NWVL Construction Safety Evaluation

• Site conducted

  Select

• Document No.

• Conducted on

  Date

• Client / Site

• Project Name

• Responsible Party

  Select Capital Projects Elisha Engineering Vijay Pal Construction Team Energy Scaff and Scaff Krishna General Works

  • Capital Projects
  • Elisha Engineering
  • Vijay Pal Construction
  • Team Energy
  • Scaff and Scaff
  • Krishna General Works

• Location

  Select Line 1 Line 2 Dry Side Line 2 Wet Side Line 3 Dry Side Line 3 Wet Side Raw Material Warehouse Baling Area Resin Bay Loading Bay 1 Loading Bay 2

  • Line 1
  • Line 2 Dry Side
  • Line 2 Wet Side
  • Line 3 Dry Side
  • Line 3 Wet Side
  • Raw Material Warehouse
  • Baling Area
  • Resin Bay
  • Loading Bay 1
  • Loading Bay 2

• If "other" was selected provide location

• General Contractor (If applicable)

• Safety Evaluator

  Sakaraia Kaumaitotoya

  Abdul Ashif

AERIAL and SCISSOR LIFTS

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• Workers have been trained in the use of equipment?

  Yes

  No

  N/A

• Lift occupants wearing harness correctly? Employees been trained in fall protection?

  Yes

  No

  N/A

• Workers tied off to boom or basket using the manufacturers anchor points?

  Yes

  No

  N/A

• Lift controls clearly marked and readable?

  Yes

  No

  N/A

• Both feet remain on the floor of the basket?

  Yes

  No

  N/A

• Operators are staying within the load limits of the basket / lift?

  Yes

  No

  N/A

• Lift is stationary when boom is elevated?

  Yes

  No

  N/A

• Operators / employees are refraining from transferring at height while in a scissor lift?

  Yes

  No

  N/A

• Mid-rail chain / gate used when in operation?

  Yes

  No

  N/A

• Operators maintaining safety compliance while operating lift?

  Yes

  No

  N/A

• Notes:

CONCRETE / MASONRY

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• Rebar / flat stakes guarded (covered) to eliminate impalement hazard?

  Yes

  No

  N/A

• Employees working in concrete wearing proper hand and foot protection?

  Yes

  No

  N/A

• Connectors, ties or whips used to secure pressurized air hoses?

  Yes

  No

  N/A

• Guard down on pump (pump truck)?

  Yes

  No

  N/A

• Masonry saw blades guarded?

  Yes

  No

  N/A

• Fugitive dust controlled while cutting block or conducting finish work?

  Yes

  No

  N/A

• Masons wearing face shields AND safety glasses while cutting block?

  Yes

  No

  N/A

• Formwork capable of supporting vertical / lateral loads?

  Yes

  No

  N/A

• Shoring equipment inspected?

  Yes

  No

  N/A

• Base plates secured to foundation / mud sill / formwork?

  Yes

  No

  N/A

• Jacks / supports do not exceed the rated capacity?

  Yes

  No

  N/A

• Limited access zone equal to the wall height plus 4 feet (1.2 meters)?

  Yes

  No

  N/A

• Limited access zone strictly enforced?

  Yes

  No

  N/A

• Walls over 8 feet (2.5 meters) braced to prevent collapse?

  Yes

  No

  N/A

• Masons maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

CONFINED SPACE

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• JSA and rescue plan on-site and available? Employees been trained on the plan?

  Yes

  No

  N/A

• Entry permit completed and signed?

  Yes

  No

  N/A

• Air sampling completed and documented prior to entry?

  Yes

  No

  N/A

• Proper warning signage posted at entry to the permit space?

  Yes

  No

  N/A

• Forced air ventilation used for the duration of entry?

  Yes

  No

  N/A

• Proper lighting provided?

  Yes

  No

  N/A

• Rescue team trained and readily available?

  Yes

  No

  N/A

• Retrieval system (Tripod) available and utilized?

  Yes

  No

  N/A

• Entrants attached to the retrieval line?

