Mesa Line Services Safety Inspection

• Contractor Company:

• Client:

• Job Name / Number:

• Task Observed:

• Location:
  Address

• Conducted on:

  Date

• Jobsite Supervisor:

• Prepared by:

• Personnel Onsite: (Head Count)

• Task Hazard Analysis (check box if this applies to the current job)

Task Hazard Analysis

• Was a THA completed for all tasks being performed?

  Yes

  No

  N/A

• Are all hazards addressed on the THA?<br>

  Yes

  No

  N/A

• Are appropriate control measures in place for the hazards?

  Yes

  No

  N/A

• Have all employees signed the THA?

  Yes

  No

  N/A

• Has the Take 5 Meeting been held and documented on the THA Form?

  Yes

  No

  N/A

• Does the contractor review the THA with all visitors to jobsite?

  Yes

  No

  N/A

• Are all tasks properly and identified on the THA?

  Yes

  No

  N/A

• Are all obstructions such as, overhead lines, or items unique to the jobsite identified on the THA?

  Yes

  No

  N/A

• Other.

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Mechanical Equipment (check box if this applies to the current job)

Mechanical Equipment

• Are safety belts worn while operating?

  Yes

  No

  N/A

• Is the equipment being used as intended?

  Yes

  No

  N/A

• Have pre-use inspections been completed on all equipment?

  Yes

  No

  N/A

• Is all equipment in satisfactory condition?

  Yes

  No

  N/A

• Is the housekeeping inside of the equipment satisfactory?

  Yes

  No

  N/A

• Is there a fire extinguisher on equipment or available onsite? And properly tagged and in date?

  Yes

  No

  N/A

• Have all operators been trained in the operation of their equipment?

  Yes

  No

  N/A

• Has equipment been grounded where needed?

  Yes

  No

  N/A

• Is there a backup alarm on all equipment or is the contractor using a spotter?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Cranes (check box if this applies to the current job)

Cranes

• Are safety belts worn while operating?

  Yes

  No

  N/A

• Is the crew involved in a critical lift?

  Yes

  No

  N/A

• Has a critical lift plan been competed prior to the lift?

  Yes

  No

  N/A

• Have pre-use inspections been completed on all equipment?

  Yes

  No

  N/A

• Is all equipment in satisfactory condition?

  Yes

  No

  N/A

• Is the housekeeping inside of the equipment satisfactory?

  Yes

  No

  N/A

• Is there a fire extinguisher on equipment or available onsite? And properly tagged and in date?

  Yes

  No

  N/A

• Is a signalman identified on the THA?

  Yes

  No

  N/A

• Have all operators and signalmen completed the required training for job position?

  Yes

  No

  N/A

• Has equipment been grounded where needed?

  Yes

  No

  N/A

• Are the outriggers fully extended, with proper outrigger pads and solid ground or surface?

  Yes

  No

  N/A

• Is the crane and or swing radius barricaded properly?

  Yes

  No

  N/A

• Are employees staying out of the drop zone / line of fire (also known as the bite)?

  Yes

  No

  N/A

• Yes

  No

  N/A

• Is there a backup alarm on all equipment or is the contractor using a spotter?

  Yes

  No

  N/A

• Is the proper rigging in use?

  Yes

  No

  N/A

• Has the rigging been inspected with capacity tags intact / in place?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Housekeeping (check box if this applies to the current job)

Housekeeping

• Has the contractor addressed all housekeeping issues on jobsite?

  Yes

  No

  N/A

• Are flammable liquids properly stored?

  Yes

  No

  N/A

• Are flammable liquids properly labeled?

  Yes

  No

  N/A

• Are there any chemical spills?

  Yes

  No

  N/A

• Is the spill a hazardous chemical?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Personal Protective Equipment (check box if this applies to the current job)

Personal Protective Equipment

• Are all employees wearing at a minimum a hardhat, safety glasses w/side shields, proper footwear, and proper safety vest? I

  Yes

  No

  N/A

• Are all employees wearing work gloves appropriate for the hazard?

  Yes

  No

  N/A

• Are all employees wearing appropriate fall protection when required? Note: 100% fall protection is required while working at elevated heights.

  Yes

  No

  N/A

• Are all employees working on or near energized equipment outfitted and wearing FR clothing properly. ***IF NOT STOP WORK IMMEDIATELY***

  Yes

  No

  N/A

• Is PPE in good condition?

  Yes

  No

  N/A

• Are employees staying out of pinch / crush points (or the bite)?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Weather Conditions (check box if this applies to the current job)

Weather Conditions:

• Are mitigation measures for Heat Stress in place addressed and reviewed?

  Yes

  No

  N/A

• Is storm or severe weather preparedness and evacuations addressed during the THA meeting and noted?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Work Zone Protection (check box if this applies to the current job)

Work Zone Protection (If there is no content, this section does not apply to the current job)

• If there is a road closure, is the proper closure, signage, detours, and sidewalks closed?

  Yes

  No

  N/A

• Are the workers properly protected from vehicle traffic?

  Yes

  No

  N/A

• Are all persons in the work zone wearing high visibility clothing?

  Yes

  No

  N/A

• Have all required permits been obtained for any public road crossings?

  Yes

  No

  N/A

• Have all road crossings been properly guarded?

  Yes

  No

  N/A

• Are all staying out of the work zone when not involved in the task?

  Yes

  No

  N/A

• Are spotters / flaggers being used at all times?

  Yes

  No

  N/A

• Are flaggers properly trained?

  Yes

  No

  N/A

• Are proper communication methods in use? (What form)?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Right of Way or Substation (check box if this applies to the current job)

Right of Way or Substation

• Has the transmission dispatch or client representative been contacted prior to entering the substation?

