Planned Assurance Inspection Record Form

• Full Name/Team/Contractor:

• Date:

  Date

• Prepared by:

• Project Title:

• ELR & Mileage:
  Address

• Weather & temp:

Supervision

• Name of PIC:

• Rail experience (years):

• Vegetation experience (years):

• Vegetation qualifications:

• Comments:

• Name of Contractor Supervisor:

• Rail experience (years):

• Vegetation experience (years):

• Vegetation qualifications:

• Comments:

Site safety

• COVID-19 controls present?

  Yes

  No

  N/A

• COSS brief:

  Good

  Adequate

  Poor

  N/A

• SSOW:

• Welfare available?

  Yes

  No

  N/A

• Emergency kit present?

  Yes

  No

  N/A

• Climbing rescue kit present?

  Yes

  No

  N/A

• Fuel spill mat present?

  Yes

  No

  N/A

• Boundary fenceline intact?

  Yes

  No

  N/A

• Adequate lighting? (Nights)

  Yes

  No

  N/A

Site documents

• Work package plan?

  Yes

  No

  N/A

• SSOW pack suitable?

  Yes

  No

  N/A

• Task brief suitable?

  Yes

  No

  N/A

• ALO form?

  Yes

  No

  N/A

• Risk assessments?

  Yes

  No

  N/A

• Daily/weekly work plan?

  Yes

  No

  N/A

• Tool & equipment check sheets?

  Yes

  No

  N/A

• Tool & plant service records?

  Yes

  No

  N/A

• HAVS forms?

  Yes

  No

  N/A

• Third party agreements?

  Yes

  No

  N/A

• Bird nesting form?

  Yes

  No

  N/A

• Ecology recommendations?

  Yes

  No

  N/A

• Operative competencies?

  Yes

  No

  N/A

• First aid competency?

• LOLER certificates?

  Yes

  No

  N/A

Work site & activities

• Access/Egress:

• Work site description:

• Number of operatives and roles:

• PPE:

• Tools, plant, and equipment:

• Work activities on site:

• Work activity compliance:

• Method used to secure plant:

• Additional comments:

Within 6.5m clearance area:

• All woody vegetation removed?

  Yes

  No

  N/A

• Stumps lowered to 75mm or below?

  Yes

  No

  N/A

• Stumps over 50mm diameter eco-plugged?

  Yes

  No

  N/A

• Eco-plugs installed correctly?

  Yes

  No

  N/A

• Woody vegetation and stumps under 50mm treated with herbicide?

  Yes

  No

  N/A

Outside 6.5m clearance area:

• Vegetation with potential to fall into striking zone reduced/pollarded/removed?

  Yes

  No

  N/A

• Third-party vegetation pruned away from 6.5m clearance area?

  Yes

  No

  N/A

• Correct pruning cuts used on all remaining vegetation?

  Yes

  No

  N/A

• Stumps of leaf-fall species eco-plugged/treated with herbicide?

  Yes

  No

  N/A

Arisings:

• Wood chip located outside 6.5m clearance zone?

  Yes

  No

  N/A

• Wood chip spread to 100mm or less?

  Yes

  No

  N/A

• Windrows created to the correct specification?

  Yes

  No

  N/A

• Habitat piles created to the correct specification?

  Yes

  No

  N/A

• Monoliths situated outside the 6.5m clearance area and not within striking distance of any railway assets or 3rd party assets?

  Yes

  No

  N/A

• All arisings situated at least 1m away from railway assets?

  Yes

  No

  N/A

Actions to be entered into CMO:

• Enter an Action, an Action Owner, and an Action Date.
  If N/A, enter “No actions”.

• 1.

• 2.

• 3.

• 4.

• 5.

• 6.

• 7.

• 8.

• All actions have been assigned correctly, and Close Calls recorded where required.

  Sign