Site Safety Assessment

• Site:

• Client:

• Conducted on:

  Date

• Prepared by:

• Client representative(s) present during assessment:

• Project scope and general comments:

• Document No.

Site Safety Plan

• Written safety plan on site.

  Yes

  No

  N/A

• Safety plan is:

  Company-specific

  Site-specific

• JHA/AHA/POD on site.

  Yes

  No

  N/A

• JHA/AHA/POD are:

  Company-specific

  Project-specific

  Shift-specific

• JHA/AHA/PODs appear to address tasks, hazards, and safety measures being performed.

  Yes

  No

  N/A

• JHA/AHA/POD appear to contain sufficient detail.

  Yes

  No

  N/A

• JHA/AHA/PODs have been reviewed with crew.

  Yes

  No

  N/A

• Temporary traffic control plan in place.

  Yes

  No

  N/A

• Plan developed by state certified Traffic Control Supervisor (TCS).

  Yes

  No

  N/A

• Plan in writing and on site for review.

  Yes

  No

  N/A

• Permit obtained from authority having jurisdiction (CDOT, county, city).

  Yes

  No

  N/A

• Plan reviewed with crew prior to work.

  Yes

  No

  N/A

• Work zone appears to be set up per MUTCD standards.

  Yes

  No

  N/A

• Work zone appears to be set up per Method of Handling Traffic (MHT).

  Yes

  No

  N/A

• Flaggers are state certified, wearing appropriate PPE, and using proper STOP/SLOW paddle.

  Yes

  No

  N/A

General and Emergency Safety Provisions

• Water and restroom facilities available.

  Yes

  No

  N/A

• Adequate lighting.

  Yes

  No

  N/A

• First aid kits available and stocked.

  Yes

  No

  N/A

• Federal safety standards and industry best-practices require first aid supplies to be easily accessible at the worksite. First aid contents should be checked before being sent out on each job and at least weekly to ensure that expended items are replaced.

• First aid trained personnel on site if medical services are not available within 4 minutes.

  Yes

  No

  N/A

• In the absence of a clinic, hospital, or physician, that is reasonably accessible to the worksite, federal safety standards and industry best practices require a first-aid trained person to be available at the worksite. OSHA considers "reasonably available" to mean within 3-4 minutes. Training must be confirmed by a valid certificate from a recognized organization such as the American Red Cross or the American Heart Association. Though not required by federal safety standards, additional training in CPR is also recommended.

• Fire extinguishers available on each floor and near flammable liquids in storage or in use.

  Yes

  No

  N/A

• Federal safety standards and industry best-practices require a fire extinguisher to be readily available on site for every 3000 square feet of work area and on each floor of the building.

• Fire extinguishers appear functional, free of damage, and tagged to confirm annual inspection within the last 12 months.

  Yes

  No

  N/A

Housekeeping

• Debris picked up. Work area free of trip hazards.

  Yes

  No

  N/A

• Floor holes guarded or provided with secure labeled covers.

  Yes

  No

  N/A

• Potential impalement hazards from protruding rebar, form stakes, pipe stubs and nails capped or covered.

  Yes

  No

  N/A

• Materials properly stored.<br> - Materials clear of stairways and exit routes<br> - 4:1 maximum stack height to base ratio

  Yes

  No

  N/A

• Other housekeeping observations or comments.

  Safe

  At Risk

  N/A

Hazard Communication

• Chemical containers properly labeled.

  Yes

  No

  N/A

• SDSs on site for chemicals present.

  Yes

  No

  N/A

• Chemicals properly stored (appropriate containers, flammables clear of ignition sources, etc.).

  Yes

  No

  N/A

• Fire extinguishers are provided within 50 feet of flammable or combustible liquids in quantities of over five gallons.

  Yes

  No

  N/A

Electrical

• Electrical panels and equipment is fully enclosed, including face plates on switches and receptacles.

  Yes

  No

  N/A

• Circuit breakers labeled.

  Yes

  No

  N/A

• Temporary power GFCI protected.

  Yes

  No

  N/A

• Temporary lighting protected from damage by guards or adequate distance.

  Yes

  No

  N/A

• Temporary lighting circuits separate from non-lighting receptacle circuits.

  Yes

  No

  N/A

• Extension cords appear to be in serviceable condition.

