Information

  • Audit #

  • Inspection date

  • Prepared by

  • Project

  • Personnel

  • Site ID

  • Address

1. Traffic Control

  • 1. Is the site a Traffic site?

  • 1.1 Is the Traffic Control setup in-house or external (3rd party)?

  • 1.1.1 Is the Field Specialist correctly certified for Traffic Control work?

  • 1.1.2 Are Stop/Slow bats, hazard lights and beacons, traffic signs and cones being used correctly?

  • Provide photo of traffic setup, including signage

  • 1.1.1 Is the Traffic Management Plan (TMP) on-site and being used effectively by 3rd Party Traffic controllers?

  • Provide photo of traffic setup, including signage

  • Provide photo of TMP

2. Personal Safety

  • 2.1. Is hi-vis clothing being worn by all?

  • 2.2. Are protective pants and long-sleeves being worn by all?

  • 2.3. Are protective overalls being worn by the in-MH worker?

  • 2.4. Are protective gloves being worn by all?

  • 2.5. Are steel-capped boots worn by all?

  • 2.6. Is the in-manhole worker wearing a hardhat?

  • 2.7. Is the condition of both topside & in-MH harnesses acceptable, and are they are within calibration/test date?

  • 2.8. Is the static winch being used together with an in-manhole self-retracting lanyard (SRL) and are both in good condition and within calibration/test date? (only exemption is when using type 3 MSA Winch or RPD with ladder rungs)

  • Provide photo of tripod setup including Winch and SRL

  • 2.9. Is the topside worker wearing a harness and tethered by a fall arrest, and are both within calibration/test date?

  • 2.10. Is the Oxybok available to the in-MH worker, and within calibration/test date?

  • 2.11. Are ear muffs or ear plugs available?

  • 2.12. Are mobile phones on and easily accessible?

  • 2.13. Is sunscreen and insect repellant available?

  • 2.14. Are safety glasses available?

  • 2.15. Is water, hand cleaner and paper towel available?

  • Provide photo water container, soap etc.

3. Gas Meters

  • 3.1. Has the gas meter been response (bump) tested?

  • 3.2. Is the gas meter within test/calibration date?

  • Provide photo of gas meter test tag

  • 3.3. Is the gas meter secured to the rope with 2 separate attachment points, and has the tail end of the rope been tied off to tripod leg?

  • Provide photo of gas meter secured to rope

  • 3.4. Was the area around the manhole tested for gases and checked for hazards?

  • 3.5. Has the atmosphere in the manhole been gas tested?

4. Equipment

  • 4.1. Are tools clean and stored appropriately in their respective buckets?

  • 4.2. Is the drill operational and properly maintained?

  • 4.3 Is all 240V electrical equipment inspected and tagged?

  • 4.3 Is the velocity meter operational and within calibration date?

5. Operational

  • 5.1. Is the work site clean and tidy and free of trip hazards?

  • 5.2. Are ropes attached to chokers and being used appropriately for lowering the gas meter and tool buckets

  • 5.3. Is the monitor AT LEAST 1 meter away from the manhole or securely fixed to the tripod leg so it can't fall into the manhole?

  • Provide photo of monitor and its proximity to the manhole

  • 5.4. Is the work area barricaded off safely?

  • Provide photo of work area

  • 5.5. Are the appropriate "confined space" signs placed out to warn the public?

  • 5.6. Are the site conditions safe for a confined space entry? (consider atmospheric testing, hydraulic conditions/ flow depth, visual and verbal contact can be maintained with in-manhole worker.)

  • 5.6.1 DO NOT PERFORM Confined Space Entry. List what site conditions are unsafe for confined space entry.

  • 5.7. Are the sensor cables secured neatly and not hanging in flow, including when monitor is stored in manhole?

  • 5.8 Is the topside worker in continuous verbal/visual contact with the in-MH worker?

6. Paperwork

  • 6.1. Has the confined space entry permit been completed, and has the relevant control room been notified (if required)?

  • 6.2. Has the risk assessment (HIDRA) been reviewed and signed off by all people onsite?

  • 6.3. Discuss with crew, are there any additional risks at site that have NOT YET been recorded on the HIDRA?

  • What additional risks did the crew identify? Update the HIDRA to include these now

  • 6.4. Is there a current and approved Project Management Plan (PMP) onsite?

  • 6.5 Are the project specific SWMS on site and have all crew reviewed and signed off on them?

  • Provide photo of SWMS sign-off page

  • 6.6. Has the site visit log been updated?

