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TABLE OF CONTENTS
Introduction
2 Steps to Develop a Site Specific Safety Plan
3 Pre-Project Safety Checklist
4 Site Specific Safety Plan (Sample)
5 Job Safety Analysis (JSA) Task Specific
6 Job Safety Analysis (JSA) Task Specific – Blank Form
7 Safety and Health Inspection Form
8 Subcontractor’s Site Specific Safety and Health Plan
9 Summary
SECTION 11 ■ Safety & Health Manual | Site specific safety plan 11.
06/07
SWR Institute Safety & Health Manual
Introduction
T
his section of SWR Institute’s Safety & Health Manual is prepare for the various hazards that are part of all construction
dedicated to ensuring job site safety as recommended and repair work. By utilizing these tools, a company can build
by OSHA. Thorough job site safety preparation a step-by-step action plan to train its employees how to foresee
requires planning and procedure implementation potential dangers and take necessary precautions, as well as the
before onsite work commences. The forms and checklists procedures to follow when accidents occur.
contained herein are provided to help companies plan and
Date of briefing
Job description
Submission of this completed form is a prerequisite for issuance of the Start Work Notice.
Instructions: Complete this form for all construction work. Identify all hazards that could be present in the job to be preformed. If a box is
checked “Yes”, then state the hazard and describe your hazard control method. If a hazard is not listed below and is present on the job, then
check the box for item 41 “Other” and describe hazard and hazard control method.
YES NO
EXAMPLE Ladders/Scaffolds/Stairways – for example: Body Harness, Lanyards, Training, Safety Net, Other
Hazard/Hazard Control Ladder Use - Our employees are only using 6-foot ladders. If a greater height needs to be reached,
a man basket will be used.
Yes No
1. Fall Protection – For example: Fall Protection Plan, Body Harness, Lanyards, Guardrails, Handrails, Training, Other
Hazard/Hazard Control
2. Ladders / Scaffolds / Stairways – For example: Body Harness, Lanyards, Safety Net, Aerial Lifts, Guardrails, Training, Other
Hazard/Hazard Control
3. Excavation / Trenching / Shoring – For example: Excavation Permit, Selection of Protective Systems, Shoring, Slope Detail,
Spoils Pile, Soil Classification, Sloping and Benching, Hydraulic Shoring, Access Ladders, Traffic Plates, Other
Hazard/Hazard Control
4. Lockout and Tagout Control of Hazardous Energy – For example: Locks and Tags, Blinds, Safety Meetings, Training, Other
Hazard/Hazard Control
5. Electrical Hot Work, Permit Required – For example: Energized Electrical Permit, Rubber Mat, Sleeves, PPE, Other
Hazard/Hazard Control
6. Electrical / Power Transmission – For example: Wiring Design, Wiring Protection, Hazardous Location Installation, Other
Hazard/Hazard Control
7. Hoisting / Rigging – For example: Operator Permits, Equipment Inspections and Tags, Training, Other
Hazard/Hazard Control
SECTION 11 ■ Safety & Health Manual | Site specific safety plan 11 .
SWR Institute Safety & Health Manual
Yes No
8. Confined Space – For example: ESH Entry Approval/Permit, Training, Air Monitoring, Rescue Plan and Equipment, Other
Hazard/Hazard Control
9. Demolition – For example: Preparatory Operations, Work Practices, Chutes, Mechanical Demolition, Barricades, Other
Hazard/Hazard Control
10. Signs/Signals/Barricades – For example: Caution Tape, Barriers, Barricades, Signs, Traffic Cones, Tags, Traffic Vests, Other
Hazard/Hazard Control
11. Head Protection and Rollover Protective Structure – For example: Hard Hats, Bump Caps, Equipment Inspection, Other
Hazard/Hazard Control
12. Eye Protection – For example: Safety Glasses, Safety Goggles, Face Shields, Portable Eye Wash Unit, Other
Hazard/Hazard Control
13. Ear Protection – For example: Ear Plugs, Ear Muffs, Other
Hazard/Hazard Control
14. Breathing Protection – For example: Engineering Controls, Respirators, Air Filters, Dust Masks, HEPA Filters, Other
Hazard/Hazard Control
15. Hand Protection – For example: Gloves, Gauntlets, Sleeves, Barriers, Cream, Other
Hazard/Hazard Control
16. Torso Protection – For example: Flame Resistant Clothing, Coveralls, Aprons, Bib Overalls, Other