  Yes

  No

  N/A

• Other electrical observations or concerns.

  Safe

  At Risk

  N/A

Personal Protective Equipment

• Eye protection

• Eye protection usage policy.

  100% policy

  Point of hazard

  No formal policy

• Eye protection worn as required.

  Yes

  No

  N/A

• Eye protection appears to meet ANSI Z87 requirements and is in serviceable condition.

  Yes

  No

  N/A

• Head Protection

• Head protection usage policy.

  100% policy

  Point of hazard

  No formal policy

• Head protection worn as required.

  Yes

  No

  N/A

• Head protection appears to be in serviceable condition.

  Yes

  No

  N/A

• Head protection is worn correctly (suspension in the proper direction, no ball caps under hard hat, etc.)

  Yes

  No

  N/A

• High Visibility Clothing

• High visibility clothing usage policy.

  100% policy

  Point of hazard

  No formal policy

• ANSI rating

  ANSI Class III

  ANSI Class II

  Non-ANSI rated

• High visibility clothing worn as required.

  Yes

  No

  N/A

• High visibility clothing appears to be in serviceable condition (clean, zipped up, etc.)

  Yes

  No

  N/A

• Hand Protection

• Hand protection usage policy.

  100% policy

  Point of hazard

  No formal policy

• Hand protection worn as required.

  Yes

  No

  N/A

• Hearing Protection

• Hearing protection usage policy.

  Required

  Optional

  N/A

• Noise monitoring assessment has been performed to determine worker exposure.

  Yes

  No

  N/A

• Assessment found noise exposures to be:

  < 85 dB

  85 - 90 dB

  > 90 dB

• Hearing protection appears to be appropriate for the exposure and worn properly.

  Yes

  No

  N/A

• Employees have been trained on when and how to use hearing protection.

  Yes

  No

  N/A

• Respiratory Protection

• Respirator usage is voluntary.

• Air monitoring has been conducted to assess the need, or lack of need, for mandatory respiratory protection.

  Yes

  No

  N/A

• Air monitoring should be performed to assess average exposures to workers over an 8-hour time-weighted average in order to determine if respiratory protection should be required or left optional. Pinnacol Assurance can provide this service at no cost to you. To request air monitoring or other safety and industrial hygiene services, please contact Pinnacol's Safety on Call line at 303-361-4700.

• Voluntary respirator use limited to filtering face piece respirators (disposable dust masks).

  Yes

  No

  N/A

• Voluntary use of tight fitting respirators (half-mask and full-mask respirators) other than filtering facepiece respirators (dust masks) requires implementation of those elements of a written respiratory protection program necessary to ensure that the employee using a respirator voluntarily is medically able to use that respirator, and that the respirator is cleaned, stored, and maintained so that its use does not present a health hazard to the user.

• Voluntary use respirators are NIOSH approved.

  Yes

  No

  N/A

• Workers who wear filtering face piece respirators voluntarily have received Appendix D of OSHA's respiratory protection standard.

  Yes

  No

  N/A

• Workers who voluntarily wear filtering facepiece respirators (dust masks) should be provided with a copy of the information below.
  
  29 CFR 1910.134 - Appendix D - Information for Employees Using Respirators When Not Required
  
  Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use is encouraged, even when exposures are below the exposure limit, to provide an additional level of comfort and protection for workers. However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the worker. Sometimes, workers may wear respirators to avoid exposures to hazards, even if the amount of hazardous substance does not exceed the limits set by OSHA standards. If your employer provides respirators for your voluntary use, of if you provide your own respirator, you need to take certain precautions to be sure that the respirator itself does not present a hazard.
  
  You should do the following:
  
  1. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirators limitations.
  
  2. Choose respirators certified for use to protect against the contaminant of concern. NIOSH, the National Institute for Occupational Safety and Health of the U.S. Department of Health and Human Services, certifies respirators. A label or statement of certification should appear on the respirator or respirator packaging. It will tell you what the respirator is designed for and how much it will protect you.
  
  3. Do not wear your respirator into atmospheres containing contaminants for which your respirator is not designed to protect against. For example, a respirator designed to filter dust particles will not protect you against gases, vapors, or very small solid particles of fumes or smoke.
  
  4. Keep track of your respirator so that you do not mistakenly use someone else's respirator.

• Respirator use is mandatory.