  • 6.7. Has the daily entry been completed for the site?

7. Certification

  • 7.1. Do all people on site have a valid confined space entry ticket?

  • 7.2. Do all people onsite have a valid OHS white card?

  • 7.3. Do all people onsite have valid relevant client inductions (if required)?

  • 7.4. Do all people have ADS ID cards?

  • 7.5 Is there at least one trained person on site in performing First-Aid & CPR?

8. Vehicle

  • 8.1. Is the vehicle registration current?

  • 8.2. Is the vehicle clean, tidy and organised?

  • Provide photo of cargo compartment of van

  • 8.3. Is the vehicle within its service date?

  • 8.4. Is the vehicle logbook up to date?

  • 8.5. Is there a fire extinguisher available and is it within it's service date?

  • 8.6. Does the vehicle have a correctly stocked first aid kit?

  • 8.7. Are the location of the fire extinguisher and first aid kit known to staff?

10. Rescue Simulation Exercise

  • 10.1 Was the rescue simulation completed under 2 minutes, and the in-manhole worker retrieved without them assisting/climbing out?

  • 10.1.1 What equipment or process restricted or hindered the rescue procedure?

  • 10.2. How deep is the manhole?

  • 10.3. How fast was the rescue simulation?

12. MSDS

  • 12.1. Are all relevant MSDS's onsite?

  • 12.2. Has everyone been trained on these MSDS's?

13. Emergency Response

  • 13.1 Are all field personnel onsite familiar with the Emergency Response Procedure applicable to that site?

  • What is the name of the nearest hospital/emergency department?

  • Are at least 2 members of the crew licensed and trained in driving the van?

  • 13.2 Are St John Fact sheets on site and do all crew members know the location of this sheet?

14. Environmental

  • 14.1 Has any sewage spilled outside manhole? (including transfer from equipment or worker exiting manhole)

  • 14.1.1. Has the spilled be cleaned up? (shoveling it back into manhole and/or cleaning with disinfectant spray using high pressure washer)

  • 14.2 Was any vegetation impacted/removed to access site?

  • 14.2.1 What measures were taken to minimize the environmental impact?

  • 14.3 Has risk assessment been conducted with regard to the impact on environment? (i.e if any vegetation was removed or any sewerage spill/overflows have occurred, has the HIDRA been updated)

  • 14.3.1 What environmental risks should have been updated onto the HIDRA? Add them to HIDRA now.

  • 14.4 Is any noisy equipment being used that may cause disturbance to nearby residents? (i.e drill, generator)

  • 14.4.1 Is the work occurring between 7am-6pm?

  • 14.4.1.1 Has the Field Specialist/ Regional Manager/ Client notified nearby residents of night works and the need to use generator/drill after hours?

  • Provide evidence (copy of letter, email or text message notification)

  • 14.5 If manhole was sealed prior to opening has it been resealed to prevent odours escaping?

Crew Assessment

  • Name of In-manhole worker: (wearing overalls, harness, helmet, gloves, safety glasses, gumboots/waders, Oxybok - if applicable)

  • Competency Rating: C =Competent , R = Retrain

  • Retraining Details:

  • Name of Topside worker: (wearing harness attached to lanyard, gloves, carrying mobile phone, confirms gas results prior to entry, maintains visual and verbal contact with in-manhole worker)

  • Competency Rating: C =Competent , R = Retrain

  • Retraining Details:

  • Name of Third-person (rescuer & data entry): (carrying mobile phone, completes CSE form, competent in Qstart)

  • Competency Rating: C =Competent , R = Retrain

  • Retraining Details:

If conducting a remote (telephone) audit- upload photos of site inspection here:

  • Photo of site (including barricades, signage, Tripod setup, Topside worker attached to harness)

  • Photo of in-manhole worker geared up for entry

  • Photo of Gas meter calibration sticker

  • Photo of Tripod inspection sticker

  • Photo of Winch/RPD inspection sticker

  • Photo of Harness inspection sticker

  • Photo of traffic signage (if applicable)

  • Photo of Traffic management plan (if applicable)

If conducting a remote (telephone) audit- upload photos of documentation here:

  • Photo of completed SWMS sign-off page for relevant Project

  • Photo of completed HIDRA for relevant site

  • Photo of completed Confined Space Permit for relevant site

  • Photo of completed Site Visit Log for relevant site

Corrective Actions and Sign Off

  • Enter any corrective actions that will be undertaken

  • On site representative

  • Auditor's signature

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.