HSE Surveillance Review Record

• Document No.

• Contractor name:

• ConSol number (D&C) / AGS number (I&M)

• Review Number: (Allocated from Site Action Tracking Register)

• Contractor Site Representative:

• Project (select one)

  D&C

  I&M

  Other

• Date / Time of Review

  Date

• Site Location

• Location
  Address

• Stage of Works

• Description of Works being undertaken

• Scope of Observation (ALL Topics or list the number of the Topics included in Observation) 1.0 Documentation(mandatory), 2.0 Plant (mandatory), 3.0 Traffic/Pedestrian Management (mandatory), 4.0 PPE (mandatory), 5.0 Tools and Equipment (mandatory), 6.0 Work Practices (mandatory), 7.0 Electrical Equipment (mandatory), 8.0 Pole / Confined Space Equipment (mandatory), 9.0 Vehicle Inspection, 10.0 Asbestos Removal, 11.0 Hot Work, 12.0 Excavation, 13.0 Licences, 14.0 Emergency Equipment, 15.0 Refuelling Equipment, 16.0 Working From Heights, 17.0 Environmental

• Reviewer name

1.0 DOCUMENTATION (mandatory to review)

• 1.1. Reviewer Inducted to Site?

  Yes

  No

  N/A

• 1.2. Safe Work Method Statement (SWMS) on site?

  Yes

  No

  N/A

• 1.3. SWSM Signed?

  Yes

  No

  N/A

• 1.4. Job Safety and Environmental Analysis (JSEA) completed?

  Yes

  No

  N/A

• 1.5. All site hazards identified in JSEA and controls in place for hazards?

  Yes

  No

  N/A

• 1.6. All workers / visitors signed JSEA?

  Yes

  No

  N/A

• 1.7. THL identified (TM advised or tag/sticker present)?

  Yes

  No

  N/A

• 1.8. Safety Data Sheets (SDS) on site?

  Yes

  No

  N/A

• 1.9. SDS current (less than 5 years old)?

  Yes

  No

  N/A

• 1.10. Traffic Management Plans on site?

  Yes

  No

  N/A

• 1.11. Dial Before You Dig (DBYD) documents obtained?

  Yes

  No

  N/A

• Photo of DBYD document

  Media

• 1.12. Emergency Plans in place?

  Yes

  No

  N/A

• 1.13. Emergency contact numbers available?

  Yes

  No

  N/A

2.0 PLANT (mandatory to review)

• 2.1 Plant Registered (Full or Conditional)?

  Yes

  No

  N/A

• Photo of plant

  Media

• 2.2. Daily Pre Start check list completed?

  Yes

  No

  N/A

• 2.3. Maintenance books on hand?

  Yes

  No

  N/A

• 2.4. Operating rotating beacon / light?

  Yes

  No

  N/A

• 2.5. Rear reflectors installed?

  Yes

  No

  N/A

• 2.6. Rear vision mirrors in good condition?

  Yes

  No

  N/A

• 2.7. Horn operates?

  Yes

  No

  N/A

• 2.8. Audible reversing alarm?

  Yes

  No

  N/A

• 2.9. Roll Over Protection (ROPS) installed?

  Yes

  No

  N/A

• 2.10. Fall Out Protection (FOPS) installed?

  Yes

  No

  N/A

• 2.11. Seat belt installed and used?

  Yes

  No

  N/A

• 2.12. Plant and work site at end of day securely locked down?

  Yes

  No

  N/A

• 2.13. Correct barricading used? Appropriate for work?

  Yes

  No

  N/A

3.0 TRAFFIC MANAGEMENT (mandatory to review)

• Photo of worksite

  Media

• 3.1. Pedestrian Signage available / used?

  Yes

  No

  N/A

• 3.2. Witches hats available / used around vehicle(s)?

  Yes

  No

  N/A

• 3.3. Vehicles protected with barricades?

  Yes

  No

  N/A

• 3.4. Access cleared for pedestrians?