Hazard/Hazard Control
17. Foot Protection – For example: Steel Toed Shoes, Metatarsal Guards, Boots, Other
Hazard/Hazard Control
18. Site Exits / Means of Egress – For example: Emergency Action Plans -- Marked and Clear, Outdoor Job, Other
Hazard/Hazard Control
19. Fire Protection/Prevention – For example: Extinguishers, Fire Watch, 2-Way Radio, Pull Box, Alarms, Other
Hazard/Hazard Control
20. Welding/Cutting/Brazing – For example: Welding/Burn Permit, Fire Watch, Fire Blanket, Site Screen, Gas Bottle Safety, Other
Hazard/Hazard Control
21. Hot Work, Permit Required – For example: Welding, Brazing, Torch Cutting, Temporary Heating, Pressured Air Line, Other
Hazard/Hazard Control
22. Material Handling, Storage, Use, and Disposal – For example: Flammables, Combustibles, Labeling, Gas Bottle Storage,
LP-Gas Safety, Safety Containers/Cans, Waste Materials, Disposal Process, Other
Hazard/Hazard Control
Yes No
23. Concrete / Masonry – For example: Debris Pile, Chutes, Wet Cuts, Other
Hazard/Hazard Control
24. Crane / Derrick / Hoist / Helicopter / Conveyors – For example: Drum Hoists, Elevators, Cable Inspections, Other
Hazard/Hazard Control
25. Tunnel / Shaft / Caissons / Compressed Air – For example: Underground Construction, Cofferdams, Blasting Safety, Other
Hazard/Hazard Control
26. Steel Erection – For example: Falling Object Protection, Site-Specific Erection Plan, Construction Sequence, Other
Hazard/Hazard Control
27. Vehicle Safety / Mechanized Equipment – For example: Operator Permits, Equipment Inspection, Hydraulic Inspection, Other
Hazard/Hazard Control
28. Construction Power – For example: Extension Cords, GFCI, Generators, Battery Charging, Air Receivers, Other
Hazard/Hazard Control
29. Blasting and Use of Explosives – For example: Blaster Qualifications, Transportation, Storage, Loading, Inspection, Other
Hazard/Hazard Control
30. Powder Actuated Tool Safety – For example: (HILTI) Operator Training, Valid License, Other
Hazard/Hazard Control
31. Power and Hand Tool Safety – For example: Guards, Cords, Ground Prong, GFCI, Jacks, Abrasive Wheels, Other
Hazard/Hazard Control
32. Area Lighting – For example: Flood Lights, Traffic Control Lights, Drop Lights, Flashlights, Other
Hazard/Hazard Control
33. Housekeeping – For example: Debris Pile, Hazardous Waste Disposal Containers, Clear Work Area, Other
Hazard/Hazard Control
34. Traffic Control – For example: Flagman, Signboard, Caution Lights, Traffic Vests, Whistle, Other
Hazard/Hazard Control
35. Hazard Communication / Toxic Substances – For example: Material Safety Data Sheets, Asbestos, Benzene, Other
Hazard/Hazard Control
36. Ionizing and Non-ionizing Radiation – For example: Radiation Badges, Training, Distance, Shielding, Time, Other
Hazard/Hazard Control
37. Environmental – For example: Excavation Permit, Segregated Debris Pile, Asbestos, Run-off Prevention, Other
Hazard/Hazard Control
38. Medical Protection – For example: First Aid Kit, C.P.R. Trained Personnel, 2-Way Radio, Telephone 911, Other
Hazard/Hazard Control
39. General Health and Safety Provisions – For example: Recordkeeping, Work Practices, Equipment Maintenance, Training, Other
Hazard/Hazard Control
40. Sanitation – For example: Drinking Water, Toilets, Eating Areas, Washing Areas, Other
Hazard/Hazard Control
41. Other – Identify any other hazard control associated with this job.
Hazard/Hazard Control
OSHA Required Competent Person or Persons Onsite connected to ½-inch safety line attached to a roof anchor.
• Mast Climber
• _______________________________ (Primary) • High Reach
• Pipe Scaffolding
• _______________________________ (Secondary)
Emergency Rescue Plan (Example)
Location of Medical Facility Bosun’s Chair
• Minor Injuries – Name of Facility Here, Phone # Here • Self rescue by transferring descent device to safety line and descending
• Serious Injuries – Name of Facility Here, Phone # Here to lower level.
• Directions with Maps Are Enclosed with this Site Specific Safety Plan
Swing-Stage Platform
Location of First Aid • An extension ladder may be used to reach employee if they are close
• i.e, Truck, Job Box and/or Break Room enough to the ground and all Name of Company’s Safety Policies
and Procedures regarding safe ladder use are adhered to.
