JMCC RR1.7 BNSF

• Date - Initials - Job Number(s)

• Job Name

General Project Information

• Safety Manager Assigned to this project:

• Site hours of operation:

• List Sub-Contractors and Competent Persons per sub:

• Prepared by

• Weather Conditions

• Conducted on

  Date
• Location
  Address

1. Planned / Scheduled work for the day.

• 1a. Pre-Task / Safety Briefing prior to start of work?

  Yes

  No

  N/A

• 1b. Work performed according to plan?

  Yes

  No

  N/A

• Brief description of work to be performed.

• 1c. Adequate tools, materials and Safety controls to perform work?

  Yes

  No

  N/A

• 1d. Rail road flagman on site and safety briefing given?

  Yes

  N/A

• Were risk assessment findings communicated during the job safety briefing?

  Yes

  No

  N/A

• Were track authority/protection parameters communicated during the briefing?

  Yes

  No

  N/A

• Are job briefings updated as personnel/conditions change?

  Yes

  No

  N/A

• Are safety zones around equipment established and communicated?

  Yes

  No

  N/A

• Has a right of way Fire Risk Prevention/Risk Assessment For been completed?

  Yes

  No

  N/A

2. Ladders / Scaffold

• Are ladders present in use on site?

  Yes

  N/A

• 2a. Unsafe or damaged ladders destroyed, discarded, and removed from site?

  Yes

  No

  N/A

• 2b. Ladders properly positioned?

  Yes

  No

  N/A

• 2c. Ladders properly secured?

  Yes

  No

  N/A

• Is scaffold present on site?

  Yes

  N/A

• 2d. Was scaffolding erected according to plan, and by qualified person?

  Yes

  No

  N/A

• 2e. Is inspection tag present and completed by competent person?

  Yes

  No

  N/A

• List responsible party for scaffold, type of scaffold, inspection frequency and competent person:

3. Emergency Response

• 3a. Adequate emergency plans for site?

  Yes

  No

  N/A

• 3b. Emergency procedures displayed at site?

  Yes

  No

  N/A

• 3c. Adequate first aid kits and equipment for site?

  Yes

  No

  N/A

• 3d. Are the Hazcom program and SDS sheets present, available, and up to date?

  Yes

  No

  N/A

4. Personal Protective Equipment (PPE)

• 4a. Adequate PPE supplied / utilized?<br>

  Yes

  No

  N/A

• 4b. Appropriate training in safe use, clean-up and inspection of PPE?

  Yes

  No

  N/A

5. Fall / Perimeter Protection

• 5a. Guard rails at required height?

  Yes

  No

  N/A

• 5b. Holes greater than 2" covered, secured, and clearly marked?

  Yes

  No

  N/A

• 5c. Fall arrest plan, equipment, & personnel properly trained?

  Yes

  No

  N/A

• 5d. Are all fall exposures from any height protected?

  Yes

  No

  N/A

6. Lifting Equipment

• 6a. Hoisting Equipment adequate for task at hand? (Right machine for the task?)

  Yes

  No

  N/A

• 6b. All workers, and operators aware of hoisting loads over head and near power lines, practices and procedures according to company policy and OSHA Standards?

  Yes

  No

  N/A

• 6c. Unsafe or damaged lifting equipment, including ropes, slings, chains, hooks removed from service?

  Yes

  No

  N/A

7. Work Environment

• 7a. Sufficient lighting?

  Yes

  No

  N/A

• 7b. Adequate housekeeping?

  Yes

  No

  N/A

• 7c. Adequate access/egress provided to the site and all work areas?

  Yes

  No

  N/A

8. Fire Prevention

• 8a. Are flammable liquids being properly stored?

  Yes

  No

  N/A

• 8b. Are there an adequate number of fire extinguishers present and in working order?

  Yes

  No

  N/A

• 8c. Are flammable liquids are stored in safety cans with the wire mesh flame arrestor intact?

  Yes

  No

  N/A

• 8d. Are compressed gas cylinders located or stored in a secure and upright position?

  Yes

  No

  N/A

• 8e. Are oxygen cylinders stored a minimum of 20 feet from other combustible/flammable liquids or gases?

  Yes

  No

  N/A

9. Incidents, Accident, Injury, Near Miss

• 9a. Were there any incidents, injuries, accidents or near miss' to report today?

  Yes

  N/A

• 9b. Detailed information narrative?

• 9c. Detailed Information Photo's

  Media

10. Electrical Hazards

• 10a. GFCI outlets inspected regularly?

  Yes

  No

  N/A

• 10b. Electrical equipment placed away from water?

  Yes

  No

  N/A

• 10c. Extension cords inspected prior to use?

  Yes

  No

  N/A

• 10d. Electrical equipment at safe distance from flammables?

  Yes

  No

  N/A

• 10e. Are all power tools inspected prior to use?

  Yes

  No

  N/A

11. Lock Out/Tag Out: Hazardous Energy, Equipment or Other.

• 11a. Lock-out/tag-out (LOTO) procedures for electrical or other hazardous equipment?

  Yes

  No

  N/A

12. Excavations

• 12a. Will excavation work be performed today?

  Yes

  N/A

• 12b. Has an excavator Corporate Safety Program been submitted to Superintendent?

  Yes

  No

  N/A

• 12c. Is there a competent person for excavating on site?

  Yes

  No

  N/A

• 12d. Is there an excavation plan, with associated "DIG" numbers reviewed and approved?

  Yes

  No

  N/A

• 12e. Are Safety restraint belts in place and being used?

  Yes

  No

  N/A

• 12f. Are 'BACK-UP'or other movement alarms in place and functioning properly?

  Yes

  No

  N/A

• 12g. Is traffic control required, and in place according to 'traffic control plan'?

  Yes

  No

  N/A

• 12h. Are Flaggers required?

  Yes

  No

  N/A

• Are the Flaggers certified according to City, State, & OSHA standards?

  Yes

  No

  N/A

• Are the Flaggers trained for the task at hand, and familiar with surrounding activities?

  Yes

  No

  N/A

• 12i. Have open excavations been protected?

  Yes

  No

  N/A

• 12j. Is shoring designed by a Structural Engineer?

  Yes

  No

  N/A

• 12k. Is contaminated material being handled according to plan and disposed of properly in accordance to EPA expectations?

  Yes

  No

  N/A

• 12L. Is erosion control in place? I.e: silt fence, drain screens, pump sock - filter bag, etc...

  Yes

  No

  N/A

• 12m. Has all earth work been inspected by the competent person prior to entering?

  Yes

  No

  N/A

• 12n. Are precautionary measures in place for dewatering trenches / excavations?

  Yes

  No

  N/A

• 12o. Have proper permits been acquired prior to digging?

  Yes

  No

  N/A

• 12p. Has the soil been tested to determine classification by the competent person?

  Yes

  No

  N/A

• 12q. Is benching, sloping, shoring, or shielding required?

  Yes

  No

  N/A

• 12r. Is any special insurance required, if so, has it been obtained? (RR Prospective, etc..)

  Yes

  No

  N/A

• 12s. Are dust control and street sweeping equipment being used? ie... Water truck - Street sweeper

  Yes

  No

  N/A

• 12t. Are there any atmospheric hazards?

  Yes

  No

  N/A

• 12u. Are access & egress points in place according to standards?

  Yes

  No

  N/A

13. Administrative Procedures

• 13a. Procedure for incident reporting followed? (Incident, witness, injury, etc.)

  Yes

  No

  N/A

• 13b. Has proper orientation been provided to workers, contractors, visitors?

  Yes

  No

  N/A

• All personnel have completed the BNSF Contractor Safety Orientation Program?

  Yes

  No

  N/A

• All personnel have an e-RAILSAFE ID?

  Yes

  No

  N/A

• 13c. Proper permits acquired prior to task? (Hot Works, Confined Space etc)

  Yes

  No

  N/A

• 13d. Site Safety Plan readily available?

  Yes

  No

  N/A

• Is a completed copy of the BNSF Engineering Contractor Safety Action Plan form available on site?

