Title Page

  • Contract Number

  • Job Number

  • Location
  • Date of inspection

  • Prepared by

  • Team Supervisor

  • Additional personnel on site

  • Brief description of work activity

  • Client

TSC - Work site

  • TSC Name

  • TSC briefing book completed correctly

  • TSC possess valid competency card

  • TSC wearing appropriate armband

  • TSC possess WON

  • Correct PPE worn

  • Plant Equipment Materials (PEM) form completed

TSC - T2 Protection

  • TSC Name

  • TSC wearing correct armband

  • T2 protection form completed correctly

  • TSC briefing booklet completed correctly

  • TSC possess valid competency card

  • T-COD placed

  • Red light placed in the five foot and clearly visible

  • Suitable lookout protection placed (if required)

  • TSC possess WON

  • Correct PPE worn

  • Plant Equipment Materials (PEM) form completed

PTS

  • All staff possess valid PTS competency card or TVP?

  • PTS staff received TSC brief and it is understood

  • All staff wearing correct PPE

Lookout

  • Lookout possess valid competency card

  • Lookout wearing appropriate armband

  • Lookout kit contain all items - flag/horn/whistle/light etc.

  • Lookout mobile phone turned off

  • Lookout(s) wearing correct PPE

PICOP

  • PICOP Name

  • Token taken or three detonators 20m apart at both ends of possession

  • Possession limit indicator board at middle detonator

  • Protection is 400m ahead and rear of protecting signal/points/crossing

  • Hand signaller in appropriate place (if required)

  • PICOP possess valid competency card

  • PICOP possess WON

  • PICOP wearing appropriate armband

  • Possession arrangements form completed correctly

  • ES granted authority to start work

  • PICOP wearing correct PPE

  • Plant Equipment Materials (PEM) form completed

ES

  • ES Name

  • Worksite marker boards (if required)

  • Worksite marker boards at least 100m from possession protection

  • Worksite marker boards at least 100m between worksites

  • ES possess valid competency card

  • ES possess WON

  • ES wearing appropriate armband

  • Engineering supervisors certificate completed correctly

  • Authority to start work received from PICOP

  • All TSCs signed in with ES

  • Is the ES aware of any RRV/Engineering train(s) affecting the worksite?

  • Has the ES checked and cleared the worksite before lifting the marker boards

  • Has the ES lifted the worksite marker boards and communicated correctly with the PICOP to hand back the worksite?

  • ES wearing correct PPE

  • Plant Equipment Materials (PEM) form completed

Rail Mounted Plant Compliance

  • All RRVs have a valid Certificate of Engineering Vehicle Acceptance and a copy is kept in each item of plant?

  • Thorough examination certificates available for all Rail mounted plant?

  • Thorough examination certificates available for all lifting equipment?

  • Are trailers certified?

  • Pre-use inspections carried out for all RRVs by the RRVO & countersigned by RRVC?

  • RRVO possess valid competency card and authority to work card

  • RRVC possess valid competency card

  • Dispatch and Catch form completed (if required)

  • Plant Equipment Materials (PEM) form completed

  • Tools and Equipment have reflective tape or paint and clearly visible? Example: RRV bucket painted?

Health and Safety

  • Daily Risk Assessment available and signed off by all relevant staff?

  • All persons signed in/out of site?

  • Site Managers briefing Instruction completed and briefed to all relevant Safety critical staff in advance of works?

  • All site operatives inducted?

  • Staff appropriately trained for the works they are carrying out?

  • Method Statement & Risk Assessments available and signed by all relevant staff?

  • NI10 form available?

  • Permit to Work in place?

  • Correct PPE being worn? (Behaviour/Compliance)

  • Seat belts being worn when operating plant?

  • Suitable site access and egress?

  • Site security adequate? E.g. fencing, locked gates etc.

  • Housekeeping adequate? (Slips, trips, falls, adequate lighting)

  • Traffic management (signing / lighting / guarding) in place where applicable?

  • Excavations safely guarded / battered back?

  • Underground services identified? HSG47

  • Weekly inspection of excavations completed?

  • Overhead lines protected? GS6

  • Is there an appropriate lift plan in place?

  • Work at height properly planned?

  • Aluminium tower fit for purpose and appropriate inspections carried out?

  • Scaffolding fit for purpose and appropriate inspections carried out?

  • Work on or near water properly planned?

  • Measures in place to manage and control temporary works safely?

  • Asbestos Refurbishment & Demolition Survey Report / Register available?

  • Are toolbox talks being carried out weekly?

  • Are good catches being recorded?

Kit & Equipment

  • Tools and Equipment have reflective tape and clearly visible?

  • Weekly LOLER inspections completed?

  • Weekly PUWER inspections completed?

  • Thorough examination certs available for all plant & equipment?

  • Thorough examination certs available for all lifting equipment?

  • Daily plant inspections completed?

  • CAT & Genny available and calibrated?

  • Fire fighting equipment available?

  • First aid kit and eye wash stations available?

  • Trained first aider on site and known to workers?

  • Welfare facilities in place and adequate?

  • Portable Appliance Testing (PAT) in place and up to date?

  • Any hazards that require immediate intervention not stated above?

  • Please state below any other observations identified on site

  • Please state below any other observations identified on site

  • Please state below any other observations identified on site

Environmental

  • All hazardous substances stored correctly? e.g. drip trays

  • All hazardous substances labelled correctly?

  • Spill kits available?

  • Waste disposed of correctly?

  • Dust and noise controls in place?

  • COSHH Assessments available?

  • Please state any other observations identified on site

Quality

  • Quality of works to an acceptable standard?

  • Company insurance policy available and in-date?

  • Company forms used in line with ISO procedures?

  • Company procedures adhered too?

  • Sub-contractors used for the works approved in line with company procedure?

  • Verification sub-contractor has implemented a modern slavery policy and were not in place has agreed to work under ACPL policy?

Signature

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The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.