• Respiratory hazard requiring protection:

  Select Dust Silica Acid Organic vapors Asbestos Other (explain below)

  • Dust
  • Silica
  • Acid
  • Organic vapors
  • Asbestos
  • Other (explain below)

• Air monitoring has been conducted to assess and quantify hazard and to select appropriate respiratory protection.

  Yes

  No

  N/A

• Air monitoring should be performed to assess average exposures to workers over an 8-hour time-weighted average in order to determine if respiratory protection is required and if so, what type. Pinnacol Assurance can provide this service at no cost to you. To request air monitoring or other safety and industrial hygiene services, please contact Pinnacol's Safety on Call line at 303-361-4700.

• Written respiratory protection program in place.

  Yes

  No

  N/A

• If company operations expose employees to atmospheres containing potentially dangerous concentrations of airborne contaminants (dust, chemical vapors/mists, fumes, etc.), respiratory protection may be required. If so, the company should develop and implement a formal respiratory protection program containing the following elements:
  
  - Procedures for selecting respirators for use in the workplace.
  -Medical evaluations of employees required to use respirators.
  -Fit testing procedures for tight-fitting respirators.
  -Procedures for proper use of respirators in routine and reasonably foreseeable emergency situations.
  -Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding, and otherwise maintaining respirators.
  -Procedures to ensure adequate air quality, quantity, and flow of breathing air for atmosphere-supplying respirators.
  -Training of employees in the respiratory hazards to which they are potentially exposed during routine and emergency situations.
  -Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance.
  -Procedures for regularly evaluating the effectiveness of the program.
  
  A sample respiratory protection program can be obtained by contacting Pinnacol’s Safety on Call line at 303-361-4700 or by visiting Pinnacol's Safety Services resources at www.pinnacol.com.

• Workers required to wear respirators have been medically evaluated.

  Yes

  No

  N/A

• Workers required to wear respirators have been fit tested.

  Yes

  No

  N/A

• All respirators are NIOSH approved.

  Yes

  No

  N/A

• Respirators in use:

  Select Filtering facepiece Half mask cartridge Full mask cartridge Powered-air purifying Supplied air Self contained breathing apparatus

  • Filtering facepiece
  • Half mask cartridge
  • Full mask cartridge
  • Powered-air purifying
  • Supplied air
  • Self contained breathing apparatus

• Respirators in use: N99 - Non-oil particulate - 99% efficient

• Respirators in use: N95 - Non-oil particulate - 95% efficient

• Respirators in use: R95 - Up to 8 hours with oil based particulates - 95% efficient

• Respirators in use: R99 - Up to 8 hours with oil based particulates - 99% efficient

• Cartridges in use: Magenta - HEPA (P100 - 99.97% efficient)

• Cartridges in use: Black - organic vapor

• Cartridges in use: White - acid gas

• Cartridges in use: Yellow - organic vapor and acid gas

• Cartridges in use: Olive - mercury vapor and chlorine

• Cartridges in use: Green - ammonia and methylamine

• Cartridges in use: Other

• Other cartridges in use:

• Respirators and cartridges (if applicable) are appropriate for the hazard.

  Yes

  No

  N/A

• Other PPE concerns or comments.

  Safe

  At Risk

  N/A

Ladders and Stairs

• Ladders on site.

• Ladders are of appropriate duty rating for the task.

  Yes

  No

  N/A

• For construction operations, all ladders should be either Type 1, Type 1A, or Type 1AA
  
  Ladder Type Rated Capacity Duty Rating Description
  
  Type IAA Ladder 375 lb. Extra-heavy-duty industrial ladder
  Type IA Ladder 300 lb. Heavy-duty industrial ladder
  Type I Ladder 250 lb. Heavy-duty industrial ladder
  Type II Ladder 225 lb. Medium-duty commercial ladder
  Type III Ladder 200 lb. Light-duty household ladder
  

• Ladders are of proper type and size for the task.

  Yes

  No

  N/A

• Ladders appear to be in serviceable condition.

  Yes

  No

  N/A

• Ladders set up correctly (4:1 ratio, 36" extension past upper landing, etc).

  Yes

  No

  N/A

• Other ladder concerns.

  Safe

  At Risk

  N/A

• Stairs on site.

