NiW UG Take 5

• Prepared by

• Site conducted

  Select

• Location

• Date

  Date

• Conducted on

  Date

• Task

• Am I Physically and Mentally fit for work?

  Yes

  No

  N/A

• Have I stretched and planned for regular rest breaks for this task?

  Yes

  No

  N/A

• Have I read and understood the procedure or instructions for this task?

  Yes

  No

  N/A

• Are the tools and equipment in good order?

  Yes

  No

  N/A

• Do I have the correct PPE for the task?

  Yes

  No

  N/A

Tick all Identified Damaging Energies Present

• Human Energy

  Tick

• Machine Energy

  Tick

• Thermal Energy

  Tick

• Noise Energy

  Tick

• Gravitational Energy

  Tick

• Object Energy

  Tick

• Chemical Energy

  Tick

• Susceptible Part

  Tick

• Vehicular Energy

  Tick

• Electrical Energy

  Tick

• Radiation Energy

  Tick

• Specialized Energy

  Tick

• Do I require any permits, certifications, or special authorisation?

  Yes

  No

• If YES, see your supervisor. A JHA may be required.

• Are there any hazardous energies present prior to commencing the task that cannot be controlled? (refer to the above energies/part)

  Yes

  No

• If YES, see your supervisor. A JHA may be required.

• Does the task have potential to harm others in the work area?

  Yes

  No

• If YES, see your supervisor. A JHA may be required.

• Have all the hazards been addressed before starting the task?

  Yes

  No

• If NO, do not proceed. STOP and see your Supervisor

• Have controls been applied to those hazards and confirmed as effective?

  Yes

  No

• If NO, do not proceed. STOP and see your Supervisor

• Have I got a clear plan in mind to complete the task safely?

  Yes

  No

• If NO, do not proceed. STOP and see your Supervisor

• Do I have Area Owner's authorisation to complete the task?

  Yes

  No

• If NO, do not proceed. STOP and see your Supervisor

• Is the ground Support installed to Standard?

  Yes

  No

• STOP if you answered No, call your Shift Boss

• Is there adequate ventilation?

  Yes

  No

• STOP if you answered No, call your Shift Boss

• Is the area clear of misfires?

  Yes

  No

• STOP if you answered No, call your Shift Boss

• Are the communications in the area adequate?

  Yes

  No

• STOP if you answered No, call your Shift Boss

• Are the travel ways/Housekeeping to standard?

  Yes

  No

• STOP if you answered No, call your Shift Boss

• Are the required markers/signs/barricades in place?

  Yes

  No

• STOP if you answered No, call your Shift Boss

• I can confirm that all open holes or voids nearby are barricaded?

  Yes

  No

• STOP if you answered No, call your Shift Boss

Where is the location of the nearest Refuge Chamber or Escape Way?

• undefined

Have I confirmed the area is free from entrapment risk?

• undefined

Notes/Comments/Hazards/Controls:

• undefined