  Yes

  No

  N/A

• 3.5. No equipment / cables / ropes / cords obstruct pedestrian pathway?

  Yes

  No

  N/A

• 3.6. Traffic sign - worker ahead used?

  Yes

  No

  N/A

• 3.7. Traffic control required / used?

  Yes

  No

  N/A

• 3.8. Traffic controller certified?

  Yes

  No

  N/A

4.0 PERSONAL PROTECTIVE EQUIPMENT (PPE) (mandatory to review)

• 4.1 Safety helmet in date?

  Yes

  No

  N/A

• Helmet manufacture date (must be less than three years)

  Date

• 4.2. Wide brimmed hat used?

  Yes

  No

  N/A

• 4.3. Safety boots (steel capped) worn?

  Yes

  No

  N/A

• 4.4 High visibility clothing worn?

  Yes

  No

  N/A

• 4.5. Long sleeved cotton high-visibility shirt worn for electrical work?

  Yes

  No

  N/A

• 4.6. Pole PPE used (cotton long trousers, shirt or overalls)?

  Yes

  No

  N/A

• 4.7. Safety glasses (AS approved) used?

  Yes

  No

  N/A

• 4.8. Hearing protection available / used?

  Yes

  No

  N/A

• 4.9. Riggers gloves available?

  Yes

  No

  N/A

• 4.10. LV Rubber gloves (650V) - Date stamped 12 months?

  Yes

  No

  N/A

• 4.11. Rubber Mat Electrical 650V available?

  Yes

  No

  N/A

5.0 TOOLS AND EQUIPMENT (mandatory to review)

• 5.1. Manhole key available / used?

  Yes

  No

  N/A

• 5.2. Pit seal breaker available / used?

  Yes

  No

  N/A

• 5.3. Extension ladder - fibreglass?

  Yes

  No

  N/A

• 5.4. Step ladder -fibreglass?

  Yes

  No

  N/A

• 5.5. LPG gas cylinder with regulator?

  Yes

  No

  N/A

• 5.6. Wooden /fibreglass handle crowbar?

  Yes

  No

  N/A

• 5.7. Wooden / fibreglass handle shovel?

  Yes

  No

  N/A

• 5.8. Gas detector calibrated?

  Yes

  No

  N/A

• Date calibration due?

  Date

6.0 WORK PRACTICES (mandatory to review)

• 6.1. Vehicles / plant correctly parked and guarded?

  Yes

  No

  N/A

• 6.2. Work area properly guarded?

  Yes

  No

  N/A

• 6.3. All equipment (including covers / lids) within guarded site?

  Yes

  No

  N/A

• 6.4. Work area clear of obstacles?

  Yes

  No

  N/A

• 6.5. Power cables not lying on /across ground?

  Yes

  No

  N/A

• 6.6 Adequate lighting in place (night work)?

  Yes

  No

  N/A

7.0 ELECTRICAL EQUIPMENT (mandatory to review)

• 7.1. Portable power tools used?

  Yes

  No

  N/A

• 7.2. Electrical power tools tested and tagged (every 3 months)?

  Yes

  No

  N/A

• Due for re-testing and tagging

  Date

• 7.3. RCD unit used with electrical power tools?

  Yes

  No

  N/A

• 7.4. RCD unit tested (every 3 months)?

  Yes

  No

  N/A

• Due for re-testing

  Date

• 7.5. Lock out tags available?

  Yes

  No

  N/A

8.0 POLE / CONFINED SPACE EQUIPMENT (mandatory to review)

• 8.1. Full body harness (in date)?

  Yes

  No

  N/A

• Date of expiry

  Date

• 8.2. Pole strap (in date)?

  Yes

  No

  N/A

• Date of expiry

  Date

• 8.3. Safety rope available?

  Yes

  No

  N/A

• 8.4. Tripod available? (Confined space work only)

  Yes

  No

  N/A

9.0 VEHICLE INSPECTION

• 9.1. Registration current?

  Yes

  No

  N/A

• Registration number(s) of vehicles on site?