  Yes

  No

  N/A

• Attendant on duty outside the permit space?

  Yes

  No

  N/A

• Attendant only performs monitoring duties?

  Yes

  No

  N/A

• Confined space team is maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

CRANES / RIGGING

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• Crane(s) inspected and properly maintained?

  Yes

  No

  N/A

• Crane operator, rigger and signal person certified?

  Yes

  No

  N/A

• Crane load charts visible to the operator?

  Yes

  No

  N/A

• Hand signal charts posted or available?

  Yes

  No

  N/A

• Fire extinguisher located within the cab?

  Yes

  No

  N/A

• Pick (Lift) plan on-site, reviewed and the load is within load capacity?

  Yes

  No

  N/A

• Crane outriggers fully extended and on cribbing properly?

  Yes

  No

  N/A

• Crane swing radius identified and barricaded?

  Yes

  No

  N/A

• Workers remained clear of the in the swing radius and under suspended loads?

  Yes

  No

  N/A

• All power lines are a minimum 15 feet (4.5 meters) away from all lifting and boom swing radius?

  Yes

  No

  N/A

• Rigging equipment inspected and in good condition?

  Yes

  No

  N/A

• Rigging equipment maintain lift capacity markings?

  Yes

  No

  N/A

• Crane operations maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

ELECTRICAL

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• Electrical cords maintain ground posts?

  Yes

  No

  N/A

• Electrical cords are free from damage / repair / alterations?

  Yes

  No

  N/A

• Electrical cords protected from damage (roll over)?

  Yes

  No

  N/A

• Doorways and windows are free from electrical cords?

  Yes

  No

  N/A

• Electrical cords kept clear of work areas and walk ways?

  Yes

  No

  N/A

• Electrical cords are rated for construction? Flat cords removed from site?

  Yes

  No

  N/A

• Spider box being inspected quarterly? (Assured Grounding Program)

  Yes

  No

  N/A

• Power strips and 3 way splitters construction rated?

  Yes

  No

  N/A

• Electrical equipment being used per the manufacturers specifications?

  Yes

  No

  N/A

• Are GFCI's (ELCB) being used, if not on an AGP? Is the GFCI being used closest to the operator?

  Yes

  No

  N/A

• All outlets have cover plates when outlets are energized?

  Yes

  No

  N/A

• Temp light cords are hung with non-metallic fastener, off the ground and does not cause a hazard?

  Yes

  No

  N/A

• Temp light bulbs maintain cages and all bulbs?

  Yes

  No

  N/A

• Electrical rooms maintain proper warnings and labels per NFPA 70e or equivalent?

  Yes

  No

  N/A

• Access to electrical room(s) restricted per NFPA 70e or equivalent?<br>

  Yes

  No

  N/A

• Electrical panels are covered, labeled and all breaker slots are covered?

  Yes

  No

  N/A

• 3 foot clearance around all electrical panels being maintained?

  Yes

  No

  N/A

• Employees are clear of all unprotected circuits / panels?

  Yes

  No

  N/A

• Employees are locking and tagging out equipment and panels? (NOT working on hot equipment)

  Yes

  No

  N/A

• Employees working with energy maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

FALL PROTECTION

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• JSA and fall protection rescue plan has been established and all effected employees have been trained?

  Yes

  No

  N/A

• All employees have been trained in fall protection?

  Yes

  No

  N/A

• A fall protection system is provided for all employees working above 6 feet (1.8 meters)

  Yes

  No

  N/A

• PFA rigged to prevent contact with any surface? (Max fall distance allowed is 6 feet (1.8 meters))

  Yes

  No

  N/A

• Harnesses have been inspected prior to use?

  Yes

  No

  N/A

• Employee wearing harness correctly, wearing the appropriate lifeline (lanyard) and attached to an anchor?

  Yes

  No

  N/A

• Fall protection anchors are set up per specifications and all elements are rated to 5000 lbs (2268 kg)?

  Yes

  No

  N/A

• Guardrails are able to with stand 200 lbs (91 kg) outward and down force?