• Points of access where there is a break in elevation of 19 inches or more are provided with a stairway, ramp, or ladder.

  Yes

  No

  N/A

• Stairs with four or more risers are equipped with at least one handrail and one stair rail system on each open side. The top surface of a stair rail system may also be a "handrail."

  Yes

  No

  N/A

• Handrails are between 30 and 37 inches high from the face of the riser at the forward edge of the tread.

  Yes

  No

  N/A

• Midrails, screens, or intermediate vertical members are provided between the handrail and steps.

  Yes

  No

  N/A

• Where doors open into a stairway, platforms are provided and the swing of the door does not reduce the effective width of the platform to less than 20 inches.

  Yes

  No

  N/A

• Other stairway concerns or commets.

  Yes

  No

  N/A

Scaffolds

• Scaffolds on site.

• Firm footing, mud sills, and base plates in place.

  Yes

  No

  N/A

• Casters (if used) are locked while scaffold is in use.

  Yes

  No

  N/A

• Scaffold is plumb, square, and level.

  Yes

  No

  N/A

• Cross braces are complete.

  Yes

  No

  N/A

• Working levels are fully planked.

  Yes

  No

  N/A

• Planks either overlap support 6-12" or are cleated to restrain from sliding (6-18" if planks are over 10').

  Yes

  No

  N/A

• Plank deflection does not exceed 1/60 of the plank length, indicating overload. (1" deflection per 5' feet of plank length).

  Yes

  No

  N/A

• Planking is in serviceable condition (free of checks, notches, saw cuts, excessive splits, etc.)

  Yes

  No

  N/A

• Front edge of platforms are no further than 14" from face of wall (18" for plastering operations).

  Yes

  No

  N/A

• Scaffold access and egress is provided and adequate where platform is more than two feet above or below access point.

  Yes

  No

  N/A

• If height is over 4 times the narrowest base dimension, scaffold is tied/braced to the wall.

  Yes

  No

  N/A

• Scaffold ties installed per manufacturer spec or every 26 feet vertically and every 30 feet horizontally.

  Yes

  No

  N/A

• Scaffolds with cantilevered work platforms are tied, braced, or outrigged to prevent tipping.

  Yes

  No

  N/A

• Cantilevered work platforms are used to support workers only and not to store/stage materials.

  Yes

  No

  N/A

• Fall protection over 10 feet is provided via guardrails or PFASs.

  Yes

  No

  N/A

• Other scaffold concerns?

  Safe

  At Risk

  N/A

Powered Mobile Scaffolds (Scissor Lifts)

• Powered Mobile Scaffolds (Scissor Lifts) on site.

• Lift operators have received training on proper operation and capacity.

  Yes

  No

  N/A

• Working platform is clear of trip hazards.

  Yes

  No

  N/A

• Access gate/chain is closed while lift is in use.

  Yes

  No

  N/A

• Other scissor lift comments or observations.

  Safe

  At Risk

  N/A

Working at Heights

• Workers more than 6' above a lower level.

• PFAS

• Anchors appear adequate and/or properly installed.

  Yes

  No

  N/A

• Lifelines in good condition and adjusted to restrain or limit free fall to 6 feet.

  Yes

  No

  N/A

• Lanyards in good condition and properly connected.

  Yes

  No

  N/A

• Harnesses in good condition and properly adjusted.

  Yes

  No

  N/A

• Guardrails

• Rails are complete along fall hazard.

  Yes

  No

  N/A

• Appear to be installed to withstand 200 pounds downward and outward force.

  Yes

  No

  N/A

• 42" top rails (+/-3 ") and mid rails approximately halfway between the working surface and the top rail.

  Yes

  No

  N/A

• Toe boards are in place as needed to protect workers below from falling objects.

  Yes

  No

  N/A

• Wall openings less than 39 inches high are guarded. <br>("Openings" are over 18" wide and over 30" high)

  Yes

  No

  N/A

• Warning lines (For roofing operations on low-slope (4:1) roofs only)

• Warning lines complete around unprotected roof edge.

  Yes

  No

  N/A

• Warning lines no closer than 6 feet from roof edge. <br>(10 feet if mechanical equipment is used perpendicular to warning line)

  Yes

  No

  N/A

• Access point is blocked off by rope, chain, or other barricade, or the path is offset to avoid walking directly into the work area.

