SAFE PLAN OF ACTION

Safe Plan of Action Checklist (check all that apply)

(Review checklist while completing front page Safe Plan of Action) A new SPA is required if the job scope or work conditions change.
Required
Permits Hazards Safe Plan
o Confined Space o Overhead Utilities o Power de­energization required o Insulation blankets required o Wire watcher required
o Critical Lift o Required clearance distance = _______Ft. o Safe work zone marked
o Hot Work o Crane or other o Signalman assigned o Tag lines in use o Area around crane barricaded
o Lock Out/Tag Out Lifting Equipment o Lifting equipment inspected o Personnel protected from overhead load
o Soil Disturbance (Over 12”) o Underground Utilitieso o Reviewed as­builts o Subsurface surveys o Received dig permit
o Utility Clearance Required clearance distance = _______ Ft. o Safe work zone Marked

Required PPE o Electrical o Lock Out/Tag Out/Try Out Permit required? o Confirm that equipment is de­energized
o Hard Hat, Class C o Reviewed electrical safety procedures
o Hard Hat, Class E (Elect. Protect) o Excavations o Permits o Inspected prior to entering o Proper sloping/shoring
o Ear Plugs/Ear Muffs o Barricades provided o Access/egress provided o Protection from accumulated water
Eye Protection: o Fire Hazard o Hot Work Permit o Fire Extinguishers o Fire watch
o Safety Glasses o Adjacent area protected o Unnecessary flammable material removed
o Face Shield o Vehicular Traffic or o Traffic Barricades o Cones o Signs o Flagmen o Lane closure
o Chemical Goggles Heavy Equipment o Communication with equipment operator
o Welding Hood o Noise >85 dB Hearing protection is required: o Ear plugs o Ear Muffs o Both
Hand Protection: o Hand & Power Tools: o Inspect general conditions. o GFCI in use o Identified PPE required for each tool
o Cut Resistant Gloves o Reviewed safety requirements in operators manual(s) o Guarding OK
o Welders Gloves o Hand Hazards List sharp tools, material, equipment: ________________________________________________
o Nitrile Gloves o PPE gloves, etc. o Protected sharp edges as necessary
o Surgical Gloves o Manual Lifting o Reviewed proper lifting tech. o Identified material requiring lifting equipment
o Rubber Gloves o Hand protection required o Back support belts
o Elect. Insulated Gloves o Ladders o Inspect general conditions before use o Ladder inspected with in last quarter
o Arm Sleeves o Ladder tied off or held o Proper angle and placement o Reviewed ladder safety
Foot Protection: o Scaffolds o Inspect general condition before use. o Tags in place o Properly secured
o Sturdy Work Boots o Toe boards used o Footings adequate o Materials properly stored on scaffold
o Safety Toe Boots o Slips, Trips Falls o Inspect for trip hazards o Hazards marked o Tools & material properly stored
o Rubber Boots o Extension cords properly secured o Work zone free of debris
o Rubber Boot Covers o Pinch Points List potential pinch points: ________________________________________________________
o Dielectric Footwear o Working near operating equipment o Hand/Body positioning
Respiratory. Protection: o Working w/ Chemicals o The task creates potential for direct contact with hazardous chemicals.
o Reviewed MSDS hazards and precautions o Have proper containers and labels.
o Dust Mask o Have identified proper PPE (respirators, clothing, gloves, etc.)
o Air Purifying Respirator o Heat Stress Potential o Heat stress monitoring (>85o) o Liquids available o Cool down periods
o Supplied Air Respirator o Sun Screen o Reviewed Heat Stress symptoms
o SCBA o Cold Stress Potential o Proper clothing (i.e.. gloves, coat, coveralls) o Wind chill <32o
o Emergency Escape Respirator o Reviewed Cold Stress symptoms o Warm up periods
o Environmental o Air emissions o Water discharge o Hazardous wastes o Other wastes
Special Clothing:
o Pollution prevention o Waste minimization
o Tyvek ® o Natural or Site Hazards o Weather o Terrain o Adjacent operations or processes o Biological hazards
o Poly Coated Tyvek ® o Animals/reptiles/insects hazards
o Fire Resistant Coveralls o Adjacent Work/Processes o Notified them of our presents o Other workers adjacent, above, or below.
o Rain Suit and/or co occupancy o Coordinated with adjacent work supervisor/customer operator o Can work safely
o Safety Vest o Barricades/covers o Caution barricade tape required o Danger barricade tape required o Rigid railing required
o Covers over opening o Warning signs required
Fall Protection:
Additional Information:
o Harness
o Double Lanyard Required

o Anchorage Point Available

Additional Anchorage Connector

o
Needed e.g. Cross Arm Strap, etc.

o Retractable Device Needed