  Yes

  No

  N/A

• Guardrails (cable rails) do not exceed 2 inch (50 mm) deflection in any direction?

  Yes

  No

  N/A

• Guardrails and mid-rails are at the proper height?

  Yes

  No

  N/A

• Guardrail posts are not more than 8 foot (2.4 meters) On center?

  Yes

  No

  N/A

• Guardrails / mid-rails are constructed to be on the inside on the guardrail posts?

  Yes

  No

  N/A

• Guardrails and mid-rails have been placed around floor / roof openings?

  Yes

  No

  N/A

• Floor holes greater than 2 inches (50 mm) have been covered, properly labeled and secured from movement?

  Yes

  No

  N/A

• The fall protection selected is appropriate for the fall exposure?

  Yes

  No

  N/A

• Floor hole covers are capable of handling 2 times the intended load?

  Yes

  No

  N/A

• Warning line 6 feet (1.8 meters) back for roofing activities?

  Yes

  No

  N/A

• Warning line 15 feet (4.5 meters) for non-roofing activities?

  Yes

  No

  N/A

• Safety monitor performs only monitoring duties?

  Yes

  No

  N/A

• Safety monitor is at the same surface as the work with visual and verbal contact?

  Yes

  No

  N/A

• Warning line erected on all open sides?

  Yes

  No

  N/A

• Warning line flagged and suspended at proper height?

  Yes

  No

  N/A

• Access and hoisting areas guarded?

  Yes

  No

  N/A

• All materials stored more than 6 feet back from roof or deck edge?

  Yes

  No

  N/A

• Safety compliance being maintained?

  Yes

  No

  N/A

• Notes:

FIRE SAFETY

• Does the crew maintain a JSA, properly filled out and within 15 feet of work being performed?

  Yes

  No

  N/A

• Employees trained in the use of fire extinguishers?

  Yes

  No

  N/A

• Fire extinguishers in good condition, fully charged and recently inspected?

  Yes

  No

  N/A

• Fire extinguishers replaced annually?

  Yes

  No

  N/A

• Fire extinguishers are within 75 feet (22 meters) of workers?

  Yes

  No

  N/A

• Fire extinguishers within 15 feet (4.5 meters) of hot work?

  Yes

  No

  N/A

• Minimum of 1 fire extinguisher per floor / level?

  Yes

  No

  N/A

• Fire extinguishers within 50 feet (15 meters) of flammable materials?

  Yes

  No

  N/A

• Flammables stored in an approved and closed containers?

  Yes

  No

  N/A

• No smoking signs posted near flammables?

  Yes

  No

  N/A

• Flammable liquids protected from ignition sources?

  Yes

  No

  N/A

• Flammables are clear from access and egress locations?

  Yes

  No

  N/A

• Scrap piles, debris and trash stored more than 10 feet (3 meters) from building or structure?

  Yes

  No

  N/A

• Maintaining fire safety compliance?

  Yes

  No

  N/A

• Notes:

FORKLIFTS

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• Forklift operators been trained for the specific forklift they are operating?

  Yes

  No

  N/A

• Forklift inspected prior to use?

  Yes

  No

  N/A

• Forklifts are free from modifications or alterations?

  Yes

  No

  N/A

• Outriggers being used on extended reach fork lift?

  Yes

  No

  N/A

• Forklift is operating within lift capacities?

  Yes

  No

  N/A

• Forklift slings have been inspected and maintain lift capacity tags?

  Yes

  No

  N/A

• Forklifts have lift, load and angle charts?

  Yes

  No

  N/A

• Forklift has fire extinguisher in the cab?

  Yes

  No

  N/A

• Forklift forks are down when not in operation?

  Yes

  No

  N/A

• Forklift operator wearing seat belt when in operation?

  Yes

  No

  N/A

• Forklift has an audible back up alarm that can be heard up to 200 feet (60 meters) away?

  Yes

  No

  N/A

• Spotters are used when forklift has to travel through barrier curtains or blind accesses?

  Yes

  No

  N/A

• Operator is traveling less than 15 MPH (24 kilometers) stopping at all intersections and stop signs?