  Yes

  No

  N/A

• Lines between 34 and 39 inches.

  Yes

  No

  N/A

• Warning line stanchions appear capable of resisting 16 pound force applied 30 inches up.

  Yes

  No

  N/A

• Workers between line and roof edge protected by PFAS or safety monitor.

  Yes

  No

  N/A

• Safety monitor (Roofing operations or as part of a site-specific Fall Protection Plan only)

• Monitor is on same working level as workers, within sight distance, and close enough to communicate.

  Yes

  No

  N/A

• Monitor warns workers when back is to roof edge or worker is piling material in direction of roof edge.

  Yes

  No

  N/A

• Monitor has no other duties to distract from monitoring workers.

  Yes

  No

  N/A

• Controlled Access Zone (Overhand bricklaying or as part of a site-specific Fall Protection Plan only)

• General operations - Control line is 6 - 25 feet from unprotected edge.

  Yes

  No

  N/A

• Precast Erection Operations - Control line is 6 - 60 feet or 1/2 the length of the member being erected.

  Yes

  No

  N/A

• Overhand Bricklaying - Control line is 10 - 15 feet from unprotected edge.

  Yes

  No

  N/A

• Control line extends along entire length of unprotected edge and connects to guardrails or walls.

  Yes

  No

  N/A

• Control line is flagged every 6 feet and has at least 200 pound breaking strength.

  Yes

  No

  N/A

• Control line is 39 - 45 inches high.

  Yes

  No

  N/A

• Site-specific Fall Protection Plan (For leading edge, precast concrete, and residential construction only)

• Conventional fall protection methods have been demonstrated to be infeasible and documented in safety plan.

  Yes

  No

  N/A

• Plan is in writing and on site for review.

  Yes

  No

  N/A

• Plan includes discussion of measures to be taken to protect workers who cannot use conventional fall protection methods.

  Yes

  No

  N/A

• Plan includes names of workers included under the plan.

  Yes

  No

  N/A

• Plan lists each location that conventional fall protection cannot be used. Locations are classified as Controlled Access Zones.

  Yes

  No

  N/A

• Steel erection fall protection

• Steel erectors protected at heights over 15 feet.

  Yes

  No

  N/A

• Connectors protected at heights over 30 feet.

  Yes

  No

  N/A

• Controlled Decking Zone (CDZ) in use.

• Used in area between 15 and 30 feet above lower level where leading edge decking is being installed.

  Yes

  No

  N/A

• Access to CDZ limited to leading edge workers.

  Yes

  No

  N/A

• CDZ boundaries designated and marked.

  Yes

  No

  N/A

• CDZ is no more than 90 feet wide and no more than 90 feet from leading edge.

  Yes

  No

  N/A

• Other fall protection concerns or comments.

  Safe

  At Risk

  N/A

Hand and power tools

• Hand and power tools in use.

• Hand tools in serviceable condition.

  Yes

  No

  N/A

• Power tools properly guarded and free of damage.

  Yes

  No

  N/A

• Power tools either grounded or double insulated.

  Yes

  No

  N/A

• Powder-actuated tools in use.

• Powder-actuated tools and loads properly used and/or stored.

  Yes

  No

  N/A

• Powder-actuated tool operators trained on make and model of tool in use.

  Yes

  No

  N/A

• The company's tool and fastener supplier may be able to provide this training. Often at no cost to the company.

• Powder-accuated tool operators wear head, eye, and hearing protection.

  Yes

  No

  N/A

• Powder-actuated tool operators familiar with mis-fire procedure.

  Yes

  No

  N/A

• If a powder-actuated tool misfires, the user must hold the tool in the operating position for at least 30 seconds before trying to fire it again. If it still will not fire, the user must hold the tool in the operating position for another 30 seconds and then carefully remove the load in accordance with the manufacturer’s instructions. This procedure will make the faulty cartridge less likely to explode. The bad cartridge should then be put in water immediately after removal.
  
  Lack of familiarity with this procedure may indicate a need for tool operator retraining.

• Other tool observations or comments.

  Safe

  At Risk

  N/A

Excavation

• Workers near excavations.

• Excavations protected by guardrails, fences, or barricades if not readily seen due to plant growth or other visual barriers.

