• Alpha Code

  • Site

  • Project

  • Serco

  • Prepared by

  • Phone number:

  • Other personnel on site

  • Date

  • Location

Section 1.0 - Site planning and Information

  • For this assessment the following applies

    Safe -
    At Risk -
    Fail -

Site Management and Planning

  • Scope of Works

  • Photo of site overview

  • Permit to Work?

  • Permit Number:

  • ***IMPORTANT***
    Unless specifically identified in the permit no work on RF/Antenna/Mast/Tower/Feeders is allowed!
    Where an RF Hazard is present NOP 4027 must be followed in all circumstances!

Site Information

  • Is the site access information correct and up to date?

  • Please insert correct site access information.

  • Does the Land Owner(LO) have specific H&S induction process or special requirements for safe access to site?

  • Has required process or induction been completed?

  • Please provide details of induction or process.

  • Please provide photo evidence of completion of induction.

  • Stop work until LO requirements is fulfilled.

  • Additional Site hazards to be added to site information? (4x4 access only, special key instructions, not suitable for MEWP or Crane etc.)

  • please describe additional site hazards

  • Is there a track, gravel, driveway, etc. to site? (other than normal registered road)

  • Please provide details of any hazardous or areas that require any maintenance.NOTE - Please be clear if the issue is actually Hazardous or just needs some upkeep maintenance. If it actually Hazardous does the site require caution or a complete lock-down?

  • Please provide photos of any hazards or areas requiring maintenance.

  • Is there safe parking while working on the site?

  • Picture of site layout displaying parking concern.

  • List all site keys for this site you used.

  • Is the area around site free of hazards?

  • Does the area around the site require any maintenance? Weeds, Fences, Rubbish, etc.

  • Please describe to best of your knowledge what maintenance is required.

  • Does the shelter/Cabinet require maintenance or repair?

  • Please describe to best of your knowledge what maintenance is required.

  • Are steps and ramps in good condition with a firmly fixed handrail if steps above 1m?

  • please photograph area

  • Site safety signage?

  • New Site signage pictures

  • Interior of shelter or building clean, tidy, free from - water damage, slip and trip hazards? Any overhead hazards?

  • please describe.

  • Site access & additional site hazard photos.(Photo of road leading to site + any other access info)

  • Vertical Fall Arrest Systems

  • Photo of either Railok,Latchway, Non-Climbable or Rooftop safety systems.

  • All contractors (including sub-contractors) have been provided with information relating to health and safety for the work they are undertaking?

Safety Gear

  • Personal Protective Equipment/Safety Gear appropriate to the task is in being worn and is in good condition?

  • PPE inspected before use?


  • Principal Contractor Network Requirements

  • 2 Degrees

  • Vodafone Sites

  • Spark Sites - PTN & PTP Training

  • Other

  • Workers on roofs with proprietary anchor systems in place have completed US23229 and have a copy of their current certification on site?

  • Workers on communication towers, poles and roofs have completed US 23229, 15757 and 17025 and have a copy of their current certificate on site?

  • Are all persons on site competent and trained to undertake the tasks on site?

  • Work should cease until persons competent to undertake the required tasks are on site. An incident report should also be sent to the relevant Principal Contractor

Emergency planning and equipment

  • Is the site able to call for emergency assistance - Fire, Police Ambulance?

  • Are appropriate Fire Extinguishers and First Aid kits on site?

  • Emergency assembly point identified?


  • All site areas are kept tidy with litter removed from site appropriately?


  • Have all visitors signed the visitor log and are hazards, risks and controls discussed with visitors prior to entering the site??

  • Is the work site (including footpaths and roadways) clear and free from debris, rubbish and obstructions?

  • Are slip and trip hazards being adequately managed?

  • Is lighting adequate for carrying out tasks and and/or safe access?

Section 2.0 Access to Roofs, Brittle Roofs and RF

Roof Access

  • Are persons on site working on the roof of a building?