  Yes

  No

  N/A

• Workers are clear of all lifted / suspended loads?

  Yes

  No

  N/A

• Lift basket secured to forklift?

  Yes

  No

  N/A

• Forklift maintains an operator when the lift basket has employees in it?

  Yes

  No

  N/A

• Forklift operators maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

HOUSEKEEPING

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• Impalement hazards (flat stakes, rebar or other like material) maintain impalement protection?

  Yes

  No

  N/A

• Work site / location reasonably organized - Good housekeeping?

  Yes

  No

  N/A

• Lunch trash picked up and removed from site?

  Yes

  No

  N/A

• Trash removed at regular intervals?

  Yes

  No

  N/A

• Scrap, pipe cut offs, pipe and other slip / trip hazards removed?

  Yes

  No

  N/A

• Staging / lay down area in good condition / good housekeeping?

  Yes

  No

  N/A

• Gang boxes free from combustible / flammable materials?

  Yes

  No

  N/A

• All scrap lumbar / planks has nails removed or bent over?

  Yes

  No

  N/A

• Housekeeping is being maintained?

  Yes

  No

  N/A

• Notes:

LADDERS and STAIRS

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• Ladders inspected / no visible defects?

  Yes

  No

  N/A

• Ladders rated for construction (1 AA ladder) ?

  Yes

  No

  N/A

• Spreaders fully extended and locked into position on A frame ladders?

  Yes

  No

  N/A

• Top two steps of a step ladder not being used?

  Yes

  No

  N/A

• Ladders set up on firm stable base?

  Yes

  No

  N/A

• Ladders being used for the intended purpose?

  Yes

  No

  N/A

• Proper ladder selected for task?

  Yes

  No

  N/A

• Extension ladder extends 3 feet (.91 meters) above landing surface?

  Yes

  No

  N/A

• Extension ladder set up at 4:1 angle?

  Yes

  No

  N/A

• Extension ladders tied off at the top and secured at the bottom to prevent slip?

  Yes

  No

  N/A

• Stair/ladder/ramp used at elevation break of 18 inches (457 millimeters) or more?

  Yes

  No

  N/A

• Handrails on stairs with 4 or more risers?

  Yes

  No

  N/A

• 3 feet around the ladder at the top and bottom remain clear of all materials and debris?

  Yes

  No

  N/A

• Employee is maintaining 3 points of contact while climbing ladders?<br><br>

  Yes

  No

  N/A

• Treads / landings on pan stairways filled?

  Yes

  No

  N/A

• Ladder / steps used when access a flat bed trailer?

  Yes

  No

  N/A

• Ladder users maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

MEDICAL / FIRST AID

• Emergency numbers posted on site, visible to all employees?

  Yes

  No

  N/A

• Location of nearest medical facilities posted, visible to all employees?

  Yes

  No

  N/A

• Eye wash / body wash stations set up when required?

  Yes

  No

  N/A

• Every trade maintains their own first aid kit / supplies? First aid kit fully stocked?

  Yes

  No

  N/A

• A minimum of 1 CPR / FA / AED certified employee per crew?

  Yes

  No

  N/A

• Maintaining safety compliance with medical / first aid?

  Yes

  No

  N/A

• Notes:

PERSONAL PROTECTIVE EQUIPMENT

• PPE provided to the employee / available as required?

  Yes

  No

  N/A

• PPE being maintained in good condition?

  Yes

  No

  N/A

• Replacement PPE readily available?

  Yes

  No

  N/A

• Hard hats being worn, properly and without alterations?

  Yes

  No

  N/A

• Eye protection used as required? Glasses rated as eye protection?

  Yes

  No

  N/A

• Hand protection used when required? (Digging, handling tag lines etc)

  Yes

  No

  N/A

• Safety boots (Steal toe) footwear worn when required (Compacting soil, jack hammering etc)?

  Yes

  No

  N/A

• Respirators provided / used as required?

  Yes

  No

  N/A

• Has the employee been trained in respiratory protection?

  Yes

  No

  N/A

• Does employer maintain a current written respirator program?

  Yes

  No

  N/A

• Has the employee been seen by a physician and been fit tested?

  Yes

  No

  N/A

• Employee using the proper filter for respirator?

  Yes

  No

  N/A

• Respirator being stored correctly?

  Yes

  No

  N/A

• Hearing protection used as required?

  Yes

  No

  N/A

• Face protection used as required?

  Yes

  No

  N/A

• High visibility clothing worn as required?

  Yes

  No

  N/A

• Maintaining safety compliance with personal protection equipment ?

  Yes

  No

  N/A

• Notes:

POSTINGS / SAFETY SIGNS

• OSHA Workplace Poster displayed at all locations?

  Yes

  No

  N/A

• Emergency numbers / contacts posted?

  Yes

  No

  N/A

• OSHA 300 log posted Feb. 1st through April 30th?

  Yes

  No

  N/A

• Danger / warning signs posted? Each site maintains proper signage?

  Yes

  No

  N/A

• Danger - Keep out / Construction signs posted on security fencing?

  Yes

  No

  N/A

• All posting meet safety compliance?

  Yes

  No

  N/A

• Notes:

SANITATION

• Adequate supply of potable water provided at no cost to the employee ( Minimum of 1 quart of water per hour per employee)?

  Yes

  No

  N/A

• Single use, disposable drinking cups provided? (Common cup and drinking directly from the container is prohibited)

  Yes

  No

  N/A

• Trash cans provided at all drinking locations?

  Yes

  No

  N/A

• NON-POTABLE water is clearly marked and identified?

  Yes

  No

  N/A

• 1 toilet per 20 workers at the job site? Females have a separate facilities?

  Yes

  No

  N/A

• Hand washing stations provided? 1 hand washing outlet per 20 workers?

  Yes

  No

  N/A

• Facilities (toilets and hand washing facilities) are being maintained in sanitary conditions?

  Yes

  No

  N/A

• Sanitation locations are being maintained in good conditions and maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

SCAFFOLDS

• Does the crew maintain a JSA, properly filled out and within 15 feet of work being performed?

  Yes

  No

  N/A

• Guard rails are installed and secured between 42 - 48 inches (1066 - 1219 millimeters) off of platform?

  Yes

  No

  N/A

• Mid-rails are installed and secured between 21 - 24 inches (533 - 609 millimeters) off of platform?

  Yes

  No

  N/A

• Perry Scaffolds has guard rails and mid rails when platform is at 6 feet (1.8 meters)?

  Yes

  No

  N/A

• Perry Scaffolds have outriggers when scaffold is 3 times the base?

  Yes

  No

  N/A

• Perry Scaffold is built per manufacturers specifications?

  Yes

  No

  N/A

• Employees are not "surfing" or scooting on Perry Scaffolds?

  Yes

  No

  N/A

• Employees have both feet on the platform at all times?

  Yes

  No

  N/A

• Trades maintaining good compliance with Scaffolds?

  Yes

  No

  N/A

• Scaffold(s) are free of materials for the employees to gain additional height?

  Yes

  No

  N/A

• All employees have been trained in Scaffold Awareness to work off of scaffolds?

  Yes

  No

  N/A

• Competent person inspecting scaffold before daily occupancy? From all trades working off of scaffolds?

  Yes

  No

  N/A

• Scaffold inspection tags are located at each scaffold ladder? Inspection tags filled out and maintains current inspections?

  Yes

  No

  N/A

• Scaffold was erected under the supervision of a Competent Person?

  Yes

  No

  N/A

• Working platforms fully planked?

  Yes

  No

  N/A

• Fall protection provided at 6feet (1.8 meters) and above?

  Yes

  No

  N/A

• Legs / frames bear on base plates / mud sills?

  Yes

  No

  N/A

• Mud sills free from undermining?

  Yes

  No

  N/A

• Base plates / mud sills clear from dirt, debris and obstructions? Able to inspect? Base plate secured to mud sill?

  Yes

  No

  N/A

• Planks in good condition? Scaffold grade planks? Free from splits, cuts and damage?

