JHA-JW

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Project Title:

• Location:

• Date Analysis Completed:

• Select date

  Date

• Scheduled Start Date:

• Select date

  Date

• Task Description:

• Attendees:

• Prepared By:

• Step 1. Review the scope of the job, sequence of work and all potential hazards.
  
  Step 2. Walk-through the work area and point out possible hazards. Make a list of all potential hazards identified and how hazard will be eliminated or controlled. (Identify who is responsible for eliminating or controlling hazard and how it will be handled).
  
  Step 3. Send an electronic copy of the completed written hazard analysis to the safety department contact BEFORE work begins.

New sequence of work

• Sequence of work

• Potential Hazards

• How to eliminate or control

• SEQUENCE OF WORK. POTENTIAL HAZARDS. ELIMINATE OR CONTROL METHOD

• Name of preparer:

• Select date

  Date

• Add signature

  Sign

• Safety Representative:

• Select date

  Date

• Add signature

  Sign

• Reviewed by PC (Project.) SO (Maint.)

• Select date

  Date

• Add signature

  Sign

• POTENTIAL HAZARDS AND CONDITIONS ( References in parentheses available on Intranet)

1.0 - WORKER HABITS & ACTIONS:

• Workers given adequate training for the job?

  Yes

  No

  N/A

• Has provision been made for rotating repetitive tasks?

  Yes

  No

  N/A

• Proper hoisting / lifting techniques used

  Yes

  No

  N/A

• Confined space permits required? (Confined space program)

  Yes

  No

  N/A

• If yes, annotate:

• Should fire alarm system be disabled? (See 4/21/03 letter)

  Yes

  No

  N/A

• If yes, annotate:

• Reviewed Volunteer Responsibility with all workers?

  Yes

  No

  N/A

• WORKER HABITS & ACTIONS: Additional Notes:

2.0 BUILDING CONDITION:

• Any collapse hazard evident?

  Yes

  No

  N/A

• Note all that applies:

• Are there arrangements in place to keep building secure?

  Yes

  No

  N/A

• If yes, annotate:

• Is there sufficient lighting for the work?

  Yes

  No

  N/A

• Appropriate building oversight contacted about the work?

  Yes

  No

  N/A

• Demolition procedure reviewed?

  Yes

  No

  N/A

• BUILDING CONDITION: Additional Notes:

3.0 - HEAVY EQUIPMENT:

• Operators maintaining adequate distance from other workers?

  Yes

  No

  N/A

• Equipment in good repair? Roll-over protection?

  Yes

  No

  N/A

• Ensure daily inspections prior to commencing use.

• Call before you dig procedures followed?

  Yes

  No

  N/A

• Are trenches properly sloped, shielded and barricaded?

  Yes

  No

  N/A

• Do pre-existing conditions require photography?

  Yes

  No

  N/A

• HEAVY EQUIPMENT: Additional Notes:

4.0 - LOCKOUT / TAGOUT:

• Training and personal lockout devices needed? (See 8/2/02 letter).

  Yes

  No

  N/A

• If yes, annotate:

• Blocks for gravity restraint?

  Yes

  No

  N/A

• Pressure lines bled down? Slip blinds? Valve blocks?

  Yes

  No

  N/A

• Circuit breaker lockout?

  Yes

  No

  N/A

• Valve handle removed or chained in off position?

  Yes

  No

  N/A

• Cord & plug under worker control?

  Yes

  No

  N/A

• Are "Out of Use" tags available? (See out of service documentation)

  Yes

  No

  N/A

• LOCKOUT / TAGOUT: Additional Notes:

5.0 - ENVIRONMENT, CHEMICAL, ELECTRICAL:

• Excessive dust, noise, fumes, heat, vibration?

  Yes

  No

  N/A

• If yes, annotate:

• Adequate ventilation & illumination?

  Yes

  No

  N/A

• Physical environment in the work area acceptable?

  Yes

  No

  N/A

• Will hazardous substances will be brought on the job site?

  Yes

  No

  N/A

• List applicable substances:

• All electrical equipment properly grounded?

  Yes

  No

  N/A

• GFCI receptacles available where needed?

  Yes

  No

  N/A

• Are workers familiar with policy on installing natural gas piping? (See 5/24/02 letter).

  Yes

  No

  N/A

• Pressure testing and chemical flushing of pipe installations?

  Yes

  No

  N/A

• Are plywood or plexiglass available to cover unattended electrical panels? (See 3/25/03 letter).

  Yes

  No

  N/A

• ENVIROMENTAL, CHEMICAL, ELECTRICAL: Additional Notes:

6.0 - EQUIPMENT SAFEGUARDING:

• Are all guards in place? Necessary guards provided and pinch points protected?

  Yes

  No

  N/A

• Compressors and other fixed-place equipment anchored?

  Yes

  No

  N/A

• Equipment safety checked before being put to use?

  Yes

  No

  N/A

• Equipment maintained? All rotating shafts, belts guarded?

  Yes

  No

  N/A

• EQUIPMENT SAFEGUARDING: Additional Notes:

7.0 - INCLEMENT WEATHER:

• Are weather condition safe for the task being performed? ie; heavy rain, lightning, high winds, ice, snow?

  Yes

  No

  N/A

• INCLEMENT WEATHER: Additional Notes:

8.0 - HAND & POWER TOOLS:

• Tools and cords in good condition?

  Yes

  No

  N/A

• Tools safety checked before using?

  Yes

  No

  N/A

• Proper tools provided?

  Yes

  No

  N/A

• Welding / Torching in designated areas only?

  Yes

  No

  N/A

• HAND & POWER TOOLS: Additional Notes:

9.0 - HOUSEKEEPING / STORAGE METHODS:

• Have daily cleanup arrangements been discussed?

  Yes

  No

  N/A

• How will materials be organized and stored?

  Yes

  No

  N/A

• Are the areas free of clutter, dirt and spills?

  Yes

  No

  N/A

• Are aisles, catwalks and walkways well defined and unobstructed? Storage stable? Too high? Unusual congestion?

  Yes

  No

  N/A

• Note all that applies:

• Pallet storage acceptable?

  Yes

  No

  N/A

• Are items exposed to weather?

  Safe

  At Risk

  N/A

• How will tools and equipment be stored?

  Safe

  At Risk

  N/A

• Note all that applies:

• HOUSEKEEPING / STORAGE METHODS: Additional Notes:

10.0 - FALL PREVENTION:

• Can a worker fall from one level to another or on same level?

  Safe

  At Risk

  N/A

• Note all at risk areas:

• Has document "Working in Elevated Locations" been reviewed with workers?<br>

  Yes

  No

  N/A

• Is there a need for fall protection training / refresher?

  Yes

  No

  N/A

• If yes, annotate:

• Has Exterior Maintenance been consulted?

  Yes

  No

  N/A

• Are safety lines and harnesses required?

  Yes

  No

  N/A

• If yes, annotate:

• Is scaffolding needed for the tasks?

  Yes

  No

  N/A

• Note all that applies:

• Catwalks and elevated walkways in good condition? Handrails sturdy? Guard rails, toe boards in place?

  Yes

  No

  N/A

• Are there dangers for persons below?

  Yes

  No

  N/A

• Note all that applies:

• Is there a danger from overhead high voltage electrical lines?

  Safe

  At Risk

  N/A

• If yes, annotate:

• FALL PREVENTION: Additional Notes:

11.0 PERSONAL PROTECTIVE EQUIPMENT:

• Hard hats? Safety glasses? Work boots? Cotton respirators? Gloves? Protective clothing available? Face shields?

  Yes

  No

  N/A

• Hard hats are to be approved in accordance with current safety requirements, should be free of stickers tags ect.. that do not relate to specific identification or job function, and worn bill forward (with the exception of welding / torching or surveying)
  
  All high visibility clothing ie. vest, shirts are to be High Visibility Orange or Yellow only

• Hearing protection worn? Welding helmets? Aprons?

  Yes

  No

  N/A

• Are workers trained and approved to wear respirators? (See Respiratory Protection Program).

  Yes

  No

  N/A

• PERSONAL PROTECTIVE EQUIPMENT: Additional Notes:

12.0 - MATERIALS HANDLING:

• Are material handlers properly trained?

  Yes

  No

  N/A

• What provisions will be made for securing loads?

  Yes

  No

  N/A

• Note all that applies:

• Will pallets be required?

  Yes

  No

  N/A

• In good condition?

