Site Safety Documentation[1]

8/2/2019 Site Safety Documentation[1]

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Wor k p e r m i t Working document 1Page 1/2Apply form

(To be filled in by applier)

Location Department ................................................................................................

Equipment n ...............................................................................................

Work description .......................................................................................................................................................................................................................................................................................................

Procedure mounting/demounting chopping / boring

opening of installations grinding

entering closed space high pressure spraying

burning/gouging/welding sand blasting

X-rays/radiation work digging hoisting / lifting placement of scaffold

.

Tools ....................................................................................................................................................................................................

Vehicles ..............................................................

Marks .............................................................

Number of persons ..............................................................

Persons < 18 years Yes

No

Start date .............................. End date ..............................

Work time from .............................. Work time - till ..............................

Special permits Dig permission Scaffold permission Entering closed space Hot work permission

Works on piping .MEASURES BEFORE STARTING THE WORKS(To be complete by the distributing department)

General measures Required Ok

Check environment combustible material

Free connect apparatus electrical

Block apparatus mechanical

Condition closed space with/without gas free certificate

Foresee signalisation

Mark out work space (white/red or yellow/black)

Seal wells, sewers, ... in a radius of . m

Health- and safety planSite XXX Page 1 of 20Version 1.0 d.d. 01-02-2006


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Wor k p e r m i t Working document 1Page 2/2

Specific measures : fire hazard Required Ok

Deploy fire brigade

Set ready fire hose Extra foresee in .. mobile fire extinguishers class

.

Specific measures : fall hazard Required Ok

Place up railing (between 100 cm and 120 cm)Place intermediate railing (between 40 cm and 50 cm)

Place baseboard (min. 15 cm from work surface)

.

Supplementary personal protection means to foresee by contractor

spatial view glasses / acid glasses face screen ear protection fall protection

personal gas alarm breathing protection

LEL dust mask

O2 filter mask

CO fresh air cap

H2S compressed air mask

..........................

Extra tests Required Ok

Hoisting machines

Ladders

Electrical connections

Scaffolds

.

RATIFICATION(To be complete by the distributing department)

Sort of the risks extreme high low

relative high relative low

high extreme low

Judged by (name and first name) .................................................................

.................................................................Signatures

Distributor ..............................................................

Requestor .............................................................

Valid from ............................... Valid till ...............................PROLONGATION(To be complete by the distributing department)

From Till Name and first name Signature

.............................. .............................. .............................. ..............................



3/20

Reg i s t r a t ion VGM i n s t r u c ti on s Working document 2Undersigned, ...................................................., clarifies herewith that he took upthe safety prescriptions of Waterleau and the ruling safety prescriptions of RED

STRIPE BREWERY into the general safety plan and that he transferred theprescriptions from the site regulations to his employees and subcontractors.

Explanation held on: .........................................................................

By: .........................................................................

Following persons were present and have understood the explanation of the safetyprescriptions.

Name Function Signature................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................

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4/20

Reg i s t r a t ion Too l box mee t i n g Work document 3Undersigned, ......................................................., clarifies herewith that he dealedwith the beneath standing safety subjects and that he has explained those to a

sufficient extent so that his audience has understood.

Treated safety subjects:

1. .................................................................................................................2. .................................................................................................................3. .................................................................................................................4. .................................................................................................................

Explanation held on: .........................................................................

By: .........................................................................

Following persons were present and have understood the explanation of the safetyprescriptions.

Name Function Signature................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................................................... .................................. .................................

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5/20

I n c i den t r e po r t Work document 4Page 1/4

Incident number:

1. General information

Date: ................................. Location: .................................

Hour: .................................

Person involved: Name: .........................................................Address: .........................................................

.........................................................Telephone: .........................................................

Employer: Name: ...................................................................Address: ...................................................................

...................................................................Telephone: ...................................................................Contact: ........................................................

Type of incident:

Accident with work delay Incident with damage to property

Accident without work delay Environmental incident

Almost-accident Serious risk

Nursing .....................................................

External aid:

Ambulance (called by: ........................................... ) ............................................................................................................

2. Short description of the incident

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Indicate if applicable



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3 Cause of incident

Use of tools Managing of vehicles Moving objects Working on height

Operating of machines Welding / burning

Handling with products Cleaning

Mounting / demounting Digging

Set-up of scaffold Sampling

Climbing / descending Tapping / spooling

Slipping / falling / stumbling Loosen connections

..................................................

4. Circumstances of incident

Leakage Falling object

Fire / explosion Electrical

Environmental pollution Vandalism

Transportation Unsafe handling

Slipping / falling / stumbling Hoisting works

..................................................

5. Injury

First aid: ..........................................................................................Medical treatment: ..............................................................................