  • An assessment has been made of any internal ladders used to gain access to the roof to ensure they are structurally sound?

  • Handrails are in place for ladders if required?

  • Ladders extends 1 metre above the landing platform?

  • Portable ladders meet AS/NZS 1892?

  • Portable ladders are secured at the top and the bottom?

  • If access to the roof is via an internal crawl space this should be considered a restricted space and a safe work method planned. (This must include a standby person who does not enter the restricted space).

  • If work is being undertaken in a restricted space has a safe work method statement been established and implemented?

  • Work should cease until a safe work procedures are in place

Brittle Roofs (Skylights, Asbestos Roofs, Openings, Roofs in Poor Condition)

  • Is the roof surface brittle, in poor condition or has skylights?

  • An assessment of the roof has been made to ensure it is strong enough to support the work activities being carried out. (Asbestos roofs are the majority of brittle roofs).

  • Has the roof been inspected internally (if possible) to ensure it is sound?

  • Has an competent person undertaken this assessment?

  • Are areas such as skylights, roof openings designated as no go zones and barricaded off or covered if required?

  • Are walkways with guardrails provided when work on fragile roofs cannot be avoided?

  • If walkways are not provided is a fall arrest system being used?

  • Work on the roof must stop until safe work methods are in place.


  • Are there RF hazards on site?

  • RF warning signs are in place at access points?

  • Are persons trained/competent/certified in RF Awareness

  • Are appropriate RF monitors available and being used?

  • Are RF monitors calibrated?

  • Spark RF Shutdown Procedure NOP 4027 has been followed?

Section 3.0 - Equipment used for Working at Heights on Towers, Poles and Roofs

Machinery for working at Heights on Towers, Roofs and Structures

  • MEWP, Crane, Scaffold or Guardrails being used on Site?

  • Move to the next section

  • Are workers on the ground wearing appropriate PPE e.g. Safety Helmets, Safety Boots, High Viz Vests and Eye Protection?

  • Have exclusion zones been implemented and sufficient for the tasks being carried out?

  • Assess any of the following equipment on site

  • Mobile Elevated Work Platfrom

  • Has the operator carried out a carried out a pre start inspection of the MEWP that includes functional and visual tests (required each day)?

  • Is the MEWP clearly marked with the rated lifting capacity

  • Weight of lift?

  • Essential operating and maintenance instructions permanently displayed or stored in a conspicuous place on the MEWP?

  • Is the six monthly inspection certificate displayed?

  • Operator is trained and competent (US 23966 v1) and the corresponding unit for the type of MEWP being used?

  • Hazards associated with power lines are appropriately controlled (no closer than 6.4 metres, or between 4 - 6.4 metres with appropriate controls in place. No work can be carried out within 4 metres of a power line without the written consent of line owner and this consent must remain on site at all times?

  • Weather conditions are suitable for using the MEWP?

  • Are harnesses, lanyard and attachment points available to all workers undertaking tasks from the MEWP?

  • Is the MEWP set up on firm and level ground?

  • Crane

  • Is the plan and information provided by the crane supplier signed and accepted by the contractor on site?

  • Is the crane set up on firm, level ground with barriers in place?

  • Safe working distances are maintained from overhead power lines?

  • No persons are standing under suspended loads?

  • Tag lines are used where there could be load spin?

  • The load does not exceed the lifting capacity of the crane

  • Lifting capacity of the crane

  • Weight of lift

  • Clear lines of communication exist between the dogman/persons in bucket and the crane operator?

  • Weather conditions suitable for the use of a crane?

  • Scaffold or Mobile Scaffold

  • Are the surface conditions suitable for scaffold access and stability - e.g level and safe to work on?

  • Is there a health and safety management plan on site that clearly identifies those responsible for implementing control measures for the scaffold?

  • Are site specific hazards e.g proximity to power lines and control measures included in the Safe Work Method Statement or JSA?

