Project Specific Safety Plan

Project Specific Safety Plan

This document has been provided by Kaipara District Council to helpnon-profit / community groupsundertake council funded or supported projects in a safe and orderly way.

The forms are in approximate order for use as the work progresses:

• Sections 2 - 7 should be completed well before the work starts. This will allow form 1 to be completed and signed off by a council representative prior to the start.

• The forms 8-11 should be completed as the project starts and then continue to be used as the projectcarries on.

• The forms 12 & 13 are for use after accidents or near miss events if necessary.

• Form 14 is for monthly reporting it should be completed at the end of all short term projects lasting less than a month. For longer term projects the form will be required every month (returned to the council by the 10th of the month).

Each form has a brief summary of what it is to be used for just after the title.

Contents

Rating and controlling risk an explanation
1. / Project Specific Safety Plan Checklist and sign off
2. / Hazard and Risk Register
3. / Hazardous Substance/Dangerous Goods Register
4. / Task Analysis Worksheet
5. / Safety Training and Competency Register
6. / Emergency Plan and Procedure
7. / Project Emergency Evacuation Plan
8. / Project Pre-start Safety Assessment
9. / Project Induction Register
10. / Safety Meeting Minutes
11. / Inspection Checklist
12. / Accident / Incident / Near Miss Register
13. / Accident and Incident Investigation Report
14. / Monthly Contractor Health & Safety Report

Rating and controlling risk

The Health and Safety at Work Act requires organisations to assess Risk to health and then allocate the most effective Control to either Eliminate the risk completely or Minimise the risk (reduce that risk to an acceptable level).

Below is the risk rating chart used to assess risk at Kaipara District Council. It is necessary to look at both how harmful an event will be and compare this with how likely it is to occur. The combination of these two factors will then give a risk level, either Low, Moderate, High or Extreme.

Once the risk has beenestimated it is then possible to allocate a suitable control. The chart below gives the controls required by New Zealand regulations on the left, this has been expanded to give more detail and an example of the options available on the right. The controls are ordered from the most powerful controls at the top through to the least effective at the bottom.

An organisation should undertake an assessment of all risks and allocate suitable controls. This process should be recorded in the Hazard & Risk Register(Form 2) attached here.

1.Project Specific Safety PlanChecklist and Signoff

To be completed and handed to KDC management before start of work.

To:Kaipara District CouncilFor:(Project)

From:(Group name)For: (Outline work to be undertaken)

We undertake as follows:

1.Workplace Control and Management:

Supervisorfor this project is:………………………….……….…… (Phone) …....……...……...….

2.Hazard Management:

We will maintain a Hazard Risk Register of all existing / new hazards, assess risk and allocate controls.Yes  No

We will prepare a written Task Analysis covering all higher risk taskshazards associated with our works, in
conjunction with workers, and give it to K.D.C. before any work involving that hazard
commences on projectYes No

Are there hazardous products/processes associated with this work?YesNo
(If yes, the appropriate Safety Data Sheets must be attached)

3.Communication/ Worker Participation:

We undertake to hold Health and safety meetings before the work starts each day Yes No

4.Emergencies:

Our First Aid kit is located at: ………………………………………………………………………………

We have trained First Aid personnel and procedures in place on project to render assistance in the
event of an accident/ emergency YesNo

Our First Aid person is: …………………………………………………………………… (Phone) ………………………………..

We have attached an Emergency Planfor this project covering the major events that could arise YesNo

In the event of a projectemergency or evacuationour workers will report to our supervisor
and assemble at the evacuation area shown on the Emergency Evacuation Plan YesNo

5.Accident/Incident: Reporting/Investigation/Recording:

We will record allAccidents or Incidents in the attached register YesNo

We will notifyall accidents to K.D.C and follow up with anAccident / Incident Investigation Report  YesNo

6.Safety Inspections and Safety Reviews:

We agree to undertake safety inspections and reviews at the start of the work and as it continues. YesNo

7.Training/Induction:

All persons under our control on projectwill be given a projectspecific safety induction. YesNo

All persons under our control on this project are either qualified, competent or fully supervised. YesNo

Signed: …………………………………………Name: ………………………………………Date: ………………………..……

(Group representative)

Signed: …………………………………………Name: ………………………………………Date: …………………………..…

(K.D.C representative)

2. Hazard & Risk Register(Record the hazards and assess the risk that you anticipate on the project, then state the controls that will be used to reduce risk to an acceptable level. After the initial signoff this form should continue to be used fornew hazards as they ariseon the project.)