  Yes

  No

  N/A

• 13e. Supervision on site? (List Supt., PM, BNSF Rep, and Flagmen)

  Yes

  No

  N/A

• 13f. Appropriate consultative arrangements? (Ability to get resolution to concerns)

  Yes

  No

  N/A

• 13g. Routine inspections, monitoring, audits submitted regularly?

  Yes

  No

  N/A

14. Tower & Mobile Cranes

• 14a. Is there a crane on site today?

  Yes

  N/A

• 14b. Are crane inspections current and copies available?

  Yes

  No

  N/A

• 14c. Is the load chart readily available, legible, and being followed?

  Yes

  No

  N/A

• 14d. Are signal persons and riggers qualified with proof readily available?

  Yes

  No

  N/A

• 14e. Are all hook 'Safety Locks' in working order?

  Yes

  No

  N/A

• 14f. Is crane positioned at the correct safe distance from over-head power lines?

  Yes

  No

  N/A

• 14g. Are outriggers properly padded?

  Yes

  No

  N/A

• 14h. Are access ladders and steps properly protected and in good condition?

  Yes

  No

  N/A

• 14i. Does the operator have appropriate licensing accord to Job, City, & State requirements?

  Yes

  No

  N/A

• 14j. Is all rigging properly tagged and regularly inspected?

  Yes

  No

  N/A

15. Site exterior condition.

• 15a. Are site access points clear and maintained?

  Yes

  No

  N/A

• 15b. Is the public roadway at site access points clear of dirt and debris which could cause a roadway hazard?

  Yes

  No

  N/A

• 15c. Are erosion and sediment control measures in place, adequate, and in accordance with SWPPP?

  Yes

  No

  N/A

16. Site Security

• 16a. Is the site fenced to prevent un-authorized entrance?

  Yes

  No

  N/A

• 16b. Are equipment and job trucks locked at the end of shift to prevent un-authorized use?

  Yes

  No

  N/A

• 16c. Are materials and equipment stored in a secure area to prevent theft?

  Yes

  No

  N/A

• 16d. List any site security measures that are currently in place for the site, i.e. security cameras or night time security personnel.

17. Atmospheric: Lead, Asbestos, Silica

• 17a. Have potential atmospheric hazards been Identified? (If yes, please describe)<br>

  Yes

  No

  N/A

• 17b.Has formal testing been performed prior to beginning of task to identify hazard and exposure levels?

  Yes

  No

  N/A

• 17c. Has the hazard been remediated / abated, if yes, by whom? (please provide copies of completion reports)

  Yes

  No

  N/A

• 17d. Are employee's provided with appropriate PPE to be protected from exposure to hazard?

  Yes

  No

  N/A

18. General Duty Clause, Miscellaneous Findings & Other Safety Observations

• 18a. Were observations or miscellaneous findings that pose a potential hazard discovered during audit process?

  N/A

  Details

• 18b. Were there deficiencies that aren't listed discovered during audit process?

  N/A

  Details

• Brief description & photo:

  Media

19. Corrective Actions

• 19a. Enter any corrective actions that will be undertaken

• Add media

  Media

20. On-Track Safety

• Will work be performed within 25 feet of the track?

  Yes

  N/A

• 20a. Do all personnel know the authority limits?

  Yes

  No

  N/A

• 20b. Do all personnel know who the employee-in-charge is? Flagman, look-out, etc.

  Yes

  No

  N/A

• 20c. Do all personnel know what the method of warning is?

  Yes

  No

  N/A

• 20d. Do all personnel where the designated place-of-safety is?

  Yes

  No

  N/A

• 20e. In adjacent track situations, are activities conducted on the field side of the track, where practical?

  Yes

  No

  N/A

• 20f. Is a copy of the MW Operating Rules with the BNSF rule qualified employee-in-charge when personnel and/ or equipment foul the tracks?

  Yes

  No

  N/A

• 20g. Do all personnel on the project know the on-track safety strategy?

  Yes

  No

  N/A

• 20h. Are all personnel aware of the 25 foot from tack centerline safety zone?

  Yes

  No

  N/A

Sign Off

• Auditor's signature

  Sign