HGI_Safe Plan of Action (SPA)_190701_Program Management_Charity, New Orleans, La

SAFE PLAN OF ACTION

• Work Area:

• FR# / Job Task:

• Emergency #'s:

  Select 911

  • 911

• Evacuation To:

  Select South West Corner of The Orleans House

  • South West Corner of The Orleans House

TASK HAZARD ASSESSMENT:

Identify Adjacent Hazards:

• HAZARDS - SAFE PLAN

TEAM MEMBER SIGNATURES

• Team Member Signature

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• Team Member Signature

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• Team Member Signature

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• Team Member Signature

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• Team Member Signature

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• Team Member Signature

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• Team Member Signature

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HAZARDS AND SAFE PLANS CHECKLIST

• ARE OVERHEAD UTILITIES ASSOCIATED WITH TASK?

  Yes

  No

  N/A

• OVERHEAD UTILITIES SAFE PLAN

  Select Power de-energization required Insulation blankets required Wire watcher required Required clearance distance Safe work zone marked

  • Power de-energization required
  • Insulation blankets required
  • Wire watcher required
  • Required clearance distance
  • Safe work zone marked

• Required Clearance Distance in Feet:

• ARE CRANES OR OTHER LIFTING EQUIPMENT ASSOCIATED WITH TASK?

  Yes

  No

  N/A

• CRANES OR OTHER LIFTING EQUIPMENT SAFE PLAN

  Select Signalman assigned Tag lines in use Area around crane barricaded Lifting equipment inspected Personnel protected from overhead load

  • Signalman assigned
  • Tag lines in use
  • Area around crane barricaded
  • Lifting equipment inspected
  • Personnel protected from overhead load

• ARE UNDERGROUND UTILITIES ASSOCIATED WITH TASK?

  Yes

  No

  N/A

• UNDERGROUND UTILITIES SAFE PLAN

  Select Reviewed as-builts Subsurface surveys Received dig permit Required clearance distance Safe work zone marked

  • Reviewed as-builts
  • Subsurface surveys
  • Received dig permit
  • Required clearance distance
  • Safe work zone marked

• Required Clearance Distance in Feet:

• ARE ELECTRICAL HAZARDS ASSOCIATED WITH TASK?

  Yes

  No

  N/A

• ELECTRICAL SAFE PLAN

  Select Lock Out/Tag Out/Try Out Permit Required? Confirm that equipment is de-energized Reviewed electrical safety procedures

  • Lock Out/Tag Out/Try Out
  • Permit Required?
  • Confirm that equipment is de-energized
  • Reviewed electrical safety procedures

• List Required Permits

• ARE EXCAVATION HAZARDS ASSOCIATED WITH TASK?

  Yes

  No

  N/A

• EXCAVATION SAFE PLAN

  Select Permits Inspected prior to entering? Proper sloping/shoring Barricades provided Access/egress provided Protection from accumulated water?

  • Permits
  • Inspected prior to entering?
  • Proper sloping/shoring
  • Barricades provided
  • Access/egress provided
  • Protection from accumulated water?

• List Required Permits

• ARE FIRE HAZARDS ASSOCIATED WITH TASK?

  Yes

  No

  N/A

• FIRE SAFE PLAN

  Select Hot Work Permit Fire Extinguishers Fire Watch Adjacent area protected Unnecessary flammable material removed

  • Hot Work Permit
  • Fire Extinguishers
  • Fire Watch
  • Adjacent area protected
  • Unnecessary flammable material removed

• ARE VEHICULAR TRAFFIC OR HEAVY EQUIPMENT HAZARDS ASSOCIATED WITH TASK?

  Yes

  No

  N/A

• VEHICULAR OR HEAVY EQUIPMENT SAFE PLAN

  Select Traffic Barricades Cones Signs Flagmen Lane Closure Communication with equipment operator

  • Traffic Barricades
  • Cones
  • Signs
  • Flagmen
  • Lane Closure
  • Communication with equipment operator

• ARE NOISE >85 dB HAZARDS ASSOCIATED WITH TASK?

  Yes

  No

  N/A

• NOISE >85 dB SAFE PLAN

  Select Ear Plugs Ear Muffs Both

  • Ear Plugs
  • Ear Muffs
  • Both

• ARE HAND & POWER TOOLS HAZARDS ASSOCIATED WITH TASK?

  Yes

  No

  N/A

• HAND & POWER TOOLS SAFE PLAN

  Select Inspect general condition GFCI in use Identified PPE required for each tool Reviewed safety requirements in operators manual(s) Guarding OK

  • Inspect general condition
  • GFCI in use
  • Identified PPE required for each tool
  • Reviewed safety requirements in operators manual(s)
  • Guarding OK

• List required PPE:

PROTECTIVE EQUIPMENT CHECKLIST (Check all PPE required)

• EYE & FACE

  Select Safety Glasses/prescription glasses with side shields Chemical splash googles Impact goggles Full-face shield (worn over 1, 2, or 3 only) Cutting goggles Welding hood Other

  • Safety Glasses/prescription glasses with side shields
  • Chemical splash googles
  • Impact goggles
  • Full-face shield (worn over 1, 2, or 3 only)
  • Cutting goggles
  • Welding hood
  • Other

• Other:

• RESPIRATORY PROTECTION

  Select Dust Mask Fume/mist mask Half-face filter Full-face filter Full-face airline Full-face SCBA Emergency Escape Pack Emergency Escape disposable Other

  • Dust Mask
  • Fume/mist mask
  • Half-face filter
  • Full-face filter
  • Full-face airline
  • Full-face SCBA
  • Emergency Escape Pack
  • Emergency Escape disposable
  • Other

• Other:

• HAND (GLOVES)

  Select Cloth Leather Welding Metal Mesh Elect. Insulated Rubber Neoprene Latex Vinyl Butyl Nitrile Other

  • Cloth
  • Leather
  • Welding
  • Metal Mesh
  • Elect. Insulated
  • Rubber
  • Neoprene
  • Latex
  • Vinyl
  • Butyl
  • Nitrile
  • Other

• Other:

• PROTECTIVE CLOTHING

  Select Nomex/FRC Tyvek suits Rain suit Acid suit Encapsulating suit Safety Vest Other

  • Nomex/FRC
  • Tyvek suits
  • Rain suit
  • Acid suit
  • Encapsulating suit
  • Safety Vest
  • Other

• Other:

• HEARING

  Select Ear Plugs Canal Caps Earmuffs Dual Protection Other

  • Ear Plugs
  • Canal Caps
  • Earmuffs
  • Dual Protection
  • Other

• Other:

• FOOT

  Select Hard toe shoes/boots Dieletric PVC/Urethane Neoprene Rubber Metatarsal guard Other

  • Hard toe shoes/boots
  • Dieletric
  • PVC/Urethane
  • Neoprene
  • Rubber
  • Metatarsal guard
  • Other

• Other:

• HEAD

  Select Class E (Electrical-hi-voltage, 20,000 volts) hardhat Class G (General-limited voltage, 2,200 volts) hard hat Chinstrap accessory Other

  • Class E (Electrical-hi-voltage, 20,000 volts) hardhat
  • Class G (General-limited voltage, 2,200 volts) hard hat
  • Chinstrap accessory
  • Other

• Other:

• List any other PPE not listed above or required for your task:

• DOES TASK PRESENT POTENTIAL EXPOSURE TO HAZARDOUS CHEMICALS?

  Yes

  No

• If yes, has the Material Safety Data Sheet for each hazardous chemical been reviewed?

  Yes

  No

• The signature and date below certifies the completion of the Hazard Assessment.

  Sign