IDENTIFIED HAZARD / POTENTIAL HARM / Risk Level
Before controls / HAZARD CONTROLS / Risk level
After Controls / CONTROLS CHECKED
Date Checked / Date Checked

3.Hazardous Substance Register(Use this to record any hazardous materials you will be using on the project)

PROJECT / Group
Date / Substance, Chemical, Material or Solvent / MSDS Held? Y/N / Quantities / Location / Hazard Potential / Is there a Safer Alternative? / Protective Clothing / Equipment Required / Storage and clean up Requirements.
Completion guide and action sign-off
Completed Safety Data Sheets are held for all products and the information, health risks and instructions on use and protective equipment will be conveyed to workers and recorded in theCompetency Register.
Sign off……………..……………………..…………….……signed (Project supervisor ) ………………………..….(Date)

4.Task Analysis Worksheet(This sheet is necessary for any work where a person could get killed or have a serious injury. It will describe the sequence of the work and what is required to prevent harm at each stage.)

JOB DESCRIPTION / PROJECT/PROJECT / DATE
PPE required: /
Task Analysis completed by:
Date:
Equipment required:
What Warning Signs are required:
List the job in the 4 to 8 steps from start to finish
(Follow the flow of the product or the process) / List the potential SIGNIFICANT hazards beside each step. Focus
on what can cause harm and what can go wrong
(Use the Seven Point Analysis as a guide) / List the control methods required to ELIMINATE, or MINIMISE each SIGNIFICANT hazard
Number and Name of Stage List the job in the 4 to 8 steps from start to finish / Potential Hazards List the potential SIGNIFICANT hazards beside each step. / Risk Level
Prior to any control / Hazard Control MethodState what will be done to each SIGNIFICANT hazard See Pg. 2 Risk Rating And Control. / Risk Level
After control
Step
No.
1
`

Seven Point AnalysisTo help identify hazards, for each step ask – Can workers?

• strain or sprain my back or other muscle
• be caught in, on or between anything
• slip, trip or fall from height, on the same or lower level
• be injured by poor plant/job design

/

• be struck by or against anything
• come in contact with a hazardous substance
• come in contact with an energy source

Sequence Of Basic Steps / Potential Hazards / Risk Level / Hazard Control Method / Risk Level
Step No.
`

Sketch of Job if required

Task Analysis Sign-off(to be completed before this work starts by all workers involved)

All workers involved in Task Analysis have been trained / instructed in the processes and are happy to follow this plan.

Name………………………………………Signature…………………………………….………. / Name………………………………………Signature…………………………………….……….
Name………………………………………Signature…………………………………….………. / Name………………………………………Signature…………………………………….……….
Name………………………………………Signature…………………………………….………. / Name………………………………………Signature…………………………………….……….
Name………………………………………Signature…………………………………….………. / Name………………………………………Signature…………………………………….……….

5. Safety Training and Competency Register

This register is a record of training, qualifications, experience and competencies for your workers. Complete the register for each person, record employee competence level for the job he/she will be carrying out on project in the column on the far right.

Name / Project Induction
Date / Training, Qualifications, Experience / Competence
Skills
(Specify all types) / Qualifications, Certificates, Licences. / No. Years’ Experience in this work / Level of Competence in Current Job
1. Direct supervision Required
2. Competent to work un supervised
3. Competent to train others

6.Emergency Plan and Procedure(use this form to cover the main emergency situations, tell us who will do what and then ensure all your workers are familiar with the plan)

PROJECT / Group
Potential Emergency Situations / List each separately: / Procedure:
Responsibilities / Personnel: / Key responsibilities:
Evacuation Procedures / Alarms: / Assembly area:
Medical Treatment / First Aiders: / Location of nearest medical centre:

Emergency Evacuation Plan

In the case of emergency requiring evacuation of the project, either:

FIRE, EARTHQUAKE, SERIOUS ACCIDENT, STRUCTURAL COLLAPSE, TSUNAMI, EXPLOSION, AVIATION INCIDENT, HAZARDOUS SPILL OR PRACTICE EVACUATION

The following warning will sound………………………………………………

______

If this warning sounds, SHUT DOWN all plant and equipment.