Location of Fire Extinguishers • Have a qualified RDS/Chair person descend to victim with a spare
• 5# - ABC to be kept on swing-stage platform RDS/Chair setup.
• Minimum 5# - ABC in vicinity of swing-stage support system • If any of the prior methods shown cannot be successfully implemented
• 10# - ABC in vicinity of gas-powered equipment or the suspended employee(s) are unconscious or injured, call 911
for assistance.
Location of MSDS
• i.e, Truck, Job Box and/or Break Room NOTE: In an effort to avoid “suspension trauma”, suspended workers
shall create a “foot loop” by tying a knot in the safety line below the
Flammable Storage Area if Required rope-grab to stand in while awaiting rescue. If any of the prior methods
• Gasoline shall be kept in approved safety cans and will be stored in shown cannot be successfully implemented or the suspended employee(s)
the job trailer at the end of day. are unconscious or injured, call 911 for assistance.
SPECIAL NOTES • Side #3 (East) – There is an active steam vent pipe that runs
• Scaffolds must be inspected daily and documented on the “Inspection approximately halfway up the building. This will be redirected when
Record” tag attached to each part of the support system. work is being performed in the area next to and adjoining the vent pipe
– this will be coordinated with Name of Company management. The
• All rooftop equipment shall be delivered to the facilities loading dock device used for this redirect will be locked-out by both maintenance
and taken to the freight elevator’s uppermost floor – it will then be and the Name of Company’s Site Foreman.
carried to the roof via stairway #6.
• Side #1 (West) – The swing-stage platform will be assembled at • Side #3 (East) – Small canopy at column line #3 (stair #7).
ground level. This area will be accessed by Bosun’s chair/RDS – no special
Location: 1
Logo
Here
Recommended/Required PPE Required: (Example) Leather work gloves, safety glasses or goggles, face shield, half-mask
respirator, ear plugs or muffs and rubber work gloves.
Sequence of Basic Job Steps Potential Significant Hazards Hazard Control Method
Step No. 1, 2, 3 etc. Sample Step No. 1a, 1b, 1c, 1d, 2a, 2b etc. Sample Sample
Location:
Subcontractor:
Sequence of Basic Job Steps Potential Significant Hazards Hazard Control Method
Step No. 1, 2, 3 etc. Step No. 1a, 1b, 1c, 1d, 2a, 2b etc. E/I/M.
.
e. Sleeved shirts
Access Procedures
a. 1) Swing stage properly constructed and inspected?
2) Roof setup for swings properly constructed and inspected?
3) Swing Stage: Employees trained/competent/proper use?
Equipment Procedures
To: For:
(Main contractor) (Project)
From: For:
(Subcontractor) (Subcontract Works)
We undertake as follows:
1. Site Safety Representative:
Our nominated on site Safety Representative for this project is: ………………………………………………………….(name)
2. Notifiable Works:
We have notifiable works associated with our subcontract and OSH has been advised. Yes No
(If yes, a copy of the notification must be attached. Refer attached notes for supervisory requirements.)
3. Hazard Management:
An analysis of the significant hazards associated with our subcontract work and the methods
to control such hazards are attached. Yes No
(Note: If not attached, then hazard ID and method of control must be submitted prior to starting work on site.)
We understand that all new hazards identified by our staff will be notified immediately. Yes No
Hazardous products are associated with our subcontract work. Yes No
(If yes, the appropriate Material Safety Data Sheets must be attached.)
4. Communication:
The methods of communicating safety information to our employees are by: (tick methods used)
Toolbox talks Pre-task planning meetings Notice board Co-ordination meetings
Other…………………………………………………………………………………………………………………………
(State methods)
5. Emergencies:
Our first aid kit is located:………………………………………………………………………………………………………
(State location)
Signed: Date:
(Subcontractor Representative)
Approved: Date:
(Main Contractor Site/Project Manager)
9 Summary
This section of the SWR Institute Safety & Health Manual describes the It is necessary for management to make the commitment to correct
procedures for developing a Site Specific Safety Plan. identified hazards, so the entire effort is not wasted. Involve employees
by training them to recognize potential hazards and unsafe working
The rate of injury for workers in the construction industry is conditions. Get employees to buy in, empower them to correct hazards
approximately 60 percent higher than the overall average for all and unsafe working conditions. The combination of management
workers. Recognition of the hazards is essential to the prevention commitment and employee buy in will add value to your business,
of job-related injuries. This technique focuses on job tasks as a way your work place and your life.
to identify hazards before they occur. It is a relationship between the
worker, the task, the tools and the work environment.