IX-PLANT MITCHELL

• Job Name

• Client / Site

• Prepared by

• Personnel

• Conducted on

  Date
• Location
  Address

Fall Protection

• Fall Protection

• Details:

• Picture(s):

  Media

• Fall protection present at 6' or above?

  YES

  NO

  N/A

• Rescue plan present and reviewed?

  YES

  NO

  N/A

• Yes

  No

  N/A

• Guardrails at 42"/21" +/- 3"?

  YES

  NO

  N/A

• Have users been trained and documented in fall protection?

  YES

  NO

  N/A

• Has fall protection equipment been inspected prior to use? (Safety Harness, SRL, Anchor Points)

  YES

  NO

  N/A

• Are floor and wall openings protected, covered, and marked? Are covers adequate, secured, and labelled?

  YES

  NO

  N/A

• Is protection present for changes in elevation?

  YES

  NO

  N/A

Ladders/Stairs

• Ladders/Stairs

• Details:

• Picture(s):

  Media

• Is ladder free of defects?

  YES

  NO

  N/A

• Is ladder being used properly?

  YES

  NO

  N/A

• Is ladder secured?

  YES

  NO

  N/A

• Is extension ladder used on a 4:1 pitch?

  YES

  NO

  N/A

• Does ladder extend 3' or more above landing?

  YES

  NO

  N/A

• Is ladder a safe work distance from hazard?

  YES

  NO

  N/A

• Have slip/trip exposures on ladder been eliminated?

  YES

  NO

  N/A

• Are access/egress areas free of debris/materials?

  YES

  NO

  N/A

Motorized Equipment

• Motorized Equipment

• Add media

  Media

• Is operator working safely?

  YES

  NO

  N/A

• Is machine operating at least 10' away from overhead power lines?

  Yes

  No

  N/A

• Is proper operator protection in place (ROPS, Cage, Screen, etc.)?

  YES

  NO

  N/A

• Are seat belts being used?

  YES

  NO

  N/A

• Does backup alarm function properly?

  Yes

  No

  N/A

• Is fire extinguisher present with current inspection?

  YES

  NO

  N/A

• Is flag man required/present?

  YES

  NO

  N/A

• Is glass free of obstructions?

  YES

  NO

  N/A

• Does horn function properly?

  YES

  NO

  N/A

• Is weekly equipment inspection form completed?

  YES

  NO

  N/A

PPE

• Add media

  Media

• Hard hats

  YES

  NO

  N/A

• Safety glasses (goggles where applicable)

  YES

  NO

  N/A

• Face shields

  YES

  NO

  N/A

• Hearing protection

  YES

  NO

  N/A

• Respiratory Protection

  YES

  NO

  N/A

• Appropriate clothing for the task (hi-vis, chaps, fire retardant, etc.)

  YES

  NO

  N/A

• Gloves

  Yes

  No

  N/A

• Work boots

  YES

  NO

  N/A

• Visitor PPE available?

  YES

  NO

  N/A

Housekeeping

• Housekeeping

• Add media

  Media

• Is trailer access/egress hazard free?

  YES

  NO

  N/A

• Are sanitary facilities available, adequate, and clean?

  YES

  NO

  N/A

• Is an adequate supply of drinking water available?

  YES

  NO

  N/A

• Are slip, trip, and fall hazards present in or around work areas?

  YES

  NO

  N/A

• Is material storage adequate and utilized properly?

  YES

  NO

  N/A

• Is trash collected in protected containers?

  YES

  NO

  N/A

Environmental

• Environmental

• Add media

  Media

• Are airborne contaminants properly controlled/eliminated?

  YES

  NO

  N/A

• Is HazMat storage, use, and disposal adequate/appropriate?

  YES

  NO

  N/A

• Is spill containment adequate/appropriate?

  YES

  NO

  N/A

• Is concrete cut wet and/or vacuumed?

  YES

  NO

  N/A

• Is nuisance dust controlled/eliminated?

  YES

  NO

  N/A

Site/Public Protection

• Site/Public Protection

• Add media

  Media

• Are excavations properly protected?

  YES

  NO

  N/A

• Is falling object/overhead protection in place?

  YES

  NO

  N/A

• Are perimeter fences installed?

  YES

  NO

  N/A

• Is impalement protection in place? (Re-bar caps)

  YES

  NO

  N/A

• Are barricades installed properly?

  YES

  NO

  N/A

• Is adequate lighting available?

  YES

  NO

  N/A

• Is public protection signage necessary/present?

  YES

  NO

  N/A

• Is traffic control plan in place?

  YES

  NO

  N/A

• Is street closure properly identified?

  YES

  NO

  N/A

Administration

• Administration

• Add media

  Media

• Is a properly trained supervisor on site?

  YES

  NO

  N/A

• OSHA posters posted?

  YES

  NO

  N/A

• State/Fed. posters posted in English/Spanish?

  YES

  NO

  N/A

• Is an IX safety manual readily available?

  YES

  NO

  N/A

• Is trench box tabulated data readily available?

  YES

  NO

  N/A

• Have IX orientations been conducted/completed?

  YES

  NO

  N/A

• Has a JSA been submitted for each trade/task?

  YES

  NO

  N/A

• Are changing conditions being noted on JSA and communicated as needed?

  YES

  NO

  N/A

• Are Pre-con meetings documented?

  YES

  NO

  N/A

• Is there documentation of corrective actions taken since last audit?

  YES

  NO

  N/A

• Are toolbox talks being conducted and recorded weekly?

  YES

  NO

  N/A

• Silica Plan displayed in trailer?

  YES

  NO

  N/A

Hot Work

• Welding/Cutting

• Add media

  Media

• Fire extinguisher present; properly charged, inspected?

  YES

  NO

  N/A

• Is welding flash protection available?

  YES

  NO

  N/A

• Are flash arresters present?

  YES

  NO

  N/A

• Are cylinders 20' apart or separated by burn barrier?

  Yes

  No

  N/A

• Are gauges working and adjusted properly?

  YES

  NO

  N/A

• Is burn permit in use and properly filled out?

  YES

  NO

  N/A

• Are cylinders upright, capped, and properly secured?

  YES

  NO

  N/A

• Are torch hoses in good condition?

  YES

  NO

  N/A

• Is proper PPE in use (FR clothing, gloves, burning shield, safety glasses)?

  YES

  NO

  N/A

• Is welding machine properly ventilated?

  Yes

  No

  N/A

• Are welding leads in good condition?

  YES

  NO

  N/A

• Fire Watch?

  YES

  NO

  N/A

Aerial Lifts

• Aerial Lifts?

• Add media

  Media

• Annual inspection current?

  YES

  NO

  N/A

• Are operator training records readily available including fall protection training?

  YES

  NO

  N/A

• Are PFAS (Personal Fall Arrest Systems) in use during operation?

  Yes

  No

  N/A

• Is gate or chain secured?

  YES

  NO

  N/A

• Is lift operating on stable surface?

  YES

  NO

  N/A

• Is operating surface free of holes, sudden changes in elevation?

  YES

  NO

  N/A

• Are safe work distances addressed and maintained?

  YES

  NO

  N/A

• Is equipment loaded properly (not to exceed manufacturers weight limit including operator, tools, and equipment)?

  YES

  NO

  N/A

Safety Equipment/Supplies

• Tripod

• Winch

• 4 Gas Meter

• SRL(s)

• Beam Clamp(s)

• Life Lines

• Misc.

Conclusion

• I agree to address and abate the above issues prior to

  Date

• Name

• Signature

  Sign