All workers are to proceed IMMEDIATELY by the

SAFEST IDENTIFIABLE ROUTE to the SAFE ASSEMBLY POINT at:

Location

And REMAIN there, so ALL workers can be ACCOUNTED FOR

DO NOT RETURN to the project supervisor has given the

OFFICIAL CLEARANCE

MEDICAL FACILITIES LOCATED AT:

Location

When calling 111, READ THE FOLLOWING TO THE DISPATCHER:

We have an emergency at (address)………………………….

We need help from Ambulance/Fire…

Directions to the emergency are…

Our phone number is………..

The medical problem seems to be…

Now send someone to meet the emergency services as they arrive

EMERGENCY TELEPHONE NUMBERS:

Dial 111 for:

FIRE, AMBULANCE, POLICE, GAS, CHEMICAL SPILLS

PHONE NUMBERS MAY DIFFER – CHECK YOUR LOCAL DIRECTORY

HOSPITAL( )

WORKSAFE NZ (0800)030 040

CIVIL DEFENCE( )

POISON CENTRE0800 764 766

POWER (Customer Service)( )

Project supervisor is:

TRAINED FIRST AIDER IS:

FIRST AID KIT AND FIRE EXTINGUISHER LOCATED AT ………………………:

8.Project Pre-startSafety Assessment

(Use this form to assess the project set up prior to start, you may wish to alter it to suit your specific work.)

PROJECT / ASSESSOR / SIGNED
DATE
Hazards / n/a x / Controls

Height/Overhead Work:

Falling material controlled
Ladders suitable and secured
Scaffolds suitable and correct

Plant:

WoF/current test tag
Machine guardsin place
RCDs used on electrical leads
Leads in good order

General Environment controlled:

Public access/protection
Signage/barriers
Organisation/housekeeping
Wet/slippery environment
Hazardous materials
Chemicals
Services (gas/water/power) identified
Exposure to weather
Traffic properly controlled with TMP
Noise
Dust and debris
Explosion/fire
Machinery
Mobile plant
Parking allocated to workers

Personal Protective Equipment:

Safety boots
Hearing protection
Eye protection
Hi viz clothing
Safety helmet
Respiratory protection
Gloves
Overalls

Remedial Action Schedule (record what needs to be put right, by who and by when)

ITEM / COMMENTS/ACTION DESCRIPTION / PERSON TO ACTION / BY WHEN

9.Project Induction Register(Use this form to record who is at work each day)

NAME / SIGNATURE / DATE

10.Safety Meeting Minutes(use this form to record your regular safety meetings)

PROJECT / Group name
SUPERVISOR / DATE
Attendees:Signatures of attendees:
Activity/safe work practices/accident or incidents discussed:
worker issues raised: / Date to be resolved by:
Safe observations reviewed/discussed:
Task Analysis(form 4.) completed/reviewed if necessary: / Date:

11. Inspection Checklist(Use this form to assess the project regularly as the work progresses e.g. weekly. You may wish to alter this to suit you specific type of work.)

