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5/26/2018 Comprehensive Safety Checklist PNL 6-08
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Job Safety Analysis Worksheet
Project Information
Project Name: D
Project Location: Work A
Permit(s) Required Y/N: Permits Attached
Adjacent Work Y/NSee Permit Checklist Link to Permit List
JSA Type
Operations: New:
Transport: Revised:
Office: Other:
Construction:
Remediation:
Work Type: Work Ac
Equipment Checklist
Goggles: Lifeline/Body Harness: Supplied Respir
Face Shield: Hearing Protection: Air Purifying Respir
Safety Glasses: Hard Hat: Welding / Pipe Clot
Safety Shoes: Welding Mask / Goggles: Life
See Equipment Checklist Link to Equipment List Modify equipment list as needed
Job Steps Potential Hazard Hazard Mitgation Steps
Link to Hazard Checklist
Equipment Mob Setup Slips, Trips Secure area from trip hazards
Rebar puncture hazard Mark locations of rebar
Pinch Point Pinch point from equpment
Blind spots on equipment Maintain visual contact with operation
Excavation Swing / hit hazard Maintain safe distance from bucket
Pinch points Maintain clearance from equipment and drums
Chemical hazards Vapor and odor monitoring maintained as per workplan
High noise Hearing protection.Trackhoe stability Maintain rig on stable ground
Utilities Utility clearance OK
Vehicle traffic Maintain 10 MPH on all roads. Tire puncture hazard.
Hole collapse Maintain exclusion zone distance for work area
IDW handling Splatter from handling waste. Control splatter TEP
Bucket sampling Operate in visual contact with operator
Hole stability clearing debris Maintain safe WD with backhoe for clearing hole
Stockpile monitoring Stop excavation, maintain contact with operator
Foam Application Compressed air lines Secure lines from compressor
Spray hazard from foam Maintain spray away from personnel.
High noise Hearing protection.
Hazards of waste loading Maintain distance from equipment while loading waste
Environmental Control Limit waste generation as low as reasonably achievable
Team Member Signatures
Supervisor Signature: D
Instructions: Write the name of the job or task in the space provided.
Conduct a walk-through survey of the work area
Write work steps in a safe sequence
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Write work steps in a safe sequence
Permit Checklist Potential Hazard List
Utility clearance obtained
Soil excavation
Critical lift
Request for shutdown
Hot work
Confined space entry
Concrete scructure penetration Boom assembly, breakdown, proximity
Scaffold Erection plan Prop
Steel erection/decking/flooring/grating checklist Extin
Hoisting & rigging safety review Po
Electrically hazardous work
Pneumatic test
Radiation work permit
Required PPE
Hard hat
Ear protection
Eye Protection
Safety glasses
Face shieldChemical goggles
Welding hood
Hand Protection
Cut resistant gloves C
Welding gloves
Rubber gloves
Electrical insulated gloves
Arm sleves
Foot Protection
Safety shoes
Rubber boots
Boot covers
Dielectric footware
Fall protection
HarnessDouble lanyard required
Anchorage point available U
Respiratory Protection
Dust maks
Air purifying respirator
Supplied air respiator
SCBA
Emergency escape respirator
Protective Clothing
Coveralls I
Tyvek Pro
Nomex
Rainsuit
Acid suit
Confined SpaceAtmosphere Monitoring
Rescue Equipment
Rescue Service
Monitoring Equipment
PID/FID
O2/LEL
IH sampling
Respirable dust
Forms and Documents
Training records
Worker certifications and medical clearance
Written programs
Hazard assessments
Required OSHA postings, fact sheets, guides
Right to Know - MSDS - Hazcom - Prop 65 (CA)OSHA Tracking and compliance forms
DAILY TASK ANALYSIS W
o Hot Work / Welding
o Radiation
o Work Over/Near Water
o Confined Space Entry and Floor / Wall Openings
Housekeeping
Roadway / Traffic / Heavy Equipmento
o Electrical Hazards / Pressurized Lines
o Machines & Rotating Equipment
o
Spill Control and Containment
Site Security
o
o
o
o
Slips/Trips/Falls
Chemical Hazards
Medical Emergency
Manual Lifting
o
o
o
o
o
o
o
o
o
Pinch Points
Biological Hazards
Eye Hazards (i.e. projectiles, dust, gas)
Noise
Natural Hazards
Fire Hazards
o
o
Scaffolds & Ladders
Hand/Power Tools
Hand / Foot Hazards
Overhead Hazards
Heat/Cold Stress
Overhead Work
Drilling and boring
o Crane and Lifting Equipment
o
Excavation/Trenching Activities
o
o
o
o
o
Underground Utilities
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Project:
Task Location :
Task Description:
Observed by:
(1) ASSESS the risk.
What could go wrong?
What is the worst thing that can happen if something goes wrong?
(2) ANALYZE how to reduce the risk.
Is all necessary training and knowledge available to perform work safely?
Is all proper safety equipment, tools and PPE available?
(3) ACT to ensure safe operations.
Take necessary action to ensure the job is done safely.
Follow written procedures. Ask for assistance if necessary.
Cab cleanlieness Exiting cab
Window cleanliness Turning / cornering
Sounding horn Safe speed
Looking in reverse Dumping / lowering bed
Actions when approached Bucket actions
Seatbelt use Comm and eye contact
Follow pertinent procedures Material handling / locding
Proper PPE Follow pertinent procedures
Proper tool Awareness of equipment
Proper use of tools Housekeeping practices
Undersanding task
Working surfaces
Activities planned adequately Pre-task inspection
Crew prepared / briefed / trained Permits obtained as required
Hazards controls adequate Traffic controls / signs / route
Behavior Based Safety Observations
Safety Assessment Checklist
Risk Severity Scale
Additional Hazards / Observations
Safe = 1 2 3 4 5 = At Risk
Rate each observation below for risk potential (1 to 5) 0 = not
Operators
Field Crew and Labor
Supervisors and Managers
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Explanation of At-Risk Behaviors
Explanation of Good Behaviors
Corective Actions
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Date:
Duration Observed:
Proper PPE
Working on slopes
Awareness of surroundings
Walkaround / inspections
Turn signal use
Qualified on equipment
Distractions
Approaching equipment
Grasping / handling
Balance / body position
Lifting
Task simple by design
Adequate safety administration
Ergonomics
applicable
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Safety Prevention Checklist (Daily Completion by Supervisor)
Supervisor:
ContractorNumber of Employees for the
day:
Site:______________________________________________Frequency Saturday
Ensure Project Safety Plan is in place Daily
Understand Scope of Work Daily
Identify all hazards Daily
Complete all required permits Daily
Ensure crew is properly trained Daily
Communicate hazards to all crew members Daily
Ensure any required hazardous energy control Daily
Ensure equipment is available and in proper working order Daily
Hold morning safety meeting Daily
Ensure staffing is adequate Daily
Ensure other employers are informed of potentially hazardous activities that might affect them Daily
Ensure locator services have been contacted to identify any underground obstructions Daily
Supervisor's Daily Safety Prevention Score:
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Employee's Daily Safety Card DateCard Holder:
Company:
Supervisor:Do you understand the Project Safety Plan? (y/n)
Do you know the Scope of Work? (y/n)
Have you identified all hazards? (y/n)
Are all work permits completed for your work?
Are you properly trained for safety?
Do you know all the potential hazards around you?
Is hazardous energy control complete?
Is your equipment available and working properly?
Did you attend the morning safety meeting?
Do you have sufficient co-worker assistance?
Have you informed employees of your potentially hazardous work?
Have locator services been informed of your underground work?
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Employee's Daily Safety CardCard Holder:
Supervisor:
Contractor:Do you understand the Project Safety Plan? (y/n)
Do you know the Scope of Work? (y/n)Have you identified all hazards? (y/n)
Are all work permits completed for your work?
Are you properly trained for safety?
Do you know all the potential hazards around you?
Is hazardous energy control complete?
Is your equipment available and working properly?
Did you attend the morning safety meeting?
Do you have sufficient co-worker assistance?
Have you informed employees of your potentially hazardous work?
Have locator services been informed of your underground work?
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Employee's Daily Safety CardCard Holder:
Supervisor:
Contractor:Do you understand the Project Safety Plan? (y/n)
Do you know the Scope of Work? (y/n)Have you identified all hazards? (y/n)
Are all work permits completed for your work?
Are you properly trained for safety?
Do you know all the potential hazards around you?
Is hazardous energy control complete?
Is your equipment available and working properly?
Did you attend the morning safety meeting?
Do you have sufficient co-worker assistance?
Have you informed employees of your potentially hazardous work?
Have locator services been informed of your underground work?
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No. Contractor List
Employees Company
1
2
3
45
Add additional lines as needed. Link to individual sheets for summary tabulation by contractor.
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Company Acronym Title Supervisor
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Date Hours Worked
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Injury Reports 2005Case No. Injured Company Date of Injury
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Nature of Injury Severity Days of Work Missed
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Responsible Manager
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Injury Report for:Company Name:
Supervisor:
Site:Case No.#:
Injury Date:
Nature of Injury:
Severity:
Treating Clinic:
Hospital Physicians Contact Information:
Days of Work Missed:
Location of Injury:
Specific Work Being Performed at Occurrence:
Nature of Supervision at Accident:
Causal Factors (Events and conditions that
contributed to the accident):
Corrective Actions (Actions that have or will be
taken to address the hazard and prevent
reoccurrence):
Prepared By:
Title:
Date:
Signature:
Responsible Manager:
Title:
Date:
Signature:
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Safety Statistics 2005 Site Name
Contractor____________
Category Jan Feb March April MayContractor Days Away From Work Rate 2005
Contractor OSHA Recordable Rate 2005
Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for Subcontractors
Number of Days Away from Work (DAWF) for SubContractor
Fatalities
First Aids Cases
Reportable SpillsFires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)
Media Coverage
Repetitive Stress Injury (RSI)
Third Party Liability Event
Contractor____________
Category Jan Feb March April May
Contractor Days Away From Work Rate 2005
Contractor OSHA Recordable Rate 2005
Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for Subcontractors
Number of Days Away from Work (DAWF) for SubContractor
Fatalities
First Aids Cases
Reportable Spills
Fires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)Media Coverage
Repetitive Stress Injury (RSI)
Third Party Liability Event
Contractor____________
Category Jan Feb March April May
Contractor Days Away From Work Rate 2005
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Contractor OSHA Recordable Rate 2005
Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for SubcontractorsNumber of Days Away from Work (DAWF) for SubContractor
Fatalities
First Aids Cases
Reportable Spills
Fires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)
Media Coverage
Repetitive Stress Injury (RSI)
Third Party Liability Event
Contractor____________Category Jan Feb March April May
Contractor Days Away From Work Rate 2005
Contractor OSHA Recordable Rate 2005
Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for Subcontractors
Number of Days Away from Work (DAWF) for SubContractor
Fatalities
First Aids CasesReportable Spills
Fires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)
Media Coverage
Repetitive Stress Injury (RSI)
Third Party Liability Event
Contractor____________Category Jan Feb March April May
Contractor Days Away From Work Rate 2005
Contractor OSHA Recordable Rate 2005Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for Subcontractors
Number of Days Away from Work (DAWF) for SubContractor
Fatalities
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First Aids Cases
Reportable Spills
Fires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)
Media Coverage
Repetitive Stress Injury (RSI)Third Party Liability Event
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June July Aug Sept Oct Nov Dec Total0
0
0
0
0
0
0
0
0
0
0
00
0
0
0
0
0
June July Aug Sept Oct Nov Dec Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
00
0
0
June July Aug Sept Oct Nov Dec Total
0
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0
0
0
0
0
0
00
0
0
0
0
0
0
0
0
0
June July Aug Sept Oct Nov Dec Total
0
0
0
0
0
0
0
0
0
0
00
0
0
0
0
0
0
June July Aug Sept Oct Nov Dec Total
0
00
0
0
0
0
0
0
0
5/26/2018 Comprehensive Safety Checklist PNL 6-08
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0
0
0
0
0
0
00