WORKSITE SAFETY PLAN

Job Description

• Job Description

Date

• Date

  Date

Site

• Site

  Select Ohakuri Maraetai Whakamaru Aratiatia Waipapa Karapiro Arapuni Other

  • Ohakuri
  • Maraetai
  • Whakamaru
  • Aratiatia
  • Waipapa
  • Karapiro
  • Arapuni
  • Other

• Other

Work Party Supervisor

• Work Party Supervisor

  Select RIchard Yeoman Rob Burgess John Talbot Richard Hartley Lee Palmer Tony Clayton Cameron Church Rob Van Der Voort Pat Quinlan Manu Anderson Craig Colebrook Tamati Rangikataua Paul Register Reiho Ramgikataua Hayden McLennan Glen Le Couteur Harold Baker Neil Attwood Keith Flemming Steve Jensen Ken Mckenzie Jo Wi Callum Rodgers Psalm Awarau Ben Cooper Dion Dempsy Richard Gardiner Bill Larkin Other

  • RIchard Yeoman
  • Rob Burgess
  • John Talbot
  • Richard Hartley
  • Lee Palmer
  • Tony Clayton
  • Cameron Church
  • Rob Van Der Voort
  • Pat Quinlan
  • Manu Anderson
  • Craig Colebrook
  • Tamati Rangikataua
  • Paul Register
  • Reiho Ramgikataua
  • Hayden McLennan
  • Glen Le Couteur
  • Harold Baker
  • Neil Attwood
  • Keith Flemming
  • Steve Jensen
  • Ken Mckenzie
  • Jo Wi
  • Callum Rodgers
  • Psalm Awarau
  • Ben Cooper
  • Dion Dempsy
  • Richard Gardiner
  • Bill Larkin
  • Other

Access/Test Permit Number (or Work Authority Number)

Identified Hazards

• Any emissions to atmosphere?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Any contamination to soil?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Any contaminant discharge to water?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Any flammable vapours from product?

  No

  Yes

• Controls:

  Select Ventilate the area. Inform other work parties Other

  • Ventilate the area.
  • Inform other work parties
  • Other

• Other Controls:

• Any toxicity from from product / process?

  No

  Yes

• Controls:

  Select Wear gloves Safety glasses Face shield Mask with correct filters Disposable overalls Ventilate area Other

  • Wear gloves
  • Safety glasses
  • Face shield
  • Mask with correct filters
  • Disposable overalls
  • Ventilate area
  • Other

• Other Controls:

• Any electrical shock danger?

  No

  Yes

• Controls:

  Select Use RCD Check condition of power leads Check equipment is tagged and tested Other

  • Use RCD
  • Check condition of power leads
  • Check equipment is tagged and tested
  • Other

• Other Controls:

• Any slip or trip hazards?

  No

  Yes

• Controls:

  Select Good house keeping at all times Tape leads or air lines to the floor Clean up spills as they happen Look behind before stepping back Other

  • Good house keeping at all times
  • Tape leads or air lines to the floor
  • Clean up spills as they happen
  • Look behind before stepping back
  • Other

• Other Controls:

• Any heavy lifting to take place?

  No

  Yes

• Controls:

  Select Know your limits Use two man lift where required Use riggers hoists Use overhead gantry crane Use sack barrow Use pallet trolley Use forklift Other

  • Know your limits
  • Use two man lift where required
  • Use riggers hoists
  • Use overhead gantry crane
  • Use sack barrow
  • Use pallet trolley
  • Use forklift
  • Other

• Other Controls:

• Any exposure to heat, cold, UV radiation?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Any hazard resulting from ground condition?

  No

  Yes

• Controls:

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Other Controls:

• Could you fall off anything?

  No

  Yes

• Controls:

  Select Check scaffold for current inspection tags Use harness with fall restraint Other

  • Check scaffold for current inspection tags
  • Use harness with fall restraint
  • Other

• Other Controls:

• Is the pole or structure unsafe to climb?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Could anything fall on you or another person?

  No

  Yes

• Controls:

  Select Wear hard hat at all times Secure loose tools and items Good communication between work parties Other

  • Wear hard hat at all times
  • Secure loose tools and items
  • Good communication between work parties
  • Other

• Other Controls:

• Any hazardous substances?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Any danger from equipment or tools?

  No

  Yes

• Controls:

  Select Use tools that are in good working order Use as manufacturer recommendation Other

  • Use tools that are in good working order
  • Use as manufacturer recommendation
  • Other

• Other Controls:

• Any danger from noise exposure?

  No

  Yes

• Controls:

  Select Use ear plugs Use ear muffs Other

  • Use ear plugs
  • Use ear muffs
  • Other

• Other Controls:

• Is equipment / product ID or labels unclear?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Is there hot work?

  No

  Yes

• Controls:

  Select Get hot work permit Adhere to all regulations associated with hot work permit Other

  • Get hot work permit
  • Adhere to all regulations associated with hot work permit
  • Other

• Other Controls:

• Any confined space hazards?