PROJECT / Organisation Name
Safety representative: / Inspection by:
Date:
1 / Project Control / n/a x / 9 / Electrical Equipment / n/a x
1.1 / Hazard board and signage up-to-date / 9.1 / Current tagged and damage-free leads
1.2 / Environmental plan – issues / 9.2 / Current tagged R.C.D’s
1.3 / Toolbox Talk last date / / / 9.3 / Leads safely placed away from foot traffic
2 / Project Facilities / 9.4 / Equipment in good condition
2.1 / good lighting / 9.5 / Appropriate guards on equipment
2.2 / clean, potable water / 9.6 / Adequate temporary lighting
2.3 / Toilets – clean, soap, water towels / 9.7 / Current tagged RCD’s
3 / General Project Tidiness and Access ways / 9.8 / Leads safely placed away from foot traffic
3.1 / Clear, safe access to work areas / 9.9 / Equipment in good condition
3.2 / Loose materials secure from wind / 10 / Chemicals
4 / Personal Safety Equipment / 10.1 / Correctly stored
4.1 / Signage displayed and legible / 10.2 / Safety Data Sheet (SDS) available
4.2 / Hardhats being worn / 10.3 / Operators using PPE
4.3 / Correct footwear being worn / 10.4 / Spill kit available
4.4 / Glasses/ear muffs/ hi viz vests/masks used / 11 / Tools
5 / First Aid / 11.1 / All hand tools in good condition
5.1 / First Aid box on site and stocked / 12 / Scaffolding
5.2 / Accident register / 12.1 / weekly Scaftag/current
6 / Fire Prevention / 12.1 / Handrails/mid-rails
6.1 / Fire extinguishersAvailable / 12.2 / Toe boards
6.2 / Current (12 mth) / 12.3 / Platforms
6.3 / Sufficient number / 12.4 / Ladders/stairs
7 / Ladders / 12.5 / Base sound
7.1 / Good condition / 12.6 / Work platforms clear
7.2 / Secured top and bottom / 12.7 / Platforms trip free
7.3 / Stays to step ladders / 12.8 / Planks secured from lifting
7.4 / Working 2 steps down / 12.9 / Headroom clear
8 / Fall Hazards
8.1 / All falls controlled

Remedial Action Schedule (record what needs to be put right here state when)

ITEM Number / COMMENTS/ACTION DESCRIPTION / NAME OF PERSON TO DO THIS. / By When

12.Accident/Incident / Near Miss Register(record these event as they arise during the project, note any trends and act to prevent them in future. These events need reporting to KDC, serious events will need to be report to WorkSafe)

PROJECT / Organisation name
Date and Time / Details:
Name of person (injured or observer):

• Description of accident/incident/near miss
• Cause of harm (if any)
• Type of injury/disease (if any)

/ Immediate action taken:

• First Aid
• Corrective action
• Review Hazard Register

/ Serious Harm
Y/N / WORKSAFE NZ
Notified
Y/N
Date / Investigation
actioned and documented
Y/N
(Separate form) / Investigation outcomes
discussed at safety meeting on (date) :

13. Accident and Incident Investigation Report

I am using this form to report a: Serious Harm☐ Minor Harm☐ Non Harm / Near Miss☐
Date occurred: / Time / Contact telephone:
Date reported: / Reported by: / Location:
Persons affected:Yes☐ No☐ / Name of affected: / Age (or DOB):
Address: / Contact telephone:
Type of injury (tick and mark on body:
☐Strain/sprain
☐Fracture
☐Laceration/cut
☐Burn/scald
☐Bruising
☐Scratch/abrasion
☐Chemical reaction
☐Dislocation
☐Internal
☐Foreign body
☐Stress/fatigue
☐Other (specify)
……………………… / Medical treatment required: Yes☐ No☐
Treated at:
Treated by:
Type of treatment:
Loss time (Days)
Damage to property ☐ Details
Describe what happened: (Please give as much information as possible, provide drawings or photos in additional pages):
Details of any witnesses:
What caused this?
What parts of the system can be improve to prevent this happening again?
Sign and pass on to K.D.C when complete / Signature
K.D.C SectionNB: a full investigation and report is required for any serious harms or notifiable events.
WorkSafe advised ☐ Reported to GM☐
What action(s) are being taken to prevent reoccurrence? / By whom: / When:

14. Monthly Contractor Health & Safety Report. Complete the fields below or return the same information as MS Excel, Word, email or PDF format.

Contract number. / Month/year for / Date prepared: / _____/_____/______
Prepared by: / Company/Organisation name:
Council department you are working for:
Date Occurred / Time / Description and Treatment / Improvement Action to be Taken / Safety Audits / Reported Hazards / Nonharm Incident / First Aid / Medical Treatment / Lost Time Injury (Hrs) / Notifiable (Serious) Harm / Fatality / Date Worksafe Notified
Internal or external health and safety training provided to Staff:
Subject / Attendees / Duration
Subject / Attendees / Duration
Attach copies of your internal investigations along with anyInvestigations, Notifications, Notices Received or Reports made to WorkSafe. All info to be sent to your K.D.C. Contract Manager by 10th of following month.

The information provided above is a true and accurate record.

Signed: ______Date: _____/_____/____