Worksite Hazard Assessment & Road Traffic Management Plan (Completed)

Title Page

Site conducted
Date
Prepared by
Signature
Location
Case number

Vehicle Inspection

Have you completed a Vehicle Inspection Report
Complete below Vehicle Inspection Report
Conducted on
Prepared by
Registration
Brakes, Steering, gauges, lights, warning devices
Reported by:
Reported to:
Date/time reported:
Method reported:
- Telephone
- In Person
- Radio
Park machine, tag out and contact Supervisor to advise accordingly. Machine shall not be used until fault is rectified.
Visibility - windscreen, wipers, washer, demister, mirrors, windows
Reported by:
Reported to:
Date/time reported:
Method reported:
- Telephone
- In Person
- Radio
Park machine, tag out and contact Supervisor to advise accordingly. Machine shall not be used until fault is rectified.
Cabin - access/egress, seating, seatbelts, loose objects, control levers
Reported by:
Reported to:
Date/time reported:
Method reported:
- Telephone
- In Person
- Radio
Park machine, tag out and contact Supervisor to advise accordingly. Machine shall not be used until fault is rectified.
Wheels, tyres, nuts, damage, wear, pressure (visual)
Reported by:
Reported to:
Date/time reported:
Method reported:
- Telephone
- In Person
- Radio
Park machine, tag out and contact Supervisor to advise accordingly. Machine shall not be used until fault is rectified.
Guards - in place, secure, warning signs - lights, alarms
Reported by:
Reported to:
Date/time reported:
Method reported:
- Telephone
- In Person
- Radio
Park machine, tag out and contact Supervisor to advise accordingly. Machine shall not be used until fault is rectified.
Hydraulics - rams, hoses, leaks, wear
Reported by:
Reported to:
Date/time reported:
Method reported:
- Telephone
- In Person
- Radio
Park machine, tag out and contact Supervisor to advise accordingly. Machine shall not be used until fault is rectified.
Excessive wear - hooks, chains, pins, pivots, tracks, ground engagement tools
Reported by:
Reported to:
Date/time reported:
Method reported:
- Telephone
- In Person
- Radio
Park machine, tag out and contact Supervisor to advise accordingly. Machine shall not be used until fault is rectified.
Oil and Coolant levels
Reported by:
Reported to:
Date/time reported:
Method reported:
- Telephone
- In Person
- Radio
Park machine, tag out and contact Supervisor to advise accordingly. Machine shall not be used until fault is rectified.
Misc, electrical, fire extinguisher, communications
Reported by:
Reported to:
Date/time reported:
Method reported:
- Telephone
- In Person
- Radio
Park machine, tag out and contact Supervisor to advise accordingly. Machine shall not be used until fault is rectified.

Worksite Hazard Rating

Traffic Volume
Permanent Traffic Speed (Kph)
- N/A
- 10
- 20
- 30
- 40
- 50
- 60
- 70
- 80
- 90
- 100
Worksite Traffic Speed (Kph)
- N/A
- 10
- 20
- 30
- 40
- 50
- 60
- 70
- 80
- 90
- 100
Road closure?
Partial or full road closure?
Worksite Traffic Speed (Kph)
- N/A
- 10
- 20
- 30
- 40
- 50
- 60
- 70
- 80
- 90
- 100
Clearance between workers & traffic (metres)

Clearance to Traffic

Use table to ascertain hazard rating
Worksite Hazard rating
Specialist Traffic Management Required
Clearance to traffic hazard?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
High speed traffic hazard?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
Poor advance sight distance <200m hazard?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
Poor observance of directions from drivers hazard?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
Narrow pavement with no escape 2.9m width?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
Presence of workers on site?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
Excavation adjacent to worksite?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
Presence of unprotected hazards within clear zone?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
Rough or unsealed road surface?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
High volume of vehicles >10,000 vehicles per day?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
End of queue build up of traffic?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
High volume of heavy vehicles?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
Works vehicles entering or leaving site?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other
Cyclists/pedestrians through site?
Other
What is the hazard?
Controls to be used:
- Road closure
- Lane closures adjacent to work area or traffic diversions
- Speed reduction
- Use of safety barriers
- Use of vehicle mounted attenuators
- Use of warning signs
- Use of electronic Variable Message Signs
- High visibility clothing for all workers
- Various other measures
- Other

Traffic Management plan prepared and implemented

Which Temporary Guidance Scheme (TGS) is being used?
Please upload photo of TGS being used
Please upload photo of Mud Map

Traffic Management Checklist

Planning

Is traffic management plan available for inspection?
Is plan relevant for the work?
Are written authorisations for temporary roadwork speed limits required/in order?
Are documented changes to traffic management plans available for inspection (Mud Map)?

Advance Warning / SIgnage

Are all roadwork signs and devices installed according to the Traffic Management Plan?
Have any contradictory, distracting or surplus signs or markings been covered up or removed?
Are signs appropriate for current conditions?
Is signage suitably placed, especially for vehicles approaching at high speed?
Are sign mountings secure, stable and not a hazard to road users if struck?
Are signs in pairs (gated) where needed?
Are flashing arrow signs available and in use where required?

Worksite

Are all Traffic Control personnel wearing high visibility clothing appropriate to conditions and worn correctly?
Are all Traffic Control personnel wearing safety helmets, safety eyewear and other required PPE?
Are clearances between workers and adjacent traffic maintained?