  Yes

  No

  N/A

• Workers in excavations.

• Utility locates have been conducted prior to start of excavation operations.

  Yes

  No

  N/A

• Competent person familiar with excavation hazards, pertinent OSHA regulations, and soil analysis.

  Yes

  No

  N/A

• Excavation inspected daily by a competent person before workers enter.

  Yes

  No

  N/A

• Soil type determined by competent person.

  Type A

  Type B

  Type C

  ???

• Spoil at least 2 feet from edge.

  Yes

  No

  N/A

• Means of access provided within 25 feet if over 4 feet deep.

  Yes

  No

  N/A

• Excavation over 5 feet deep or otherwise in need of safeguarding per competent person.

• Excavation safeguarding is in place.

  Yes

  No

  N/A

• Excavations more than 5 feet deep that workers enter require safeguarding to protect workers from excavation collapse hazards. Excavations less than 5 feet deep also require safeguarding if determined necessary by the competent person. Recognized methods of excavation safeguarding include:
  
  -sloping (slope angle depends on current soil conditions)
  -benching (bench configurations depend on current soil conditions)
  -shielding (often referred to as “trench boxes”)
  -shoring (typically pneumatic or hydraulic systems)
  -design by a registered professional engineer
  
  Additional information on excavation safeguarding can be obtained by calling Pinnacol’s Safety on Call line at 303-361-4700 or by visiting OSHA’s website at www.osha.gov.
  

• Sloping

• Sloping appropriate for soil type. <br>- 3/4:1 for class A (53 degrees or less)<br>- 1:1 for class B (45 degrees or less) <br>- 1 1/2:1 for class C (34 degrees or less)

  Yes

  No

  N/A

• Benching (A or B soils only)

• Benching configuration is appropriate for soil type. <br>- 3/4:1 for class A (53 degrees or less)<br>- 1:1 for class B (45 degrees or less) <br>- Width of the first bench is twice the bench height<br>- Maximum bench height is 4"

  Yes

  No

  N/A

• Shielding (trench box)

• Shield is level with or above excavation edge.

  Yes

  No

  N/A

• Shield protects from all exposed vertical walls.

  Yes

  No

  N/A

• Shield fits tight in excavation to minimize movement during collapse.

  Yes

  No

  N/A

• Excavation extends no more than 2 feet below bottom of shield.

  Yes

  No

  N/A

• Shoring

• Tabulated data for proper use of shoring system on site for review.

  Yes

  No

  N/A

• Shoring system installed per manufacturer specs for soil type and depth. (sheeting, spanning, depth, etc.)

  Yes

  No

  N/A

• Combination shielding and sloping

• Sloping appropriate for soil type. <br>- 3/4:1 for class A (53 degrees or less)<br>- 1:1 for class B (45 degrees or less) <br>- 1 1/2:1 for class C (34 degrees or less)

  Yes

  No

  N/A

• Shield extends at least 18" above bottom of slope.

  Yes

  No

  N/A

• Shield protects from all exposed vertical walls.

  Yes

  No

  N/A

• Shield fits tight in excavation to minimize movement during collapse.

  Yes

  No

  N/A

• Excavation extends no more than 2 feet below bottom of shield.

  Yes

  No

  N/A

• Custom-engineered design

• Engineered by licensed P.E.

  Yes

  No

  N/A

• Plans on site for review.

  Yes

  No

  N/A

• Other excavation observations or comments.

  Safe

  At Risk

  N/A

Cranes and Rigging

• Crane set up on site.

• Pre-shift crane inspection completed by competent person.

  Yes

  No

  N/A

• Monthly crane inspection conducted, documented, and on file.

  Yes

  No

  N/A

• Annual crane inspection conducted, documented, and on file.

  Yes

  No

  N/A

• Ground conditions appear adequate.

  Yes

  No

  N/A

• Swing radius of counter weight barricaded off to avoid striking workers and equipment.

  Yes

  No

  N/A

• Outriggers pads are solid, sturdy, and appear at least 3 times the area of the outrigger plates.

  Yes

  No

  N/A

• Outriggers are fully extended.

  Yes

  No

• Crane is designed for partial outrigger extension and outriggers are extended to the minimum reduced extension.

  Yes

  No

• Crane is designed for "on rubber" lifting with reduced load chart.

