HBI JSS

• Job Name

• Job Number

• Conducted on

  Date

• Survey conducted by

• Location
  Address

• Personnel on site

Fall Protection

• Competent Person(s)

• Are employees capable of falling 6 feet or greater?

  Yes

  No

  N/A

• Has fall protection been made available?

  Yes

  No

  N/A

• What fall protection is available?

  Select Harness & Lanyard Retractable Life Line Guardrail Hole Covers Safety Net

  • Harness & Lanyard
  • Retractable Life Line
  • Guardrail
  • Hole Covers
  • Safety Net

• Is the fall protection adequate for the scope of work?

  Yes

  No

  N/A

• Has the employee(s) expected to use the fall protection equipment been formally trained on the use and maintenance of the equipment?

  Yes

  No

  N/A

• What is the condition of the fall protection equipment?

  Brand New

  Good

  Fair

  Needs Replaced

• Is equipment properly labelled and legible?

  Yes

  No

  N/A

• Are there proper anchor points or places to "tie off" to?

  Yes

  No

  N/A

Drill Rig(s):

• Operator's Name

• Have the Daily Equipment Inspection forms been completed for each shift?

  Yes

  No

  N/A

• Has the drill been properly set up?

  Yes

  No

  N/A

• Is the operator's manual available / on the rig?

  Yes

  No

  N/A

• Has swing radius protection been put into place?

  Yes

  No

  N/A

• Why is there no swing radius protection?

• Has the rig been properly maintained?

  Yes

  No

  N/A

• Is there an adequate / ready-to-use fire extinguisher on the rig?

  Yes

  No

  N/A

Crane(s)

• Operator's Name

• Does the operator have proper certification to run the crane?

  Yes

  No

  N/A

• Have the crane's daily inspection forms been completed for each shift?

  Yes

  No

  N/A

• Has the crane been properly erected?

  Yes

  No

  N/A

• Is the operator's manual available and in the crane?

  Yes

  No

  N/A

• Has swing radius protection been put into place?

  Yes

  No

  N/A

• Why is swing radius protection not in place?

• Has crane been properly maintained?

  Yes

  No

  N/A

• Is a load rating chard available?

  Yes

  No

  N/A

• Is a boom angle indicator present?

  Yes

  No

  N/A

• Is there an adequate / ready-to-use fire extinguisher on the crane?

  Yes

  No

  N/A

• Is the crane fitted with any attachments? (i.e. Drill, Vibratory Hammer, Auger Cast)

  Yes

  No

  N/A

• What attachment is present?

  Drill

  Vibratory Hammer

  Auger Cast

Heavy Equipment (e.g. Endloaders / Forklifts / Bobcats)

• Operator(s)' Name(s)

• Is the operator(s) certified to operate the equipment?

  Yes

  No

  N/A

• Have the Daily Equipment Inspection forms been completed for each shift?

  Yes

  No

  N/A

• Are travel alarms present and operational?

  Yes

  No

  N/A

• Is the operator's manual available and in the equipment?

  Yes

  No

  N/A

• Does the operator demonstrate acceptable operation of the equipment?

  Yes

  No

  N/A

• Does the operator demonstrate proper shut down of the rig?

  Yes

  No

  N/A

• Is the equipment properly stored on the job site?

  Yes

  No

  N/A

• Are all employees aware of the equipment's work area(s)?

  Yes

  No

  N/A

Rigging

• Competent Person

• Has signal person been formally trained on hand signals and demonstrates knowledge of signals?

  Yes

  No

  N/A

• Is rigging properly labelled and legible?

  Yes

  No

  N/A

• What is the condition of the nylon ropes?

  Brand New

  Good

  Fair

  Needs Replaced

• What is the condition of the shackles?

  Brand New

  Good

  Fair

  Needs Replaced

• Are the shackles adequate for the scope of work?

  Yes

  No

  N/A

• Are the wire rope slings in good condition? (No broken wires: 10 in 1 lay, 5 in 1 strand of a lay, 2 in eye)

  Yes

  No

  N/A

• What is the condition of the spreaders?

  Brand New

  Good

  Fair

  Needs Replaced

• Are the hooks in good condition? (remove if bent, twisted, excessively worn, welded on, pitted)

  Yes

  No

  N/A

• Are hooks equipped with a double action safety latch?

  Yes

  No

  N/A

• What is the condition of the turnbuckles?

  Brand New

  Good

  Fair

  Needs Replaced

Personal Protective Equipment (PPE)

• What PPE is being utilized?

  Select Hardhats Safety Glasses Gloves Respiratory Protection Hearing Protection Safety Vests Face Shields Buoyant Work Vest Tyvek Suits Other

  • Hardhats
  • Safety Glasses
  • Gloves
  • Respiratory Protection
  • Hearing Protection
  • Safety Vests
  • Face Shields
  • Buoyant Work Vest
  • Tyvek Suits
  • Other

• Has employee(s) been properly fit tested and been administered a pulmonary test?

  Yes

  No

  N/A

• What other PPE is being utilized?

• If you selected "Respiratory Protection", has employee(s) been fit tested and been administered a pulmonary test?

  Yes

  No

  N/A

• Do employees demonstrate acceptable use of PPE

  Yes

  No

  N/A

• Do employees demonstrate proper storage and maintenance of PPE?

  Yes

  No

  N/A

• Is selected PPE adequate for the scope of work?

  Yes

  No

  N/A

Confined Spaces/Excavations

• Competent Person(s)

• Confined Space or Excavation?

  Confined Space

  Excavation

• Permit Required

  Non-Permit Required

• Have proper permits been acquired?

  Yes

  No

  N/A

• Has confined space entree been formally trained and certified for confined space operations?

  Yes

  No

  N/A

• Is nearest fire department being notified of each entry into confined space?

  Yes

  No

  N/A

• Is pre-entry air monitoring being performed?

  Yes

  No

  N/A

• Is continuous air monitoring being performed?

  Yes

  No

  N/A

• Is forced air ventilation being utilized?

  Yes

  No

  N/A

• Are only intrinsically safe tools being utilized?

  Yes

  No

  N/A

• Are access and egress times being recorded?

  Yes

  No

  N/A

• How many access/egress points are available?

  1

  2

  3

  4

  Other

• How many access/egress points are available?

• Is there an adequate retrieval system available?

  Yes

  No

  N/A

• Is there a second employee always in eye sight of the employee in the confined space?

  Yes

  No

  N/A

• Have lock-out-tag-out procedures been utilized

  Yes

  No

  N/A

• Are proper postings being utilized?

  Yes

  No

  N/A

• Is there adequate lighting?

  Yes

  No

  N/A

• Has confined space entree been formally trained and certified on confined space operations?

  Yes

  No

  N/A

• Has pre-entry air monitoring been performed?

  Yes

  No

  N/A

• Has pre-entry air monitoring proven non-permit required conditions?

  Yes

  No

  N/A

• Is there proper ventilation?

  Yes

  No

  N/A

• Is a second employee present to monitor employee in confined space?

  Yes

  No

  N/A

• Is there an adequate retrieval system available?

  Yes

  No

  N/A

• Have proper postings been utilized? (i.e. "employee inside", etc.)

  Yes

  No

  N/A

• Is there adequate lighting

  Yes

  No

  N/A

• How many access/egress points are available?

  1

  2

  3

  4

  Other

• How many access points are available?

• How deep is the excavation? (in feet)

• How wide is the excavation? (in feet)

• Can excavation be considered a confined space?

  Yes

  No

  N/A

• Has pre-entry air monitoring been completed?

  Yes

  No

  N/A

• Is there proper ventilation?

  Yes

  No

  N/A

• How many access/egress points are available?

  1

  2

  3

  4

  Other

• How many access/egress points are available?

• Does the excavation have access/egress every 25 feet?

  Yes

  No

  N/A

• Is the excavation adequately shored / sloped / benched?

  Yes

  No

  N/A

• Has the entree been formally trained and certified on operations in an excavation?

  Yes

  No

  N/A

Electrical

• Are GFCIs being utilized?

  Yes

  No

  N/A

• Are GFCIs in good condition?

  Yes

  No

  N/A

• Are GFCIs tested regularly?

  Yes

  No

  N/A

• Is assured grounding being utilized?

  Yes

  No

  N/A

• Are tools properly grounded?

  Yes

  No

  N/A

• Are there overhead wires?

  Yes

  No

  N/A

• Are drill rigs, cranes, and other equipment capable of remaining outside of the minimum encroachment distances as regulated by OSHA?

  Yes

  No

  N/A

• Select the following safety procedures that have been enacted to encroach upon minimal clearance distance as per OSHA.

  Select Pre-Project Safety Meeting Machines Grounded Lines Blanketed / Marked Off 100% Spotter Lines De-energized Non-conductive Tooling Electrically Rated PPE Other

  • Pre-Project Safety Meeting
  • Machines Grounded
  • Lines Blanketed / Marked Off
  • 100% Spotter
  • Lines De-energized
  • Non-conductive Tooling
  • Electrically Rated PPE
  • Other

• Please Specify

• Are there underground wires?

  Yes

  No

  N/A

• Do we run the risk of contacting the underground lines?

  Yes

  No

  N/A

• Can the underground wires be shut of / moved?

  Yes

  No

  N/A

• Will we relocate or remove the points that put us at risk of contacting the wires?

  Relocate

  Remove

• Is the generator in proper working condition?

  Yes

  No

  N/A

• Is the generator adequately labelled for voltage output, danger, etc?

  Yes

  No

  N/A

• Is the generator grounded?

  Yes

  No

  N/A

• What is the condition of the electrical power tools?

  Brand New

  Good

  Fair

  Needs Replaced

• What is the condition of the extension cords?

  Brand New

  Good

  Fair

  Needs Replaced

Housekeeping & Storage

• Is site trash/debris being controlled?

  Yes

  No

  N/A

• Material properly stored?

  Yes

  No

  N/A

• Proper containers being utilized?

  Yes

  No

  N/A

• Site free of tripping hazards? (i.e. random wood, metal bands, etc.)

  Yes

  No

  N/A

• Conex box and/or gang box organized and free of clutter?

  Yes

  No

  N/A

Welding & Cutting

• Fire extinguisher available within 10 feet?

  Yes

  No

  N/A

• Welding / Cutting area free of combustibles?

  Yes

  No

  N/A

• Proper storage of compressed cylinders? (i.e. secured separately and upright, labelled, not in conex box or gang box, etc.)

  Yes

  No

  N/A

• Strikers being utilized to ignite torches?

  Yes

  No

  N/A

• Hoses / leads inspected regularly and bled after use?

  Safe

  At Risk

  N/A

• Gauges in proper working orded?

  Yes

  No

  N/A

Materials Handling

• Proper lifting / bending / twisting and kept to a minimum?

  Yes

  No

  N/A

• Are mechanical assists or two-man lifts being utilized for heavy objects?

  Yes

  No

  N/A

• Hand free of pinch points?

  Yes

  No

  N/A

• Machine guards in place?

  Yes

  No

  N/A

• Hands located away from area casing is contacted by jaws?

  Yes

  No

  N/A

Fire Safety

• Fire extinguishers in working order?

  Yes

  No

  N/A

• Fire extinguishers inspected and maintained appropriately?

  Yes

  No

  N/A

• Good housekeeping practiced to prevent combustible materials from igniting?

  Yes

  No

  N/A

• Adequate flammable / combustible liquid storage? (i.e. fire cabinet, appropriate gas containers, etc.)

  Yes

  No

  N/A

• Fire watch being use whenever "hot work" is being done?

  Yes

  No

  N/A

Project Set-Up

• Emergency Number / Facilities identified and posted?

  Yes

  No

  N/A

• Utility locate provided?

  Yes

  No

  N/A

• Project Safety Plan completed?

  Yes

  No

  N/A

• Project Crew Safety Agreement signed?

  Yes

  No

  N/A

• Site-specific Training completed? (i.e. OSHA 10/30, HAZWOPER, MSHA 24hr, etc.)

  Yes

  No

  N/A

Other

• Emergency numbers / facilities identified and posted?

  Yes

  No

  N/A

• Safety Manual on site?

  Yes

  No

  N/A

• MSDS on site?

  Yes

  No

  N/A

• First-aid supplies / eyewash on available?

  Yes

  No

  N/A

• Weekly Tool Box Talk (TBT) completed?

  Yes

  No

  N/A

• Daily Task Analysis (DTA) / Job Hazard Analysis (JHA) completed each day?

  Yes

  No

  N/A

• Hosed whip-checked / pinned?

  Yes

  No

  N/A

Corrective Actions

• If any, please state corrective action(s) to be implemented on this site.

Comments

• Please list any comments you may have on / for this site.

Surveyor's Signature

• Surveyor's Name.

• Surveyor's Signature.

  Sign

On-Site Representative's Signature

• On-Site Representative's Name.

• Representative's Signature.

  Sign