Information
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Select date
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Work Order Number
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Work Activity
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Location
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Road Name
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Document No.
Responsible Person
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LCC Responsible Person
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Name
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Contractor Business Name
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Contractor Business Name
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Contractor Responsible Person
Associated Procedures / Permits / Work Instructions
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Are there any Associated Procedures / Permits / Work Instructions to be recorded?
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Details
Hazards / Potential Incidents
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TASK: Drive to and from worksite
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HAZARDS / POTENTIAL INCIDENTS:
Road traffic accident / traffic management -
SCORE BEFORE CONTROLS:
Li - 2
Co - 5
Risk - H -
RISK CONTROLS OR ACTION:
Drive to conditions, vehicle checked and maintained. Licensed, competent operators. Fit for work, not fatigued. Seatbelts worn. -
SCORE AFTER CONTROLS:
Li - 2
Co - 3
Risk - M -
TASK: Machinery on site interact with other vehicles
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HAZARDS / POTENTIAL INCIDENTS:
Vehicle damage / injury -
SCORE BEFORE CONTROLS:
Li - 2
Co - 4
Risk - S -
RISK CONTROLS OR ACTION:
Approved TMP. Use spotters where necessary, competent operators. Machine operator checks done and maintained. -
SCORE AFTER CONTROLS:
Li - 2
Co - 3
Risk - M -
TASK: Machinery on site interact with workers or pedestrians
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HAZARDS / POTENTIAL INCIDENTS:
Injury to people struck by machinery -
SCORE BEFORE CONTROLS:
Li - 2
Co - 5
Risk - H -
RISK CONTROLS OR ACTION:
Approved TMP. Use spotters where necessary, competent operators. Machine operator checks done and maintained. Wear hard hats working around machinery. Exclude non essential persons -
SCORE AFTER CONTROLS:
Li - 1
Co - 5
Risk - S -
TASK: Work under overhead wires - plant and trucks tipping
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HAZARDS / POTENTIAL INCIDENTS:
Hit wires - electrocution -
SCORE BEFORE CONTROLS:
Li - 3
Co - 5
Risk - H -
RISK CONTROLS OR ACTION:
Use appropriate machine sixe. Use spotter where necessary. Follow Aurora guidelines. Look up look out. Measure power line height. -
SCORE AFTER CONTROLS:
Li - 1
Co - 3
Risk - M -
TASK: Working with assets - Telstra, power, gas, water, sewer
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HAZARDS / POTENTIAL INCIDENTS:
Damage to services, injury -
SCORE BEFORE CONTROLS:
Li - 3
Co - 3
Risk - M -
RISK CONTROLS OR ACTION:
Get location - Dial Before You Dig. Spotters. Use water jet to excavate where appropriate -
SCORE AFTER CONTROLS:
Li - 2
Co - 2
Risk - L -
TASK: Heavy lifting
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HAZARDS / POTENTIAL INCIDENTS:
Manual handling / back injury -
SCORE BEFORE CONTROLS:
Li - 4
Co - 4
Risk - H -
RISK CONTROLS OR ACTION:
Use appropriate lifting techniques, 2 men lifts or use mechanical aids ( HIABS) -
SCORE AFTER CONTROLS:
Li - 2
Co - 3
Risk - M
Complete below where additional Hazards / Potential Incident are identified
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TASK:
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DESCRIBE TASK
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DESCRIBE HAZARD / POTENTIAL INCIDENTS
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SCORE BEFORE CONTROLS
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Li
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Co
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Risk
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DESCRIBE RISK CONTROL or ACTION
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SCORE AFTER CONTROLS
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Li
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Co
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Risk
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TASK:
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DESCRIBE TASK
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DESCRIBE HAZARD / POTENTIAL INCIDENTS
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SCORE BEFORE CONTROLS
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Li
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Co
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Risk
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DESCRIBE RISK CONTROL or ACTION
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SCORE AFTER CONTROLS
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Li
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Co
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Risk
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TASK:
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DESCRIBE TASK
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DESCRIBE HAZARD / POTENTIAL INCIDENTS
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SCORE BEFORE CONTROLS
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Li
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Co
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Risk
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DESCRIBE RISK CONTROL or ACTION
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SCORE AFTER CONTROLS
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Li
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Co
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Risk
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TASK:
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DESCRIBE TASK
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DESCRIBE HAZARD / POTENTIAL INCIDENTS
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SCORE BEFORE CONTROLS
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Li
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Co
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Risk
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DESCRIBE RISK CONTROL or ACTION
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SCORE AFTER CONTROLS
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Li
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Co
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Risk
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TASK:
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DESCRIBE TASK
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DESCRIBE HAZARD / POTENTIAL INCIDENTS
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SCORE BEFORE CONTROLS
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Li
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Co
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Risk
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DESCRIBE RISK CONTROL or ACTION
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SCORE AFTER CONTROLS
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Li
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Co
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Risk
Have All Risks Been Reduced?
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Have all risks been reduced to an acceptable level (as low as reasonably practical) AND controls implemented
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If NO, stop and contact supervisor
Corrective Actions
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RECOMMENDED ACTION:
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DESCRIBE ACTION
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WORK ORDER NUMBER
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COMPLETION DATE
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SIGNED BY ACTION OFFICER
Read & Signed By All Persons Participating
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NAME & SIGN
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NAME & SIGN
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NAME & SIGN
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NAME & SIGN
Responsible LCC Employee or Contractor Signature
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NAME & SIGNATURE
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DATE
Responsible LCC Employee
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NAME & SIGNATURE
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DATE