  Yes

  No

  N/A

• Planks / Working platform clean, free from excessive debris, trash and materials?

  Yes

  No

  N/A

• Ladder provided and used to access all scaffold platforms?

  Yes

  No

  N/A

• Scaffold plank overlap a minimum of 6 inches (152 millimeter) max. to 18 inches (457 millimeters) and overlap is over a frame?

  Yes

  No

  N/A

• Scaffold is tied into structure at 12 (3.6 meters) 26 (7.9 meters) and 30 feet 9.1 meters) (or top of structure)?

  Yes

  No

  N/A

• Toe-boards provided above all access / egress points and anywhere employees are working below?

  Yes

  No

  N/A

• All types of scaffold(s) maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

STEEL ERECTION

• Does the crew maintain a JSA, properly filled out and within 15 feet of work being performed?

  Yes

  No

  N/A

• Site erection plan available for review?

  Yes

  No

  N/A

• Lay down area graded, drained and adequate?

  Yes

  No

  N/A

• Decking secured upon placement?

  Yes

  No

  N/A

• Guardrails around stair / elevator / perimeters openings?

  Yes

  No

  N/A

• Floor opening covers properly marked and secured?

  Yes

  No

  N/A

• Tools secured against accidental displacement?

  Yes

  No

  N/A

• Perimeter cables installed when decking is completed?

  Yes

  No

  N/A

• Perimeter cables flagged at 6 foot (1.8 meters) intervals?

  Yes

  No

  N/A

• Perimeter cables maintain less than 2 inch (50 millimeter) deflection?

  Yes

  No

  N/A

• Iron workers / steel erection maintaining safety compliance?

  Yes

  No

  N/A

• Ramps and runways properly guarded?

  Yes

  No

  N/A

• Notes:

TOOLS (HAND and POWER)

• Does the crew maintain a JSA, properly filled out and within 15 feet of work being performed?

  Yes

  No

  N/A

• Hand and power tools in safe operating condition?

  Yes

  No

  N/A

• Tool guards in place and functional on all power tools?

  Yes

  No

  N/A

• All tools stopped and turned off / unplugged during maintenance / refueling?

  Yes

  No

  N/A

• Power tools maintain a ground post or be double or triple insulated?

  Yes

  No

  N/A

• Tools are in like new condition with no alterations, repairs or damage?

  Yes

  No

  N/A

• Handles on tools free from splinters and cracks?

  Yes

  No

  N/A

• Safety spring(s) being maintained in all nail guns?

  Yes

  No

  N/A

• Grinders and cutting wheels maintain fully functioning guards?

  Yes

  No

  N/A

• All air delivery equipment maintain air pressure gauges and hose connection safety's (ties/whips/connection pins)?

  Yes

  No

  N/A

• Tools are properly hoisted / lowered?

  Yes

  No

  N/A

• All tools being maintained within safety compliance?

  Yes

  No

  N/A

• Notes:

TRAFFIC CONTROL

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• Personal trained in work zones traffic safety techniques?

  Yes

  No

  N/A

• Manual on Uniform Traffic Control Devices available?

  Yes

  No

  N/A

• Traffic Control Plan available and updated?

  Yes

  No

  N/A

• Work zone inspected? Documented?

  Yes

  No

  N/A

• Warning signs visible and spaced properly?

  Yes

  No

  N/A

• Warning signs alert drivers to upcoming road work?

  Yes

  No

  N/A

• Warning signs in good condition, legible, clean and working?

  Yes

  No

  N/A

• Delineation devices (cones, barrels, panels) positioned properly?

  Yes

  No

  N/A

• Delineation devices (cones, barrels, panels) in good condition?

  Yes

  No

  N/A

• Barricades provided / placed where required?

  Yes

  No

  N/A

• Barricades erected with correct directional stripes?

  Yes

  No

  N/A

• High visibility clothing is worn within the work zone? Proper rating (class 2 or class 3)?

  Yes

  No

  N/A

• Beacon lights activated on vehicles near active traffic lanes?