Kind of injury: ..............................................................................Date of recovery (estimated): ..................................................................Date of recovery (effective): ..................................................................Remarks: ..................................................................

6. Results of incident examination and analysis

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7/20


7. Cause

Direct cause: Lack of communication

Insufficient follow-up of rules and procedures

Insufficient safety signalizations

Ignoring or not-use of safety signalizations

Incorrect handling

Insufficient personal protection means

Not-use of personal protection means

Influence of alcohol or drugs

Unsuitable or failing tools or machines

Incorrect use of tools or machines

Work environment Order en neatness

Access

External factors, thirds, weather conditions

............................................................................................................

Underlying cause:

Physical of mental inaptitude

Insufficient knowledge

Overburding

Insufficient motivation

Insufficient supervision Insufficient policy

Insufficient planning or organisation

Insufficient procedures or prescriptions

Incorrect design or technique

Insufficient maintenance or inspection

............................................................................................................

8. Conclusions and recommendations

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9 Witness

Name: ........................................................................................Address: ........................................................................................

........................................................................................Phone:........................................................................................Employer: ........................................................................................

Name: ........................................................................................Address: ........................................................................................

........................................................................................Phone:........................................................................................Employer: ........................................................................................

10. Correction measures

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11. Signature

Person involved .................................... Date: .................

Prevention advisor .................................... Date: .................

Employer .................................... Date: .................

Coordinator ................................... Date: .................

Site supervisor .................................... Date: .................




9/20

I n spe c t i on c he c k l i s t s i te Work document 5aInspection date : Inspection by : Contractor :

ORDE R EN NEATNESS SITE

Are corridors, stairs passable and clean?

Is material storage safe?

Garbage containers, is garbageseparated?

Lighting on the spot alright?

Sufficient ventilation?

Fire extinguishers accessible?

...

SUPPORT TOOLS

Gas storage in conformity with ARAB

313/318 Fire extinguisher on bottle rack?

Cylinders placed upright and fixed?

Control hand tools, machines, ...- Condition- Isolation

...

PERSO NAL PROTECTION MEANS

Safety helmet (Art. 54-60)

Eye protection

Safety shoes

Protecting cloths, gloves Falling protection, line (Art. 158)

Ear protection

Breathing protection

Prevention of falling (Art. 42 - Art. 269)

...

SCAFFOLDS, LADDERS, STAIRS

Is the scaffold checked?

Is the scaffold foreseen of a test sticker?

Is the scaffold free of materials?

Falling protection in good state? Correct and safe implant

- Fixed- Frame, ladder, securization present- Ladder of sufficient length

...

FIRST AID

Is First Aid box complete?

Is the content clean?

Stretcher present?

First Aid phone numbers are marked?

Blankets present?

...

LIGFTING TOOLS, HOIST INSTRUMENTS

Crane book present and alright?

Certificates hoisting material alright?

Indications readable present on: hoist,straps,...

Visual alright?

Driver possesses a certificate?

...ELECTRICIT Y

Electrical installation in good state?

Cabinet alright?

Extension leads, plugs, ... alright?

Earthing placed?

Electrical hand tools alright?

Glow equipment alright?

Generators alright?

Welding transformer alright?

...

CHEMICALS

Legend per product present?

Hazard labels correct?

Facilities at spills present?

Protection means present?

Storage in conformity with legislation?

Storage chemical trash present?

...

ROADS , GROUNDS, TRAFIC

Boarding present?

Signalisation placed (day)?

Signalisation placed (night)?

Street lighting sufficient?

Road blockade reported?

Digging work barrier placed?

Band or turn wall necessary?

...

OTHER SAFETY POINTS

Propane-Butane storage in conformity?

Emergency road marked?

Work permit, instruction, alright?

Barrier on heights?

...

= Correct = Not acceptable = Not applicable



10/20

I n spe c t i on c he c k l is t - a c c ommo da t i on Work document 5bInspection date : Inspection by : Contractor :

OFFICE, CANTEEN, DRESSING-, WASH-, OR SANITARY ROOMS

Is the building far enough of the road?

Is the interspace large enough?

Order and neatness around the accommodation correct?

Entrances safely accessible, lighting present?

Emergency doors foreseen of panic lock?

Pictogram emergency exit placed?

Fire extinguishers present (6 kg per 30 m)?

First aid box present?

Electrical heating with thermostatic regulation installed?

Electrical heating not covered?

Main current switch accessible?

Electrical installation in conformity?

...

HYGIENE

Office (floor, ashtray, litter bin, windows)

Canteen (tables, fridge, machines, ventilation, rubbish)

Wash- and dressing rooms (ventilation, wash and shower installation, sewageconnection)

Sanitary rooms (general neatness, sewage connection)

Warehouse (storage, paths, unload- and hoisting means)

...CONTAINER FOR STORAGE MATERIAL

Safely accessible?