  • The scaffold was erected, altered or dismantled by a person(s) who have been trained and have suitable experience with the type of scaffold being used?

  • Are the wheels locked and turned out on mobile scaffolds?

  • If a portion of the scaffold is above 5 metres above the ground the following conditions must be met

  • The person assembling, altering or dismantling the scaffold have a certificate of competence

  • Scaffold inspection card/register (Safety Tag) clearly visible in place by the access ladder and checked weekly?

  • Notification has been sent to WorkSafe NZ

  • Edge protection provided where a person could fall 2 or more metres

  • Scaffold protected from passing vehicles or plant

  • Ladders are secured top and bottom.

  • Ladder extended 900-1000 mm above the landing platform.

  • Planks are in good condition, 3 planks minimum and butted and secured.

  • Edge Protection?

  • Designed and constructed to by a competent person?

  • Positioned appropriately?

  • Will barriers and guard rails be regularly inspected

  • Includes a toe board or mesh infill to prevent tools, materials and debris falling from the roof?

  • Not used on a roof with greater than 35 degree slope (In this instance a MEWP, or Fall Restraint/Arrest system must be used)

Section 4.0 - Fall Restraint and Fall Arrest

Rope Access

  • Is the approved double lanyard climbing method being used on Spark Towers?

Fall restraint and fall arrest systems

  • Are fall restraint or fall arrest systems being used on site?

  • Move to the next section

  • All personnel trained and certified for working at height?

  • Has the rigger undertaken a visual inspection of the structure, pole etc prior to work commencing?

  • Is each person familiar with the work plan?

  • Are personnel attached at all times while working at height?

  • Has a drop zone been implemented and sufficient for the tasks being carried out?

  • Is all equipment secure to prevent a fall from height?

  • Does each member of the team have the required PPE?

  • Two certified rescue climbers are on site at all times?

  • Notification has been sent to WorkSafe NZ of the work?

  • Has a SWMS or JSA been prepared for height work on site?

  • Are there established safe access pathways to the anchor points?

  • Is a certified fall restraint system available for use?

  • If using a fall arrest system are suitable certified anchor points being used?

  • Date anchor points certified to?

  • Certified load?

  • If certified anchor points are not available a Temporary Anchor Point Permit must be completed and a copy held on site

  • The temporary anchor point permit has been signed by a competent rigger?

  • Rope access work must cease until the permit is completed

  • The temporary anchor point permit has been signed by the rescue climber?

  • Rope access work must cease until the permit is completed

Section 5.0 - Other Safety Critical Risks

  • For this assessment the following applies

    Safe -
    At Risk -
    Fail -

Pedestrian and Public Safety

  • Are members of the public/pedestrians passing the site?

  • Is a spotter required on site?

  • Is safe pedestrian access maintained on site at all times?

  • Work vehicles are parked safely?

  • Pedestrian and public safety

Electrical Safety

  • Is electrical (230 v and over) work being undertaken on site?

  • Procedures are in place for ensuring electrical equipment is de-energised before electrical work is carried out and methods in place to ensure that it cannot <br>be inadvertently re-energised (isolation, tagging and lockout)?

  • Persons conducting work on electrical equipment are appropriately trained, registered and hold a practising license for the type of work being undertaken?

  • Proven to be de-energised before work commences?

  • Only ladders constructed of timber or fibreglass are to be used for work on or near electrical apparatus?

  • All electrical equipment, extension leads and portable power tools are in good condition and regularly inspected, tested and tagged?

  • Undertaken a CPR course (within the last 12 months) and Basic First Aid course (within the last 2 years)?

Live electrical work

  • Is live electrical work being undertaken on site?

  • A risk assessment and safe work method statement has been prepared before any live work is undertaken?

  • When working on or near live electrical apparatus the following Safety Gear (PPE) is being worn

  • Clothing covers the body from neck to wrist to ankle, (cotton)

  • Sleeves rolled down and shirts tucked into trousers (protecting against entanglement and arc flash)

  • Non metallic fasteners (or fasteners are protected by a layer of the same material as that of the garment)?