  Yes

  No

  N/A

• Contractors maintaining traffic control safety?

  Yes

  No

  N/A

• Notes:

TRENCHING / EXCAVATION

• Does the crew maintain a JSA, properly filled out and within 15 feet (4.5 meters) of work being performed?

  Yes

  No

  N/A

• Competent person identified on the JSA and has completed daily inspections?

  Yes

  No

  N/A

• Competent person on-site and at location when trench is occupied?

  Yes

  No

  N/A

• Soil has been properly classified by manual tests and properly documented?

  Yes

  No

  N/A

• Competent person identified on the JSA and has completed daily inspections?

  Yes

  No

  N/A

• Atmospheric conditions tested prior to entry (where required) ?

  Yes

  No

  N/A

• Employees are protected from cave-in by protective systems?

  Yes

  No

  N/A

• Sloping / benching adequate for soil type?

  Yes

  No

  N/A

• Spoils / materials / equipment set back 2 feet (.6 meters) from edge? No material / equipment on the benches?

  Yes

  No

  N/A

• Travel distance to egress is no more than 25 feet (7.62 meters)?

  Yes

  No

  N/A

• Stability of adjacent structures ensured?

  Yes

  No

  N/A

• Pavements / structures not undermined unless supported?

  Yes

  No

  N/A

• Utilities located / identified prior to start of excavation? PM or Dig Alert contacted?

  Yes

  No

  N/A

• Signs / barricades provided on all open trenches? Barricades a minimum of 6 feet (1.8 meters) away from the trench?

  Yes

  No

  N/A

• Surface encumbrances removed or supported?

  Yes

  No

  N/A

• Water runoff controlled to prevent accumulation?

  Yes

  No

  N/A

• Access prohibited when water accumulation is uncontrolled?

  Yes

  No

  N/A

• Back filling occurs following removal of support system?

  Yes

  No

  N/A

• Trenches and excavations are within good safety compliance?

  Yes

  No

  N/A

• Excavation shield / trench box extend at least 18 inches (457 mm) above shelf or vertical slide?

  Yes

  No

  N/A

• Excavation contractor maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

WELDING / CUTTING / HOT WORK

• JSA and Hot work permit filled out completely and is accurate?

  Yes

  No

  N/A

• Welding screens provided and used when required?

  Yes

  No

  N/A

• Regulators / gauges / valves in proper working order?

  Yes

  No

  N/A

• Cylinders maintained in good condition?

  Yes

  No

  N/A

• Welding hoses in good condition?

  Yes

  No

  N/A

• Fire extinguisher within 20 feet (6.1 meters) of hot work?

  Yes

  No

  N/A

• Valve caps in place when stored / transported?

  Yes

  No

  N/A

• Area identified and employees protected from falling slag?

  Yes

  No

  N/A

• Combustibles removed / protected from heat / spark / slag?

  Yes

  No

  N/A

• Cylinders secured in upright position?

  Yes

  No

  N/A

• Fuel gas cylinders separated from oxygen cylinders (by 20 feet / 6.1 meters) when not in use, or has a firewall between tanks?

  Yes

  No

  N/A

• Fuel gas has a flash arrestor in-line or at the handle?

  Yes

  No

  N/A

• Cylinders in transportation are secured in a vertical position?

  Yes

  No

  N/A

• Fire watch is in place when required?

  Yes

  No

  N/A

• Welders are operating safely and maintaining safety compliance?

  Yes

  No

  N/A

• Notes:

OTHER

• Construction areas properly illuminated?

  Yes

  No

  N/A

• Security fencing installed, maintained in good condition and is closed when site is not occupied?

  Yes

  No

  N/A

• Frequent / regular inspections by the contractor of the job site completed? Documented?

  Yes

  No

  N/A

• Defective equipment tagged or removed from job site?

  Yes

  No

  N/A

• Was the site free from any Immanent Danger to Life or Health (IDLH) exposures?

  Yes

  No

  N/A

• Notes:

MISC. INFORMATION

• Notes:

• This space is available for draw out.

  Drawing