• 9.2. Windscreen - no cracks/ chips?

  Yes

  No

  N/A

• 9.3. Cargo barrier installed?

  Yes

  No

  N/A

• 9.4. Sufficient storage?

  Yes

  No

  N/A

• 9.5. Vehicle in good condition, free from damage?

  Yes

  No

  N/A

• 9.6. Ladder racks?

  Yes

  No

  N/A

• 9.7. Conduit carrier with end caps?

  Yes

  No

  N/A

• 9.8. Vented gas storage facility?

  Yes

  No

  N/A

10.0 ASBESTOS REMOVAL

• 10.1. Area appropriately barricaded?

  Yes

  No

  N/A

• 10.2. Asbestos signage erected?

  Yes

  No

  N/A

• 10.3. Appropriate PPE used (disposable suit, gloves, P2 mask, glasses, non-laced boots)?

  Yes

  No

  N/A

• 10.4. Workers clear of area during asbestos removal?

  Yes

  No

  N/A

• 10.5. Asbestos bags used for ACM?

  Yes

  No

  N/A

• 10.6. Hand tools used to break up ACM?

  Yes

  No

  N/A

• 10.7. Tools washed down upon completion of ACM removal?

  Yes

  No

  N/A

• 10.8. Asbestos bags sealed and marked correctly? (Including hours in Victoria)

  Yes

  No

  N/A

11.0 HOT WORK

• 11.1. Hot work permit issued?

  Yes

  No

  N/A

• 11.2. Fire extinguisher located near hot works?

  Yes

  No

  N/A

• 11.3. Hot work not undertaken on extreme weather days (i.e. excessive temperatures)?

  Yes

  No

  N/A

12.0 EXCAVATION

• 12.1. Trench barricaded?

  Yes

  No

  N/A

• Photo of trench and barricade

  Media

• 12.2. Spotter used with excavator?

  Yes

  No

  N/A

• 12.3. Spotter has no other duties?

  Yes

  No

  N/A

• 12.4. Spoil placed 1 metre from trench?

  Yes

  No

  N/A

• 12.5. Where possible spoil placed away from road / gutter side of trench?

  Yes

  No

  N/A

• 12.6. Socks placed in gutter before storm water drains?

  Yes

  No

  N/A

• Photo of storm water drain and protection

  Media

13.0 LICENCES

• 13.1. Workers have Construction Induction Cards?

  Yes

  No

  N/A

• 13.2. All drivers have current vehicle drivers licences?

  Yes

  No

  N/A

• 13.3. ISGM ID cards (I&M staff only) letter (D&C contractors)?

  Yes

  No

  N/A

• 13.4. Plant operator licensed / certificate of competency?

  Yes

  No

  N/A

• 13.5. Confined Space trained when entering confined spaces?

  Yes

  No

  N/A

• 13.6. Working at Heights training when climbing poles?

  Yes

  No

  N/A

14.0 EMERGENCY EQUIPMENT

• 14.1. First Aid Kit (meets Code of Practice)?

  Yes

  No

  N/A

• 14.2. Signage on vehicle (first aid and fire extinguisher)?

  Safe

  At Risk

  N/A

• 14.3. First Aid Kit stock within labelled date (bandages and eye wash)?

  Yes

  No

  N/A

• 14.4. Fire blanket available?

  Yes

  No

  N/A

• 14.5. Fire extinguisher (at least 2kg) available?

  Yes

  No

  N/A

• 14.6 Sharps kit available?

  Safe

  At Risk

  N/A

• 14.7. Spill kit available on site?

  Yes

  No

  N/A

15.0 REFUELLING PLANT AND EQUIPMENT

• 15.1. Safety Data Sheet held for fuel?

  Yes

  No

  N/A

• 15.2. Refuelling undertaken in open space?

  Yes

  No

  N/A

• 15.3. Spill kit available when refuelling?

  Yes

  No

  N/A

• 15.4. Fire extinguisher placed near refuelling location?