  Yes

  No

  N/A

• Crane operated per proper load chart (full extension, partial extension, on rubber, etc.)

  Yes

  No

  N/A

• Maximum crane radius at least 20 feet from overhead power lines.

  Yes

  No

• Power lines have been de-energized, locked-out, and visibly grounded by utility owner.

  Yes

  No

• The crane’s work zone has been defined, is at least 20 feet back from the power line, and has been demarcated with an elevated high-visibility marking (warning line, barricades, signs, etc.).

  Yes

  No

  N/A

• Operator has been instructed against operating crane past established work zone boundaries.

  Yes

  No

  N/A

• Complete requirements for cranes operating near overhead power lines are specified in OSHA Construction safety standard 1926.1408 which can be viewed at www.osha.gov. Operators, riggers, and signal persons should be familiar with this standard.

• Any other risk concerns involving crane or setup or operation?

  Safe

  At Risk

  N/A

• Company performing rigging operations.

• Riggers are trained in safe rigging principles.

  Yes

  No

  N/A

• Riggers have reasonable idea of load weights (shipping docs, mfg specs, raw material calculations, etc.)

  Yes

  No

  N/A

• Signal person has been trained and evaluated by the employer or qualified 3rd party and understands how to give and read signals, has a basic understanding of equipment limitations, understands relevant OSHA crane standard requirements, and has demonstrated qualification via oral, written, or practical testing.

  Yes

  No

  N/A

• Documentation of signal person qualification on site.

  Yes

  No

  N/A

• Rigging equipment is in serviceable condition (capacities labeled, free of damage, kinks, stains, etc.)

  Yes

  No

  N/A

• Observed rigging practices appear effective and safe. <br>- tag lines used where appropriate<br>- no workers under suspended loads<br>- loads appear stable<br>- rigging equipment appears to be used per intended use and within its capacity

  Yes

  No

  N/A

• Other rigging comments or observations.

  Safe

  At Risk

  N/A

Aerial Lifts

• Aerial lifts in use.

• Aerial lift operators trained and authorized.

  Yes

  No

  N/A

• Aerial lift controls clearly marked.

  Yes

  No

  N/A

• Fall protection used in aerial lift.

  Yes

  No

  N/A

• Type of fall protection used in aerial lift:

  Select SRL rated for below D-ring anchoring SRL not rated for below D-ring mounting Lanyard adjusted for restraint Lanyard adjusted for arrest

  • SRL rated for below D-ring anchoring
  • SRL not rated for below D-ring mounting
  • Lanyard adjusted for restraint
  • Lanyard adjusted for arrest

• To ensure proper function of the SRL in the event of a fall, SRL should be rated by the SRL manufacturer for use in an inverted position as the anchor point in the aerial lift is below the worker's D-ring.

• Total fall distance of the lanyard may result in worker hitting the ground before the fall is fully arrested. Company should consider using lanyards adjusted short enough to restrain workers from being ejected over the lift's guardrail or use self-retracting lanyards (SRLs) rated by the manufacturer for inverted use due to the anchor points in the lift being located below the workers' D-ring.

• Other aerial lift comments or observations.

  Safe

  At Risk

  N/A

Heavy Equipment

• Heavy equipment on site.

• Equipment with obstructed view to the back are equipped with backup alarms.

  Yes

  No

  N/A

• Equipment appears to be free of significant damage, leaks, and other safety concerns.

  Yes

  No

  N/A

• Parked equipment has brakes set and all buckets, blades, and other implements grounded.

  Yes

  No

  N/A

• Operators have been trained, evaluated, and authorized by employer to operate equipment.

  Yes

  No

  N/A

• Training documented and on file.

  Yes

  No

  N/A

• Employer claims training has been provided but has no records for verification.

  Yes

  No

  N/A

• Machine-specific evaluation and authorization documented and on file.

  Yes

  No

  N/A

• Employer claims evaluation has been conducted but has no records for verification.

  Yes

  No

  N/A

• Operators wear seat belts while operating.

  Yes

  No

  N/A

• Operators maintain 3 points of contact while dismounting equipment.

  Yes

  No

  N/A

• Other heavy equipment observations or comments.

  Safe

  At Risk

  N/A

Sign-off

• Add drawing

  Drawing

• Evaluator's signature:

  Sign