  No

  Yes

• Controls:

  Select Competent personal only Adhere to all regulations associated with confined space permit Other

  • Competent personal only
  • Adhere to all regulations associated with confined space permit
  • Other

• Other Controls:

• Are there any culverts or covers to be driven over?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Any underground service hazards?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Any other contractors / staff involved, on site?

  No

  Yes

• Controls:

  Select Make your intentions known Good communication between work parties at all times Other

  • Make your intentions known
  • Good communication between work parties at all times
  • Other

• Other Controls:

• Can any new hazards arise during the job?

  No

  Yes

• Controls:

  Select Stop and address new hazard Inform others of new hazard Update WSSP Other

  • Stop and address new hazard
  • Inform others of new hazard
  • Update WSSP
  • Other

• Other Controls:

• Can a tripping or LOS result from the task?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Any danger from adjacent equipment?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Minimum Approach Distance breach possible?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Any danger from traffic, mobile plant?

  No

  Yes

• Controls:

  Select Be aware if working or walking through loading bay Use a spotter if backing a vehicle into loading bay Other

  • Be aware if working or walking through loading bay
  • Use a spotter if backing a vehicle into loading bay
  • Other

• Other Controls:

• Will the job impact on third parties?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Does department of labour need to be notified?

  No

  Yes

• Controls:

  Select Other

  • Other

• Other Controls:

• Does this job require lifting plant (crane, HIAB etc)?

  No

  Yes

• Controls:

  Select Trained and competent operators only Daily check sheet to be done for crane Inspect slings for damage and current tags Other

  • Trained and competent operators only
  • Daily check sheet to be done for crane
  • Inspect slings for damage and current tags
  • Other

• Other Controls:

Other hazards

• Are there any other hazards?

  No

  Yes

• Hazard:

• Controls:

• Are there any other hazards?

  No

  Yes

• Hazard:

• Controls:

• Are there any other hazards?

  No

  Yes

• Hazard:

• Controls:

• Are there any other hazards?

  No

  Yes

• Hazard:

• Controls:

In the event of an emergency the Work Party has:

• Plan for rescue of injured employees?

  Yes

  No

• Ready access to first aid equipment?

  Yes

  No

• Access to communication with emergency services?

  Yes

  No

Sign Off

Work Party Member

• Select RIchard Yeoman Rob Burgess John Talbot Richard Hartley Lee Palmer Tony Clayton Cameron Church Rob Van Der Voort Pat Quinlan Manu Anderson Craig Colebrook Tamati Rangikataua Paul Register Reiho Ramgikataua Hayden McLennan Glen Le Couteur Harold Baker Neil Attwood Keith Flemming Steve Jensen Ken Mckenzie Jo Wi Callum Rodgers Psalm Awarau Ben Cooper Dion Dempsy Richard Gardiner Bill Larkin Other

  • RIchard Yeoman
  • Rob Burgess
  • John Talbot
  • Richard Hartley
  • Lee Palmer
  • Tony Clayton
  • Cameron Church
  • Rob Van Der Voort
  • Pat Quinlan
  • Manu Anderson
  • Craig Colebrook
  • Tamati Rangikataua
  • Paul Register
  • Reiho Ramgikataua
  • Hayden McLennan
  • Glen Le Couteur
  • Harold Baker
  • Neil Attwood
  • Keith Flemming
  • Steve Jensen
  • Ken Mckenzie
  • Jo Wi
  • Callum Rodgers
  • Psalm Awarau
  • Ben Cooper
  • Dion Dempsy
  • Richard Gardiner
  • Bill Larkin
  • Other

• Signature

  Sign

• Work Party Supervisor

  Select RIchard Yeoman Rob Burgess John Talbot Richard Hartley Lee Palmer Tony Clayton Cameron Church Rob Van Der Voort Pat Quinlan Manu Anderson Craig Colebrook Tamati Rangikataua Paul Register Reiho Ramgikataua Hayden McLennan Glen Le Couteur Harold Baker Neil Attwood Keith Flemming Steve Jensen Ken Mckenzie Jo Wi Callum Rodgers Psalm Awarau Ben Cooper Dion Dempsy Richard Gardiner Bill Larkin Other

  • RIchard Yeoman
  • Rob Burgess
  • John Talbot
  • Richard Hartley
  • Lee Palmer
  • Tony Clayton
  • Cameron Church
  • Rob Van Der Voort
  • Pat Quinlan
  • Manu Anderson
  • Craig Colebrook
  • Tamati Rangikataua
  • Paul Register
  • Reiho Ramgikataua
  • Hayden McLennan
  • Glen Le Couteur
  • Harold Baker
  • Neil Attwood
  • Keith Flemming
  • Steve Jensen
  • Ken Mckenzie
  • Jo Wi
  • Callum Rodgers
  • Psalm Awarau
  • Ben Cooper
  • Dion Dempsy
  • Richard Gardiner
  • Bill Larkin
  • Other

• Signature

  Sign