  Yes

  No

  N/A

• MATERIALS HANDLING: Additional Notes:

13.0 - ENGINEERING / DESIGN:

• Are there any plans to deviate from AFC prints? If so, has the change been approved by the Engineer?

  Yes

  No

  N/A

• Explain:

• Has a sketch been provided documenting the change?

  Yes

  No

  N/A

• Are City permits required for the work?

  Yes

  No

  N/A

• If yes, annotate:

• ENGINEERING / DESIGN: Additional Notes:

14.0 - PERSONAL SAFETY / PASSERBY HAZARDS:

• Trip hazards? Floor openings covered? Sharp objects? Overhead clearance? Railings? Warning signs?

  Yes

  No

  N/A

• Note all that are applicable:

• Danger signs needed?

  Yes

  No

  N/A

• If yes, annotate:

• Flagman needed?

  Yes

  No

  N/A

• If yes, annotate:

• Area barricaded?

  Yes

  No

  N/A

• If yes, annotate:

• Anything loose on parapet or ledge?

  Yes

  No

  N/A

• If yes, annotate:

• Restraining devices required?

  Yes

  No

  N/A

• If yes, annotate:

• Tie backs in place?

  Yes

  No

  N/A

• Sidewalks and private roadways in good repair?

  Yes

  No

  N/A

• Pedestrians alert to moving vehicles?

  Yes

  No

  N/A

• Can worker be caught in or between objects?

  Safe

  At Risk

  N/A

• If yes, annotate:

• Will a crane be required? Has master rigger been consulted?

  Yes

  No

  N/A

• If yes, annotate:

• Are extension cords hoses ect.. routed safely?

  Yes

  No

  N/A

• PERSONAL SAFETY / PASSERBY HAZARDS: Additional Notes:

15.0 - EMERGENCY RESPONSE:

• Emergency phone numbers posted (on wall and or other known locations) for First Aid, Fire, Chemical, electrical emergency?

  Yes

  No

  N/A

• Do workers know whom to call?

  Yes

  No

  N/A

• Are needed supplies on hand?

  Yes

  No

  N/A

• Posted fire brigade lists up to date? Brigade members know procedures they must follow when activated?

  Yes

  No

  N/A

• Emergency cleanup provision in place for chemical spills?

  Yes

  No

  N/A

• Has emergency evacuation procedure been provided? Are personnel aware of evacuation plan?

  Yes

  No

  N/A

• Are fire extinguishers charged and in good condition?

  Yes

  No

  N/A

• Checked monthly and marked?

  Yes

  No

  N/A

• Is there adequate safe storage for combustibles, rags ect..?

  Yes

  No

  N/A

• Are there possible spontaneous combustion hazards?

  Yes

  No

  N/A

• Are flammable or explosive materials used?

  Yes

  No

  N/A

• Are eye wash stations available?

  Yes

  No

  N/A

• If yes note locations:

• MSDS accessible?

  Yes

  No

  N/A

• Is emergency plan in place for Refrigerant gas leaks?

  Yes

  No

  N/A

• EMERGENCY RESPONSE: Additional Notes:

16.0 - LADDERS:

• In good condition?

  Yes

  No

  N/A

• Are ladders designed for anticipated use?

  Yes

  No

  N/A

• Has worker completed ladder safety training? (See 2/20/03 letter).

  Yes

  No

  N/A

• LADDERS: Additional Notes:

17.0 - PERMITS / REPORTS:

• Confined space?

  Yes

  No

  N/A

• If yes, annotate:

• Hot work?

  Yes

  No

  N/A

• If yes, annotate:

• Fire guard report?

  Yes

  No

  N/A

• If yes, annotate:

• Energized electrical work permit?

  Yes

  No

  N/A

• If yes, annotate:

• Call before you dig?

  Yes

  No

  N/A

• If yes, annotate:

• DOB or other permits required?

  Yes

  No

  N/A

• PERMITS / REPORTS: Additional Notes:

18.0 - ACCIDENT PREVENTION PLAN:

• On large projects has accident prevention plans been reviewed with Crew Overseers, Volunteers? (See 3/25/03 letter).

  Yes

  No

  N/A

• Have workers been informed of Accountability Program?

  Yes

  No

  N/A

• ACCIDENT PREVENTION PLAN: Additional Notes:

19.0 - OVERALL JOB HAZARD ANALYSIS ADDITIONAL NOTES:

• END