  Yes

  No

  N/A

• Does the crew understand the easement delineation of the ROW?

  Yes

  No

  N/A

• Is the crew/crews staying on R.O.W.?

  Yes

  No

  N/A

• Does the crew understand the proper clearances from power lines?

  Yes

  No

  N/A

• Does contractor keep gates closed and locked?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Fall Protection (check box if this applies to the current job)

Fall Protection

• Is 100% Fall Protection being observed while working at elevated heights? ****STOP ALL WORK IMMEDIATELY IF NOT****

  Yes

  No

  N/A

• Does each person working at elevated heights have the appropriated PFAS? ****STOP ALL WORK IF NOT****

  Yes

  No

  N/A

• Is the appropriate Anchorage point in use? (5000 lb requirement).

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Excavation (check box if this applies to the current job)

Excavation (check box if none apply to current job)

• Have locates been called, located, marked, and cleared?

  Yes

  No

  N/A

• Has an excavation competent person inspected the job site prior to entry each shift and when conditions change?

  Yes

  No

  N/A

• Are all evacuations properly shored and/or sloped?

  Yes

  No

  N/A

• Are opened excavations & opened trench ways barricaded, or properly protected?

  Yes

  No

  N/A

• Is fall protection in place for excavations or pier holes (PFAS, with proper anchor point, guardrails or hole covers)?

  Yes

  No

  N/A

• Are excavations or trench’s made safe when unattended (is public protected from fall or cave in exposures)?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Hydro vac operations (check box if none apply to current job)

Hydro vac operations

• Are the employees wearing rain or water protective suits?

  Yes

  No

  N/A

• Are the employees wearing face shields?

  Yes

  No

  N/A

• Are the employees wearing hearing protection?

  Yes

  No

  N/A

• Are dig permits up to date?

  Yes

  No

  N/A

• Are the employees using fall protection after 6ft depth is reached?

  Yes

  No

  N/A

• Are proper anchorage points in use (what form anchor point)?

  Yes

  No

  N/A

• Are hydro vac exactions barricaded / or protected to prevent employee or public access or falls.

  Yes

  No

  N/A

• Communications (check box if this applies to the current job)

Communications (section must be completed for all jobs)

• Is a complete emergency plan documented and on site? Note: Plan shall include emergency contacts, map to local hospital and procedures to follow in the event of an emergency.

  Yes

  No

  N/A

• Has the plan been reviewed with all employees?

  Yes

  No

  N/A

• Is a copy of the safety manual on site?

  Yes

  No

  N/A

• Are SDS available to on site personnel?

  Yes

  No

  N/A

• Are adequate first aid supplies available on site?

  Yes

  No

  N/A

• Is there a Blood Borne Pathogen kit onsite?

  Yes

  No

  N/A

• Is a radio in use when flagging, pulling wire, etc. (or hand signals)

  Yes

  No

  N/A

• Has job site supervision completed OSHA 30hour training, including subcontractor employees?

  Yes

  No

  N/A

• Have all employees completed OSHA 10 hour training, including subcontractor employees?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Hand Tools (check box if this applies to the current job)

Hand Tools (check box if none apply to current job)

• Are hand tools in good working conditions (i.e. broken handles, etc.)?

  Yes

  No

  N/A

• Are ladders in good working condition?

  Yes

  No

  N/A

• Are GFCIs used on all electrical equipment? Are all power cords in good condition

  Yes

  No

  N/A

• Are all power hand tools in good working condition with appropriate guards?

  Yes

  No

  N/A

• Is the proper tool in use for the task?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Work performed under an operating order (check box if this applies to the current job)

Work performed under an operating order (check box if none apply to current job)

• Does the Foreman know who holds the clearance, non-reclose order or hold order for the facilities being worked?

  Yes

  No

  N/A

• Has the transmission dispatch representative been contacted?

  Yes

  No

  N/A

• Do the Foreman and crew know and understand the clearance points?

  Yes

  No

  N/A

• NRO Number? (Where is this documented onsite?)

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Working on or Near Energized Equipment (check box if this applies to the current job)

Working on or Near Energized Equipment

• Are all employees maintaining appropriate approach distances?

  Yes

  No

  N/A

• Are all energized facilities covered or guarded to prevent contact?

  Yes

  No

  N/A

• Has contractor been advised of equipment under an NRO order and have they logged in with Dispatch?

  Yes

  No

  N/A

• Are all employees working on or near energized equipment outfitted and wearing FR clothing properly. ***IF NOT STOP WORK IMMEDIATELY***

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

• Are the employees working with transformers or regulators? (check box if this applies to the current job)

Transformers or regulators

• Has the transformer been verified as PCB or non PCB?

  Yes

  No

  N/A

• Are the employees disposing of the transformers properly?

  Yes

  No

  N/A

• Grounding (check box if this applies to the current job)

Grounding (check box if none apply to current job)

• Have all lines and equipment been de- energized, tested, and grounded when required?

  Yes

  No

  N/A

• Have all sources of energy been considered including induced voltage?

  Yes

  No

  N/A

• Are powerline grounds being installed and removed properly (chain or parallel)?

  Yes

  No

  N/A

• Is equipotential grounding used?

  Yes

  No

  N/A

• Has the equipotential zone been barricaded, is the barricaded and maintained?

  Yes

  No

  N/A

• Are crews grounding the equipment?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Add Section Notes and Observations.

Notes of Obersavation: Please provide comments below:

• Is the site Safe - At Risk - Or N/A?

  Safe

  At Risk

  N/A

• Add Section Notes and Observations.

• Add site descriptive media to detail your site audit.

  Media

Sign Off

• Supervisor/s

  Sign

• Date:

• Auditor/s

  Sign

• Date: