SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Description of Activity to be carried out:

Work Location:

AIR FLUSHING / MECHANICAL CLEANING OF

UNDERGROUND & ABOVE GROUND PIPING

MC3

Risk Assessment Log Section:

Step

1.0

Critical Steps in this Activity:

JGC approve the use of this MSJSA :

Name:

Position: JGC HSE Manager

Signature:

Date:

Activity Guidelines used:

Potential Hazards:

Transportation of material/Equipment on site

(Loading / offloading of material manually on
vehicle and using Trailer, Crane, Forklift etc.)

HSE Controls to be Implemented:

Improper loading of material

Failure of lifting gears

Crane failure

Tool box talk will be conducted by Supervisor.

Supervisor will be responsible to complete safe activity
prechecklist sheet daily before start of work.
Loading of material will be done under proper supervision.
Ensure that overloading is prevented
Highlight any protruding load.
Use wooden wedges to prevent material from rolling.
Only Third party certified and color coded lifting gears will
be used
Daily inspection of crane and lifting gears to be done and
checklist to be filled.
For the lifting operation, wind speed should be less than
25 knots. The total lift weight should not exceed 75 % of
crane chart capacity (SWL)
Secure all material properly
Supervisor / Approved Riggers to assess each lift i.e.,
crane position, location away from edges of excavation or
weak ground
Third party certified operator will operate the crane / fork
lifter.

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Step

Critical Steps in this Activity:

Potential Hazards:

HSE Controls to be Implemented:

Unsafe Crane Operation

Fire hazard
Falling down / Struck against / Struck
By

Road Traffic Accidents

Personnel Injury due to slip / trip,
Environmental Hazard due to leakage
of oil from equipment

Position the crane on solid and level ground,

Outriggers fully extended on approved pads
In case of sand storm / less visibility lifting operation
should be reviewed with HSE personnel.
Use proper signboards
Fork lifter and crane to be used as per size, shape and
weight of load.
Banksman will be third party certified and will wear high
visibility Vest for identification.
Barricade the loading / offloading area.
Double Tag line to be used to control load during lifting.
Banksman with vest to guide all vehicle maneuvering.
Safe access to be provided in case of requirement.
No un-authorized person allowed in the area
Check and protect any overhead or under ground
services.
Descon activities to be integrated into JGC transport and
traffic management plan.
Fire extinguisher to be available with crane and fork lifter.
No smoking in the crane cabin.
Good housekeeping to be maintained
Avoid standing at the edge of the trailer or vehicle while
loading / offloading
No passengers allowed traveling on the back of the
trailer/vehicle.
Ladder will be used to go up on trailer
Ensure nobody comes under the suspended load
Ensure reverse horn of fork lifter / crane working
No standing at the back of trailer /vehicle.
All drivers / operators to have valid driving license
Road traffic signs to be followed.
Speed limits to be followed
Proper House Keeping will be carried out to avoid slip /
trip hazards
Ensure use of drip tray
Management of spills will comply with the measures
stated in the Spill Contingency, Procedure RLO-0000FPR-50128.

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Step

Critical Steps in this Activity:

Potential Hazards:

Back pain / Muscular skeletal

disease / Hand injury

HSE Controls to be Implemented:

2.0

Preparation for air flushing/cleaning

Unskilled / Untrained manpower

Defective equipment / tools

Inadequate PPES

Poor communication

Trained worker in (Manual handing ) will only be allowed

to do the job
Training for manual material handling.
Seek assistance whenever needed during manual lifting.
Use appropriate / suitable PPEs

Competent person to be appointed to supervise the job.

Tool box talk will be conducted by Supervisor.
Supervisor will be responsible to complete safe activity
pre checklist sheet daily before start of work.
Only trained and skilled manpower to do the job
Supervisor to ensure the Method Statement, Safe Work
Method Statement & Risk Assessment at job location
Use of proper and defect free tools / equipment
Safety device of equipment in functioning condition (e.g.
dead man switch)
Only JGC inspected and valid color coded equipment to
be used
Supervisor to ensure availability of proper and sufficient
quantity of PPES
Supervisor having good communication skills
Communication to manpower in the language they
understand
Proper communication means (e.g. radio) to be provided

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Step

Critical Steps in this Activity:

Potential Hazards:

No /Improper barricade & Safety

Signs

HSE Controls to be Implemented:

Improper supervision

Improper storage of material/ tools /

equipment

At appropriate distance & proper hard barricade

for above and under ground job points.
Use appropriate safety signboards for air flushing /
cleaning job
Full time supervision for air flushing job.
Supervisor to ensure walk down along whole length of
pipeline to be cleaned / flushed to ensure all fittings etc.
removed, holes blanked and barriers in place.
Material to be stored properly
Equipment to be parked properly

Proper and valid PTW to be obtained where applicable

Improper PTW
Heat Stress

Poor emergency response / 1st Aid

assistance

Ensure availability of cold water at job site in summer

Drink water frequently to avoid dehydration in summer
Ensure availability of heat stress shelter at job site in
summer
Act as per instructions against each flag color to prevent
yourself from heat stress in summer
Ensure availability of 1st aider, 1st aid kit and list of 1st
aiders at job site
List of emergency numbers to be made available
Immediately inform Descon Duty Manager on Descon
Hotline # 5228431 in case of any accident / injury /
incident.

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Step

Critical Steps in this Activity:

Potential Hazards:

Use of defective air compressor

3.0

Use of Air Compressor for Air Flushing

HSE Controls to be Implemented:

Occupational Health problem due to

noisy atmosphere
Leakage of Lub. Oil

Fire hazard
Skin injury due to improper use of
compressed air.

Compressed air leakage due to

improper hose connection or
damaged hose

Improper earthing

All air compressors and other equipment will be JGC

Inspected, color coded.
Perform regular inspection on daily basis to identify
defects
Periodic maintenance to be done
Immediately report any defect/damage/malfunction or
missing part to supervisor
Ensure all moving parts of equipment are properly
guarded
Ensure all safety gadgets and gauges working properly
Wear hearing protection in noisy environment.
Ensure drip tray to avoid any spill due to leakage
Management of spills will comply with the measures
stated in the Spill Contingency, Procedure RLO-0000FPR-50128.
Provision of fire extinguisher with the air compressor.
Compressed air not to be used for personal cleaning
purpose i.e. removing dust from clothes using
compressed air
Inspection of air hose assembly and hose connections
before each use.
Wire checks will be used on hose joints
Hoses to be routed properly to prevent slip / trip hazard
Proper earthing of the air compressor to be done

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Step

4.0

Critical Steps in this Activity:

Air
Blowing
decompression)

(Continuous

Potential Hazards:

Quick

Improper planning

HSE Controls to be Implemented:

Improper isolation
Improper use of tools

Supervisor to make sure for Proper and valid PTW where

applicable
Supervisor to plan the job before starting activity.
Information to working groups in surrounding area about
this activity.
Supervisor to recheck isolation and lock out / tag out
before starting job
Use of proper tools for the job & no misuse of tools

Noise / Dust / Personal injury during

manual handling

Appropriate PPES will be worn as per job requirement

and job atmosphere / environment

Leakage / Burst of air hose due to

kinks formation

Maintain working area clean and tidy.

Route hose properly with no kinks
Hose, coupling, fittings will be checked visually to be well
in place. Hose joint will be provided with safety chain /
pin
Workers attending equipment will not leave the equipment
un-attended and wear applicable PPEs
Only calibrated gauges to be used
Periodic checks for leakage to be done

Faulty gauges
Leakage from blind / spade, valves

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Step

5.0

Critical Steps in this Activity:

Mechanical Cleaning

Potential Hazards:

Unsafe rigging / lifting

Slip/trip hazard

Unsafe use of compressed air

HSE Controls to be Implemented:

Follow safe rigging / lifting precautions as described in

Step # 1.0.

Critical lifting operation to be carried out in the presence

of rigging supervisor.

Rigging & lifting training for workers

Plan before start lifting.

Tools / material to be properly stacked / secured

Proper housekeeping and stacking of material to avoid

slip / trip hazards

Kinks free and proper routing of hose

If using compressor, follow precautions described in Step

# 3 regarding use of compressor for air flushing / blowing

Nozzle to be provided with dead-man switch if manually

doing air cleaning

Appropriate PPES to be used as per job nature and

working environment

Dust / Noise

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Step

Critical Steps in this Activity:

6.0

Pipes at height (Air flushing / Mechanical

cleaning)

Potential Hazards:

Falling hazard / Falling Object

hazard

HSE Controls to be Implemented:

Slip/trip hazard due to improper hose

laying
Heat Stress

JGC Working at Height Procedure (S-000-1654-114

Section 4.22) to be used as guideline for working at
height.
Working at height training of workers
Provide full body harness and lanyards to be use and
anchored safely.
Material / tools properly secured on platforms during
working at height jobs
No tools or equipment will be thrown up or down
During working at height, area down side will be properly
barricaded and signs fro working at height will be posted.
Safe access & egress including ladder and scaffolding to
be provided and used by all workers
Side railings shall be ensured on open sides at height.
Ensure that the scaffolds are weekly inspected and
tagged and are safe as per the JGC Scaffolding
Procedure S-000-1654-125
Special care will be taken during windy conditions
Adequate lighting will be provided for night job.
No one walk along unguarded portions.
Any obstructions form the access and the walk way
platform shall be kept clear
Job at height to be stopped in case of high wind speed
(sandstorm etc.)
Air hose to be routed properly to avoid kinks formation
and slip /trip hazard
Ensure availability of cold water at job site in summer
Drink water frequently to avoid dehydration in summer
Ensure availability of heat stress shelter at job site in
summer
Act as per instructions against each flag color to prevent
yourself from heat stress in summer
Ensure availability of 1st aider, 1st aid kit and list of 1st
aiders at job site
List of emergency numbers to be made available

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Step

7.0

Critical Steps in this Activity:

Under ground pipes (Air flushing / Mechanical

cleaning of )

Potential Hazards:

HSE Controls to be Implemented:

Working on underground lines without

PTW
Fall into excavation
No/Unsafe access & egress
into excavation
Dust / Noise
Collapse / cave in of excavation / trench

Working without / invalid PTW

Unskilled Manpower

Improper access / egress

Poor communication with
inside Confined Space

workers

Oxygen deficiency / enrichment

Flammable gases accumulation / Too
much hot / humid During hot summer

Poor lighting inside confined space

Poor Emergency Response

Proper and valid PTW

Hard barricading around excavation / trench

Safe access & egress not more than 25 feet away from
job point
- Use of appropriate PPES as per job nature
- Proper supporting system for trench/excavation
- No storage of material and no parking of vehicle /
equipment within 2 meter from edge of excavation /
trench.
CONFINED SPACE ENTRY IN DEEP EXACAVATION
- JGC Confined Space Entry Procedure S-000-1654-124
will be used as a guideline for confined space jobs.
- Supervisor to ensure proper and valid PTW for confined
space entry
- Supervisor to ensure confined space training for himself
and workers involved in confined space job
- Trained hole watcher with high visibility vest for
identification to maintain in / out log
- Proper access and egress to be provided
- Pressure horn to be there with hole watcher
- Means of communication e.g. radio etc. to be arranged as
per requirement
- Gas testing to be done for Oxygen conc., flammable
gases and toxic gases in the confined space before start
of work and afterwards as per testing frequency
requirement
- Ensure for proper ventilation in the confined space.
Provide forced ventilation if natural ventilation is not
enough
- SCBA to be used if needed
- Work in groups and give interval (rest time) if required
- If hot summer day, try to do job during cooler part of the
day
- Supervisor to ensure proper lighting (preferably low
voltage) inside the confined space
- Ensure availability of 1st aider, 1st aid kit and list of 1st
aiders at job site
- List of emergency numbers to be made available
- Immediately inform Descon Duty Manager on Descon
-

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Step

Critical Steps in this Activity:

8.0

Refueling of Equipments e.g. Air Compressor,

welding generators etc

Potential Hazards:

Environmental hazard due to Spillage /

leakage of oil during refueling.

HSE Controls to be Implemented:

Fire Hazards during refueling.

Struck Against / Struck By / Damage to

structure etc

Stay near your equipments fueling point when refueling.

Never overstretch refueling hose
Never overfill or top the fuel tank
Refueling to be done at slow rate to reduce the potential
for spillage and static ignition buildup
Let the fuel dispenser shut off automatically and leave the
nozzle in the tank for six to eight seconds so the fuel can
settle down and any fuel in the nozzle can drip down into
fuel tank
Ensure drip tray under the equipment to be refueled.
Hose and refueling assembly should be in good condition
Refueling to be done only by refueling vehicle and trained
person.
If fuel is needed to be taken on site in cane, use the
recommended jerry cane
Ensure the availability of fire extinguisher near refueling
point
No ignition source /smoking near refueling point
Wearing of appropriate PPES at all time during refueling
Switch off equipment before starting refueling
Switch off mobile phone before starting refueling
Ensure proper access / egress to the equipment being
refueled
Driver to be guided by a banks man while reversing
through marrow access / egress
Audible reverse alarm to be fitted with refueling ehicle

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

HSE Information / Requirements
Resources and Competency
Does the Work Team have the necessary capacity, capability, experience & authority to avoid, minimize, monitor and control the risks (Training / Awareness / Equipment, etc.)?
Detail minimum expected requirements:

Workforce has been trained relevant to the job they have to perform. Air Flushing, Confined Space entry, Working at Height,
Rigging Refueling and Heat stress training will be given to skilled workforce as per their job natures. Supervisor will conduct tool
box talk daily before start of work. Equipment has been inspected and certified by JGC
Communications / Workforce Consultation
Have all members of the Work Party attended the Toolbox Talk, and have they been made fully aware of the risks that they are taking (Residual risks)?

TBT Record No.

Yes
Supervisor to conduct tool box talk daily before start of work explaining the hazards involved in the job and preventive measures
To be taken.
External Risk
Has an assessment been conducted to identify all external (to the activity) hazards and potential risks (3rd parties such as other workforce teams or other adjacent parties)? What is the
result?
Risk Assess. No.

Job Safety Analysis has been carried out keeping in view all external Risks / Hazards. No simultaneous activities will be carried out
in the barricaded area
H&S Training
Employees should be trained in the proper interaction with equipment, and the proper response to incidents involving this equipment. List the training your employee(s) has received.

All employees attended JGC induction training and DESCON HSE trainings. Workforce will be trained relevant to the job they have to perform.
Air Flushing / Cleaning, Working at height, confined space entry, Refueling, Rigging and Heat stress training will be given to
workforce as per their job natures.
Specialist Training
Will the workforce require any specialist training?

YES

YES / NO (IF YES, list the specialist training required for the job):

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Workforce will be trained relevant to the job they have to perform. Air Flushing / Cleaning, Working at height, confined space
entry, Refueling, Rigging and Heat stress training will be given to workforce as per their job natures.
High Potential Risks
Does the task require special access / egress / heavy lifting / entry into confined spaces or work at height / in excavations?
(IF YES, a separate Risk Assessment needs to be completed).
YES

YES / NO

Risk Assess. No.

Working at height

Other Impacts
Are there any other ways in which the work will be affecting and/or protecting the Health and Safety of the team members?

YES / NO (If so, please describe below):

YES
Heat Stress
PTW / Isolations: Other Certificates / Permits
What other precautions (e.g. electrical isolation, permits to work) are required and who will authorize them?

PTW / Cert. Nos.

YES
Permit to work will be obtained wherever applicable.
Contingency / Emergency Response
Should special emergency procedures be instituted, e.g. Emergency Drill, providing Fire Wardens, extra First Aid cover, etc.?

YES / NO (If so, please describe below):

No

Air Emissions
Will the work you perform produce or cause the release of any air emissions?

No

YES / NO

(If YES, list air emissions and method for preventing impact to the environment):

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Water Discharges
Will the work you perform produce or cause the release of any wastewater?

YES / NO (IF YES, how will the wastewater be handled?):

No
Materials
What materials (chemicals, oils, etc.) and/or equipment will you be handling or bringing on-site to perform the contracted work?

NOT APPLICABLE.

Environmental Training
Have employees been trained in the proper handling of materials and equipment, and the proper response to incidents involving these materials? List the training your task employees
have received.

There is no hazardous material, so no need to get special training

Waste Generation
Will the work you perform result in any wastes? YES / NO (IF YES, list the disposal location, as well as amounts and types of wastes expected and the proposed disposal method):

YES
All waste will be disposed off as per JGC Waste Management Procedure RLO-0000-FPR-50126.
Energy
Will the work you perform consume energy (electricity, compressed air, natural gas, steam, etc.)? YES / NO (IF YES, explain what type of energy will be consumed, and how you will
minimize consumption):

Yes, Diesel fuel will be used in cranes, generators, air compressors etc. Equipment will be stopped if it is not needed to reduce fuel consumption
Other Impacts
Are there any other ways in which the work will be affecting and/or protecting the environment?

No

YES / NO (If YES, please describe below):

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Environmental Monitoring
Describe any environmental monitoring to be performed, including sampling methods, frequency, analytical requirements and laboratory to be used:

Not Applicable
Legal requirements
Identify environmental legal requirements applicable to the work that has not already been addressed by the Project.

Not Applicable

SAFE WORK METHOD STATEMENT (SWMS) Incorporating Job Safety Analysis

Training modules required to complete Activity:

List Codes of Practice, Legislation, Standards which apply to this Activity:

JSA will be used as a training module

Standard
Codes

ASTM-1599
ASME B31.3
ASME B16.5

List Plant / Equipment / PPE required for this Activity:

Crane, power generator, welding machines,

compressor.

List Equipment / Maintenance

Checks required for this Activity:

Pre job equipment check

will be done before starting
the job

PPEs:
Safety Helmet

Engineering Certificates / Permits / Approvals required for this Activity

(e.g. RLC Permit Road closure, Utility isolation, Special Waste license, etc.)

No
Type

Reference/Documents

Safety Shoes

Safety Glasses

Coverall

As per job requirement:

Gloves , Ear Plugs, Dust Masks, Breathing
Aparatus, Safety Harness

Person(s) Responsible for Supervising / Inspecting Work:

Person(s) responsible for supervising the work, inspecting and approving work areas, work methods, protective measures, plant equipment and power / other tools:

NB: List of qualifications/experience is held in local JGC files see JGC HSE Group for details.

Name: .

Position:

Name: .

Position:

Signature: .................................................................

Signature: .................................................................

For a list of names and signatures of staff instructed in this Safe Work Method Statement and JSA, see JGC training records.
Copy 1 - To be posted at the Worksite / Supervisor at the Worksite
Copy 2 - To be retained by JGC HSE Group (24 months)
Copy 3 - To be held by the subcontractor (24 months)

SAFE ACTIVITY PRE-CHECK (SAP) SHEET

Company:

Date:

Foreman (print
name):

Location:

Task Description:
MUSTER / ASSEMBLY POINT LOCATION:
IS YOUR DESIGNATED PLACE OF WORK TIDY? - YES or NO (If "NO" housekeeping must be performed prior to work commencing).
PERMIT TO WORK REQUIREMENTS

YES

Key Task Related Hazards

(tick box)
NO
N/A

Excavations
Access Only
Plant & Equipment
Electrical

Key Preventative Control Measures

Confined Spaces
Isolations
Lock Out / Tag Out
Hot work
Instrumentation
Pre / Commissioning / START-UP
EXCAVATION

YES

NO

N/A

HOTWORK (Non PTW controlled)

SHORED / SLOPED / BENCHED

FIRE EXTINGUISHER

LADDERS PROVIDED

FIRE BLANKET

BURIED SERVICES IDENTIFIED

CYLINDERS UPRIGHT & SECURED

VEHICLE STOP BARRIERS / BOARDS

COMBUSTIBLES REMOVED

EXCAVATION INSPECTED

CONFINED SPACES

NO

N/A

EMERGENCY COMMUNICATIONS
WORK BELOW RESTRICTED

PERMIT to WORK

BARRIERS / SIGNS POSTED

GAS TEST COMPLETED

FLAME ARRESTORS FITTED

TALLY BOARD or similar

WELDING CABLES IN GOOD CONDITION

EMERGENCY ACCESS

CHEMICALS

COMMUNICATIONS

MSDS REVIEWED / AVAILABLE

SAFETY HARNESSES

SKIN / EYE / THROAT IRRITANT

SUITABLE (Ex.) LIGHTING

SHOWER or EYEWASH AVAILABLE

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

SPECIAL PPE AVAILABLE AS PER MSDS

SCAFFOLD INSPECTED

CONTAINERS LABELLED PROPERLY

INSPECTION SCAFTAG POSITIONED & IN DATE

SIGNS POSTED

SAFE ACCESS / EGRESS PROVIDED

RISK ASSESSMENT CONDUCTED

TOEBOARDS, KICKPLATES IN ORDER

HAZARDS COMMUNICATED

HANDRAILS SECURED

GROUNDING

HARNESS & LANYARDS INSPECTED

CONTAINMENT REQUIRED / PROVIDED

STATIC LINES - TIE OFF POINTS

ABSORBENT AVAILABLE IN SITU.

YES

NO

N/A

PORTABLE TOOLS

PLANT & EQUIPMENT INSPECTED

TOOLS, APPLIANCES INSPECTED

LIFTING GEAR, RIGGING INSPECTED & CERTS.

BANKSMAN / COMPETENT PERSON
IDENTIFIED
LIFTING PLAN / CALCS & M/S CHECKED

DEFECTS REPORTED

OPERATOR CERTIFIED

OPERATORS CERTIFIED

CABLES, HOSES INSPECTED

PPE REQUIREMENTS IDENTIFIED

PORTABLE APPLIANCES INSPECTED

EXTENSION CABLE CHECKED & TAGGED

FLAGMEN TRAINED / POSITIONED

OCCUPATIONAL HEALTH

N/A

SPECIAL PPE (VISORS, GLOVES, etc)

VENTILATION

PLANT & EQUIPMENT

NO

FIRE WATCH (Safety Passport check)

YES

STANDBY MAN

SCAFFOLDING

YES

GUARDS POSITIONED

YES

NO

N/A

PPE

SAFE ACTIVITY PRE-CHECK (SAP) SHEET

FIRST AIDER / FIRST AID KIT

HARD HAT

HEAT STRESS

BOOTS

DUST

GLASSES

HYGIENE (FOOD / WATER) CONTAINERS

COVERALLS / HIGH-VISIBILITY VESTS

NOISE

FACE MASKS

VIBRATION

GENERAL WORK GLOVES

YES

ELECTRICITY

NO

N/A

SPECIALIST PPE

PTW REVIEWED (COMPETENT PERSON)

WELDERS, FIRE RETARDANT GLOVES

SYSTEM LOCK OUT

ELECTRICAL RUBBER GLOVES

SYSTEM TAGGED OUT

EAR DEFENDERS / PLUGS

JSA / METHOD STATEMENT IN PLACE

HARNESSES / LANYARDS

SYSTEM DISCONNECTED

WELDERS SCREEN

SYSTEM TESTED

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

FACE MASK (DUST - FUMES)

MANUAL HANDLING

YES

NO

N/A

RESPIRATORS

WORKER(S) TRAINED (Safety Passport check)

SELF CONTAINED BREATHING APPARATUS

LIFTING, PULLING

FIRE RETARDENT CLOTHING

STRETCHING

ENVIRONMENTAL CONSTRAINTS

SHARP OBJECTS, PINCH POINTS

ENV. STUDY REPORT COMPLETED

(TROLLEYS, FORKLIFTS, etc) available

ENV. HAZARDS IDENTIFIED IN MS

SOUND GROUND / UNDERFOOT CONDITIONS

WORK AREA CHECKED (R&E SPECIES)

GENERAL

YES

NO

N/A

WASTE CONTAINERS / AREA IDENTIFIED

FLYING PARTICLES

SPILL CONTAINMENT

CABLES SECURED ABOVE HEAD HEIGHT

ENV. MONITOR INFORMED / AVAILABLE

VOIDS / HOLES COVERED & SECURED

SITE PLANT & VEHICLES

BARRIERS & TAPE PROVIDED

SAFE DISTANCE - VEHICLES & PEDESTRIANS

ALL HAZARDS COMMUNICATED

SIGNS ERECTED AND VISIBLE

OTHER WORKERS SAFETY CONSIDERED

NOISE / EXHAUST HAZARDS IDENTIFIED

Foreman

/ Supervisor: I have discussed the above potential hazards involved in the task, reviewed the SAFE
ACTIVITY PRECHECKLIST SHEET Card with the employees under my control, and implemented suitable and sufficient
controls to minimize the risks involved.
Name (print)

Signature

Employees: I / WE ACCEPT THE RESPONSIBILITY FOR THE SAFE BEHAVIOUR OF MYSELF AND MY CO-WORKERS
DURING THE TASKS IDENTIFIED ABOVE:
EMPLOYEE NAME

SIGNATURE

EMPLOYEE NAME

1.

10.

2.

11.

3.

12.

4.

13.

5.

14.

6.

15.

7.

16.

8.

17.

9.

18.

SIGNATURE