  • Suitable eye protection?

Traffic Management

  • Is the worksite in the road corridor or subject to frequent vehicle movements?

  • Copy of the traffic management plan signed by the contractor and maintained on site?

  • Traffic management setup is correct and according to the TMP?

  • STMS contact number listed?

  • Is there an escape route for the traffic controller?

  • Comes and barriers in good condition?

  • After hours TMP in place if necessary?

Section 6.0 - Health and Safety Summary

Spark Asset Management

  • Have you installed, replaced, upgraded or alter any of the following assets?( drop down list- more than one asset can be selected.)

  • Select asset.

  • Decommissioned,Upgraded, Altered or Relocated <br>

  • Surface?

  • Total Lenght (m)

  • Access:

  • Date:

  • Decommissioned, Upgraded, Altered or Relocated

  • Date:

  • Decommissioned, Upgraded, Altered or Relocated

  • Manufacturer?

  • Date:

  • Please select:

  • Use of building?

  • Location of Assets in building?

  • please select:

  • Manufacturer?

  • Model?

  • Date:

  • Asset ID?

  • Antenna installed -

  • Is the tower-

  • Tower, Mast, Light pole type-

  • Tower, Mast, Light pole owner-

  • Date:

  • Is antenna on building

  • Building owner?

  • Date:

  • Fall protection-

  • Please select-

  • Date:

  • Anchor point/s is -

  • Location-

  • Date:

  • Please select-

  • New, Decommissioned,<br>Upgraded, Altered or Relocated? <br>

  • Type-

  • Length (m)?

  • Date?

  • New, Decommissioned,<br>Upgraded, Altered or Relocated?

  • ICP?

  • Meter Number?

  • Owner?

  • Location?

  • Date?

  • New, Decommissioned,<br>Upgraded, Altered or Relocated?

  • Owner?

  • Capacity (kVA)?

  • Location?

  • Date?

  • New, Decommissioned,<br>Upgraded, Altered or Relocated?

  • Model?

  • Location?

  • Date?

  • DC Plant-

  • New, Decommissioned,<br>Upgraded, Altered or Relocated?

  • Model?

  • Asset ID of shelter?

  • Manufacturer?

  • Number of Rectifiers?

  • Battery Model?

  • Number of battery in strings?

  • Date?

  • UPS's, Inverters, DC-DC converters or Controllers

  • New, Decommissioned, Upgraded, Altered or Relocated?

  • Model?

  • Asset ID of Shelter?

  • Manufacturer?

  • Air Conditioning, Fans or Filters-

  • Air Conditioning -

  • Outdoor unit model?

  • Indoor unit Model?

  • Asset ID of Shelter?

  • Outdoor unit manufacturer?

  • Outdoor unit model?

  • Outdoor unit Capacity?

  • Indoor unit Manufacturer?

  • Indoor unit model?

  • Indoor unit capacity?

  • Refrigerant?

  • Number of filters?

  • Filter Type?

  • Asset ID of shelter?

  • Date:

  • Fan is

  • Function?

  • Type?

  • Asset ID of shelter?

  • Function?

  • Type?

  • Asset ID of shelter?

  • Manufacturer?

  • Model?

  • Filter is?

  • Function?

  • Type?

  • Asset ID of Shelter?

  • Function?

  • Type?

  • Filter material?

  • Depth(mm) x Width(mm) x Height(mm)

  • Frame Material

  • Asset ID of Shelter?

  • Date?


  • Are any other hazards present on site, list below

  • Are these hazards and risks being appropriately controlled?

  • Were any unsafe work practices observed at the time of the assessment

  • Please describe the unsafe practice observed below

  • Required corrective actions

  • Agreed date for completion of corrective actions

  • Assessor

  • Site representative

  • Additional people

  • Person
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