Keeley Companies Aerial/Tower Climbing

• Client / Site

• Personnel

• Conducted on

  Date
• Location
  Address

• Prepared by

Planning

• Was a Pre Task/JHA performed for the activities observed?

  Safe

  At Risk

  N/A

• Is there a rigging plan filled out and discussed with the crew?

  Safe

  At Risk

  N/A

• Is there more than one team member that is FA/CPR certified?

  Safe

  At Risk

  N/A

• Is there more than one team member trained in Tower Rescue?

  Safe

  At Risk

  N/A

• Rescue plan in place?

  Safe

  At Risk

  N/A

General

• Housekeeping performed?

  Safe

  At Risk

  N/A

• Safe access to the work area?

  Safe

  At Risk

  N/A

• Fire Extinguisher in good condition, inspection tag current, and pin in place?

  Safe

  At Risk

  N/A

• Utilities identified and discussed with team members?

  Safe

  At Risk

  N/A

• First aid kit and eye wash on site? (good condition and not expired)

  Safe

  At Risk

  N/A

• Barricades and site signage posted?

  Safe

  At Risk

  N/A

Personal Protective Equipment

• Hard hats worn by all team members?

  Safe

  At Risk

  N/A

• Safety toe/Steel toe boots worn by all team members?

  Safe

  At Risk

  N/A

• Safety glasses worn by all team members?

  Safe

  At Risk

  N/A

• Class II reflective vest/shirt worn by all team members?

  Safe

  At Risk

  N/A

• Ear plugs worn when necessary? (General rule of thumb: When standing 5' or more apart and you have to raise your voice hearing protection is needed.)

  Safe

  At Risk

  N/A

Fall Protection

• Fall Protection equipment inspected?

  Safe

  At Risk

  N/A

• Fall Protection equipment in good working order?

  Safe

  At Risk

  N/A

• 100% tie off practices in use?

  Safe

  At Risk

  N/A

• Are all tags on Fall Protection equipment legible?

  Safe

  At Risk

  N/A

Radio Frequency (RF) Hazards

• Have RF hazards been considered and discussed with Team Members?

  Safe

  At Risk

  N/A

• Is a procedure in place to reduce exposure if necessary?

  Safe

  At Risk

  N/A

• Are RF monitors available and in use?

  Safe

  At Risk

  N/A

Personnel Lifting/Aerial Booms

• 100% Fall Protection practices in use?

  Safe

  At Risk

  N/A

• Lift device inspected and alarms operational?

  Yes

  No

  N/A

• Any damage to the boom and/or bucket noted during the Assessment? (If At Risk operations should stop immediately until inspected by competent person and/or maintenance?

  Safe

  At Risk

  N/A

Rigging and Blocks

• Are proper rigging practices being utilized?

  Safe

  At Risk

  N/A

• Is rigging equipment in good condition and tags legible?

  Safe

  At Risk

  N/A

• All rigging equipment inspected prior to use?

  Safe

  At Risk

  N/A

DOT

• Zonar Inspection Completed?

  Safe

  At Risk

  N/A

• Cabs clean with no loose trash that can present a hazard to the drivers controls?

  Safe

  At Risk

  N/A

• All lights operational on the truck and the trailer?

  Safe

  At Risk

  N/A

• Trailer properly mounted and free of loose debris?

  Safe

  At Risk

  N/A

• Emergency trailer brake away system working properly and tested?

  Safe

  At Risk

  N/A

• Tires in good condition? (No deep cuts on tires, axels leaking, etc.)

  Safe

  At Risk

  N/A

• Wheel chalks properly placed and parking brake applied?<br>Proper amount of wheel chalks for each piece of equipment? (2 for truck and 2 for trailer)<br>

  Safe

  At Risk

  N/A

Work Zone Traffic Control

• Road signs properly placed and in good condition?

  Safe

  At Risk

  N/A

• Cones in good condition and properly placed with a start and end taper?

  Safe

  At Risk

  N/A

• Sidewalks closed properly to prevent injury to the public?

  Safe

  At Risk

  N/A

• Flagger performing duties properly and placed in a safe location?

  Safe

  At Risk

  N/A

Tool and Equipment

• All tools in proper working condition?

  Safe

  At Risk

  N/A

• Are extension cords in good condition?

  Safe

  At Risk

  N/A

• Are all tools properly guarded and guards are in place and in use?

  Safe

  At Risk

  N/A

• Are GFCI's in use?

  Safe

  At Risk

  N/A

Good Catch/Near Miss

• Did the crew discuss a Good Catch/Near Miss during the visit?

• Rate the crews focus for safety during your visit?

• Foreman/Supervisor Name:

  Sign

• Assessor's Name

  Sign