UTAS Take 5 Safety Analysis V4 Checklist

1. Stop, Step back and Think

• Am I clear on what the task is?

  Yes

  No

• Do I have the required skills, training and licenses?

  Yes

  No

• Is there a JSEA or SWMS available for this task ?

  Yes

  No

• Is my equipment fit and correct for the task and in good working order?

  Yes

  No

• Do I have the correct Personal Protective Equipment for the task?

  Yes

  No

Consider the following permits

• Is a WORKING AT HEIGHTS permit required ?

  No

  Yes

• Simply define task requiring permit:

• Is a HOT WORK permit required?

  No

  Yes

• Simply define task requiring permit:

• Is a CONFINED SPACE permit required ?

  No

  Yes

• Simply define task requiring permit:

• Is a FIRE SYSTEM IMPAIRMENT permit required ?

  No

  Yes

• Simply define task requiring permit:

• Is a SURFACE PENETRATION or EXCAVATION permit required ?

  No

  Yes

• Simply define task requiring permit:

• Tick the box if you have arranged the required permits.

2. Identify the Hazards and Controls with the following JSEA

• Are there any manual handling hazards?
  (Lifting, awkward positions, impacts or over exertion)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

• Are there any Gravity hazards?
  (Slips, trips and falls, or being struck by falling objects)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

• Are there any Mechanical hazards?
  (Caught in moving parts, struck by plant or flying objects)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

• Are there any Electrical hazards?
  (Faulty tools or live power)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

• Are there any Chemical hazards?
  (Inhalation, swallowing, acids, solvents or asbestos)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

• Are there any High Pressure hazards?
  (Liquid, gas or air)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

• Are there any Noise hazards?
  (Potential hearing damage, masking of emergency alarms)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

• Are there any Biological hazards?
  (Potential disease contact, ,zoonoses, animals)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

• Are there any Radiation hazards?
  (X-rays, sunlight, ultra violet)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

• Are there any Environmental hazards?
  (Dust, heat, cold, snow, ice)

  No

  Yes

• What are the HAZARDS or RISKS ? List them here:

• What CONTROLS are you putting in place to reduce risks to LOW ? List them here:

3. Consultation with Supervisor or Manager.

• Did you consult with you or Supervisor or UTAS Contact person for items in Section 2 where you answered YES and during the JSEA preparation

  Yes

  No

• List your reason for not contacting your works Supervisor or UTAS Contact person.

4. Make the Hazards safe.

• Are all hazards now removed or at LOW level?

  Yes

  No

• Add reasons below for not reducing the hazard to a LOW risk rating:

• Where needed, I have updated the JSEA or SWMS for this task?

  Yes

  Existing OK

• Add the JSEA or SWMS title and reference number below: then forward a copy to your works Supervisor or UTAS Contact person.

5. Is the site now be SAFE so the task can be started ?

• Tick the box if you have identified and assessed all hazards and made them safe. It is now SAFE to start the work.

6. Contractor / Worker Sign Off

• Name of Person signing:

  Select Alan Mason Barry Russell Troy Finearty Roger Wallis Greg Chandler Andrew Southorn Mike Bird Other Person

  • Alan Mason
  • Barry Russell
  • Troy Finearty
  • Roger Wallis
  • Greg Chandler
  • Andrew Southorn
  • Mike Bird
  • Other Person

• Enter name of person signing this audit in the space below then select "Sign"

• Contractor / Worker Signature

  Sign