone regulations, including MUTCD, being followed? (KTL)

  • Traffic Control Zone Set Up Appropriately

  • Audible Alerts Available for Immediate Use (e.g. Horn, Whistle)

  • Traffic Regulations Followed

  • Appropriately Reflective Traffic Apparel In Use

Tools and Equipment (attributes noted as CESR are also KTL)

  • Body Belt (KTL)

  • Climbers (KTL)

  • Proper Chainsaw Storage and Operation

  • Hot Stick (CESR)

  • Hand Tools

  • Small Electrical Tools

  • Mechanical Jumpers

Is vehicle housekeeping and material storage being maintained?

  • First Aid / Blood-Borne Pathogens Kits

  • Fire Extinguisher

  • Environmental Spill Equipment

  • Materials Maintained, Stored and Secured

  • DOT Emergency Equipment

  • Vehicle Interior Free of Trash/Clutter

Are effective communications being used during critical tasks?

  • Confirmation When Energizing or De-Energizing Lines/Equipment

  • Good General Communications (e.g. DCC, Grid, SCS, Customer)

  • ETR Communications

  • Designated Observer, Spotter and Equipment Operator

  • Isolating and Grounding Line Communications

  • Proper Use of 3-Way Communication During Critical Task(s); Including Use of Phonetic Alphabet

Work Methods (KTL) (attributes noted as CESR are also KTL)

  • Pole Climbing Techniques

  • Switching and Tagging (CESR)

  • Poles / Adjacent Poles Tested for Structural Integrity (Visual, Probing, Sounding)

  • Pole Climbing Verification

  • Trenching and Excavation

  • Enclosed no Confined Space Entry

  • Pole Removal Equipment and Procedures

  • Procedure Use and Adherence (Circle/Slash, Procedure Administration

Additional HP Tools

  • Performs Self-Check (STAR)

  • Uses Questioning Attitude (QVV; Stop When Unsure)

  • Verification Practices (Peer Check; Concurrent Verification; Independent Verification)

  • Utilizes Situational Awareness (2 Minute Drill)

Feedback & Follow-up

  • Feedback to Employee

  • Follow-up Required

Notes

  • Notes

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.