Electrical installation in conformity? Are storage racks secured against falling over?

Contains container inflammable or explosive products?

Fire extinguisher present (6 kg per 30 m)?

...WAREHOUSE

Has the warehouse a flat floor?

Safe access for persons and material?

Electrical installation in conformity?

Earthing present?

If warehouse is also work floor, is emergency exit present?

Fire extinguisher present (6 kg per 30 m)? ...CONTAINER IN USE AS WORK SPACE

In conformity with local legislations?

Mechanical ventilation sufficient internal height - 180 cm?

Lighting present?

Fire extinguishers present (6 kg per 30 m)?

Space free from inflammable liquid and gas?

Clean floor?

Entrance good accessible?

...




11/20

I n spe c t i on c he c k l i s t a c t i v i t ie s ge ne r a l Work document 5cInspection date : Inspection by : Contractor :

DIGGING WORKS

Subterranean pipes localized and

marked? Subterranean pipes out of use?

Passages held free?

Safe storage of material?

...

DESTRUCTION WORKS

Persons protected against noise?

Persons and environment protectedagainst falling objects?

Inspection of hoisting machines andaccessories?

Loads rated by certified riggers?

Free or protected passages?

Openings enclosed with fix fence?

Orderly stock and carry away ofrubbish?

...WORKS ON DIFFERENT LEVELS

Adapted passages above wells? Adapted passages around wells?

Protection against ground collapse?- calculation of stability- protection against crumbling off

...

GROUND WATER TABLE PUMPS

Wells dimmed? Give pipes stumbling danger?

...

CONCRETE WORKS

Facilities for safe access of enclosedplaces?

Use of stable (preferable metal)formworkselements

...

HOISTING

Are all risks examinated?- disconnect installation- emptying installation- free passages- capacities and mobility

Are entrances enclosed? Remain passages safe?

Is certified rigger present?

...PROBING

Use of efficient and certified material?

Data available on map?

Piping marked?

...

MACHINES / MATERIAL

Examination obliged installation tested?

All machines in good state?

Electrical installation in order?

...MANIPULATIONS

Installation emptied?

Valves closed and danger marked?

Hazardous products safe?- efficient packed- risk and hazard identification present- prevention measures marked

Efficient inspection before use?

ELECTRICITY

Installation tested for start-up?

Installation under tension marked?

Installation ready to start marked?

Interventions with personal padlock?

Signalisation PROHIBITED TO SWITCH?

...




12/20

Reque s t f o r a c c e s s on s i t e a f te r wo r k i ngh ou r s

Work document 6

Considering the identification of the persons who are on site, we ask you to fillin this form for each worker to become access on site after the normal workinghours.

Employer: Name: Address:

Phone: . Fax: ..

Present superior:

Date: From: Till:

Number of persons:

Name Function Signature................................... .................................. .................................................................... .................................. .................................

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13/20

A n n ou n c e m e n t o f n e w e m p l o y e e s Work document 7Considering the identification of persons who are on site, we ask you to fill in this formfor each worker to become access on site.

Employee Name: .....................................................................Address: .....................................................................

.....................................................................Phone: .....................................................................

Employer: Name: .....................................................................Address: .....................................................................

.....................................................................Phone: ....................... Fax: .......................

Direct superior: .....................................................................

Personnel number: .....................................................................

Date van employment: ..............................................................Date of birth ..............................................................

Nationality ..............................................................

If EU EG citizen: E101 form in annex

Identity card number: ..............................................................Social security number: ..............................................................

All data available by means of this form are kept under strict secrecy to protectthe private life. The data can be put at someones disposal after request ofofficial authority.



14/20

Fo rmu l a t i on o f r ema r k s Work document 8Undersigned, .............................................................. of thecompany, .............................................................., wants to declare a remark to the

site management. The site management obliges hisselfs to formulate an answer oneach remark that has been formulated via this organized way.

Remark

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Date: ..............................................................................................

Name and signature of the contractor:

For: ..............................................................................................

Results

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Date: ..............................................................................................

Name and signature of site supervisor:

For: ..............................................................................................



15/20

I den t i f i c a t i on shee t f o r c on t r a c t o r s Working document 9Page 1/3

Within the framework of the activities Construction of an effluent treatment plant onthe site of RED STRIPE BREWERY on location 214 Spanish Town Road, Kingston

Jamaica

the undersigned clarifies the principalWaterleau Global Watertechnology NV.Radioweg 18B-3020 HerentBelgiumthat he has received the safety plan en that he will comply with it.

For the execution of the works the following identification data apply:

Firm: Name: ...........................................................................Address: ...........................................................................

...........................................................................Telephone: ............................... Fax: ............................VA.T..: ...........................................................................

Date of order: ................................................................Sort of works: ................................................................

................................................................Presumable start date: .........................................

end date: .........................................

Number of foreseen workers on site: ..................Number of foreseen vehicles on site: ..................

Notified body:Name: .......................................................................................Address: .......................................................................................

.......................................................................................Phone : ............................... Fax: ............................



16/20

I den t i f i c a t ion shee t f o r c on t r a c t o r s Working document 9Page 2/3

Managing Director:

Name: .......................................................................................Phone: ............................... Fax: ............................

Prevention advisor:Name: .......................................................................................Phone: ............................... Fax: ............................

Project engineer:Name: .......................................................................................Phone: ............................... Fax: ............................

Site supervisor:Name: .......................................................................................Phone: ............................... Fax: ............................

Safety expert on site:Name: .......................................................................................Phone: ............................... Fax: ............................

First aid (present on site):Name: .......................................................................................Certificate: .......................................................................................Means: .......................................................................................Phone: ............................... Fax: ............................

Insurer work accident:Name: .......................................................................................Address: .......................................................................................

.......................................................................................

Phone: ............................... Fax: ............................



17/20

I den t i f i c a t ion shee t f o r c on t r a c t o r s Working document 9Page 3/3

Medical officer:Name: .......................................................................................

Phone: ............................... Fax: ............................In case of external practice:Name: .......................................................................................Address: .......................................................................................

.......................................................................................Phone: ............................... Fax: .............................

Identification subcontractors:Name: .......................................................................................Address: .......................................................................................

.......................................................................................

Managing Director: ...........................................................................Phone: ............................... Fax: ............................


.......................................................................................Managing Director: ...........................................................................Phone: ............................... Fax: ............................


.......................................................................................Managing Director: ...........................................................................Phone: ............................... Fax: ............................

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



18/20

I den t i f i c a t i on shee t f o r s i t e m a t e r i a l Work document 10Page 1/3

For the execution of the works, the responsible of following company declares that:

Firm: Name: ...........................................................................Address: ...........................................................................

...........................................................................Phone: ............................... Fax: ..............................

Following site material is applied:

Name Identification Administrator................................... .................................. .................................................................... .................................. .................................

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For equipment wherefore an official test is obliged, the test certificates are presenton site and a copy has to be handed over to the site management.

For equipment which make use of chemical products (others then fuel), the productinformation is available on site.

All site material that are apparatus, machines, installations, rooms, , arefound safe and are checked on safety and soundness on a regular base.The users of the site material are sufficiently educated and possibly medicalfollowed up to use the material.



19/20

I den t i f i c a t ion shee t f o r s i t e ma t e r i a l Work document 10Page 2/3

Are scaffolds used? : Yes : No

Are hoisting machines used? : Yes : No

Which : Tirfort

Electrical hoist

Sky workers

Tele handler

Scissor lifts

Mobile crane

Lift truck

Front lift Hang lift

Others: ........................................

Are these hoisting machines tested by a notified body? : Yes : No

Which equipment / means are used?

Drill hammer & drill machines

Electrical shorten saws

Cut out saws

Grinding tools

Shoot hammers (pattern)

Table saws

Electrical groups

Compressors

Core drills

Others: ...................................

Which products are used?

Inflammable products and max. quantity on site

(White Spirit, degreaser, petrol, ...)Product: ............................................... quantity: ......................................................... quantity: ..........

Chemical products and max. quantity on site(Methyl-ethyl keton, glues, .......)

product : ............................................... quantity: ......................................................... quantity: ..........




20/20

I den t i f i c a t ion shee t f o r s i t e ma t e r i a l Work document 10Page 3/3

Use of:

- Distiller (propane / butane) : Yes : NoIf yes:

- check valve foreseen? : Yes : No

- fire extinguisher foreseen? : Yes : No

- storage of bottles? : Yes : No

- bottles identified? : Yes : No

- Oxy / acetylene distillers : Yes : NoIf yes:



- storage of bottles?

: Yes

: No- bottles identified? : Yes : No

- pressure gauges tested? : Yes : No

- Boilers (roofer) : Yes : NoIf yes:



- storage of bottles? : Yes : No

- bottles identified? : Yes : No

- retention tank foreseen? : Yes : No

- instructions for personnel? : Yes : No

Electrical equipment

- Use of extension lead : Yes : No

- Type H07RNF, H05RNF of CTMB : Yes : No

- Are they identified : Yes : No(name of firm mentioned on cable or colour code)

- Sockets

Sealed (IP classified as required?) : Yes : No

Is this equipment tested by a notified body? : Yes : No

Date: .......................................................................................

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


Health- and safety planSite XXX Page 20 of 20Version 1 0 d d 01 02 2006

Site Safety Documentation[1]

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Transcript of Site Safety Documentation[1]