  Yes

  No

  N/A

• 15.5. No naked flames in refuelling area?

  Yes

  No

  N/A

16.0 WORKING AT HEIGHTS

• 16.1. Industrial fibreglass ladder used?

  Yes

  No

  N/A

• 16.2. Ladder at 1:4 incline?

  Yes

  No

  N/A

• 16.3. Ladder secured to pole?

  Yes

  No

  N/A

• 16.4. Three (3) points of contact used to ascend/ descend ladder?

  Yes

  No

  N/A

• 16.5. Pole bag / tool belt used for tools?

  Yes

  No

  N/A

• 16.6. EWP operating on level ground?

  Yes

  No

  N/A

17.0 ENVIRONMENTAL

• 17.1. Work site neat and tidy?

  Yes

  No

  N/A

• 17.2. Work site not contaminated?

  Yes

  No

  N/A

• 17.3. Soil erosion controlled?

  Yes

  No

  N/A

• 17.4. Sediment controlled?

  Yes

  No

  N/A

• 17.5. Silt / sediment fence installed?

  Yes

  No

  N/A

• 17.6. Waste water managed?

  Yes

  No

  N/A

• 17.7. Dewatering controlled / managed?

  Yes

  No

  N/A

• 17.8. Noise controlled / minimised?

  Yes

  No

  N/A

• 17.9. Handling and disposal of asbestos managed?

  Yes

  No

  N/A

• 17.10. Air quality controlled (i.e. dust wet down)?

  Yes

  No

  N/A

• 17.11. Stockpiling of soil managed?

  Yes

  No

  N/A

• 17.12. Site reinstatement managed?

  Yes

  No

  N/A

• 17.13. Acid sulphate soils controlled?

  Yes

  No

  N/A

• 17.14. Vibration monitored around buildings?

  Yes

  No

  N/A

• 17.15. Flora and Fauna protection controlled and managed?

  Yes

  No

  N/A

• 17.16. Weed control managed?

  Yes

  No

  N/A

• 17.17. Cultural and Heritage areas identified, controlled and managed?

  Yes

  No

  N/A

• 17.18. Plant /vehicle wash down controlled and managed?

  Yes

  No

  N/A

BRIEF DESCRIPTION OF NON CONFORMANCE ISSUES

• NON CONFORMANCE ISSUE 1.0

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• NON CONFORMANCE ISSUE 2.0

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• NON CONFORMANCE ISSUE 3.0

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• NON CONFORMANCE ISSUE 4.0

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• NON CONFORMANCE ISSUE 5.0

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• NON CONFORMANCE ISSUE 6.0

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• NON CONFORMANCE ISSUE 7.0

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• NON CONFORMANCE ISSUE 8.0

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• NON CONFORMANCE ISSUE 9.0

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• NON CONFORMANCE ISSUE 10.0

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• NON CONFORMANCE ISSUE 11.0

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• NON CONFORMANCE ISSUE 12.0

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• NON CONFORMANCE ISSUE 13.0

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• NON CONFORMANCE ISSUE 14.0

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• NON CONFORMANCE ISSUE 15.0

  Select Attended to during review Immediately 5 days 14 days 30 days

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• NON CONFORMANCE ISSUE 16.0

  Select Attended to during review Immediately 5 days 14 days 30 days

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• NON CONFORMANCE ISSUE 17.0

  Select Attended to during review Immediately 5 days 14 days 30 days

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• NON CONFORMANCE ISSUE 18.0

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• NON CONFORMANCE ISSUE 19.0

  Select Attended to during review Immediately 5 days 14 days 30 days

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• NON CONFORMANCE ISSUE 20.0

  Select Attended to during review Immediately 5 days 14 days 30 days

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OTHER OBSERVATIONS AND ADDITIONAL NOTES

Sign Off

• On site representative's signature

  Sign

• Reviewer's signature

  Sign

• Regional Contract Manager signature

  Sign

• Version number: draft 5. Date: 7Jan 2013