Activities to be performed include sources of hazardous energy (lockout-tagout), working at height (incl. roof), elevated work platforms or mobile equipment, electrical work, hot work, line breaking, cranes, confined spaces, powered manual tools, sharp objects, chemical or biological exposures, hazardous materials, hazardous waste, demolition, or excavation?
Work performed at/above 1.2m (4') or at/within 1.8m (6') of roof edge/ledge?
Access needed to reach areas above guard rail, barrier? e.g. fire protection systems, lights, sensors in ceiling on equipment at height etc.?
Edge protection, barriers, guardrails?
Engineered and certified tie-off points (=5,000Kg)?
Wet, contaminated, slippery surfaces or handles/rails?
Adequate space to use scissor lift or similar device to access work at height?
Hazards from sharp edges, materials, equipment, facility infrastructures?
Live electrical work performed or electrical work > 240 Volts?
Competent person performs risk assessment, determines and implements controls?
Electrical controls (arc flash, current) using hierarchy of controls readily available and used?
Permit in place and effective controls implemented? -reviewed with supervisor-
Elevated Work Platforms and Mobile Equipment
Elevated Work Platforms or Mobile Equipment (Manlift, scissorlift, fork-truck etc.) expected to be used or are you working in close vicinity of these?
Daily pre-use inspection completed and deficiencies corrected?
Operator certified / trained and current?
Fall protection systems in place and effective? anchor points
Equipment extensions (certified / weight load limit indicated) or slings (nylon, steel, rope) inspected, appropriately rigged and adequate for the weight load / task / environment and in good condition?
Access of equipment to work location evaluated? -struck by / struck against
Equipment movement in work area evaluated? -struck by / struck against
Load movement out of sight or with limited visibility? spotter / signaling person required
Are barricades and warning signs in place when working at height, on roof / near edges, hazardous processes, moving equipment, cranes, lifting equipment, etc.?
Any battery / electrical charging stations or compressed gas exchange required? -eyewash stations / safety showers if corrosives in place, proper secured storage and handling of compressed gas cylinders --do NOT roll--
People and moving equipment separated by barricades or similar? If not, use spotter
Cranes used or in / around work area?
Daily pre-use inspection completed and deficiencies corrected?
Operator certified and current?
Maintenance, testing and inspection records up-to-date and deficiencies corrected?
Any extensions (certified and weight load limit indicated) or slings (nylon, steel, rope) inspected, appropriately rigged and adequate for the weight load / task / environment and in good condition?
Work load limit posted on equipment and attachments?
Work load limit, including configuration considerations, not exceeded?
Load movement may occur out of sight or with limited visibility? spotter / signaling person required
Loads lifted over persons, close proximity to obstacles incl. overhead power lines? --not permitted
Crane lift study and permit completed and communicated?
Is any excavation being performed or in close vicinity?
Utilities / telecom called to verify location if digging, open areas, trenches, or disturbed ground?
Approved sub-contractor completed risk assessment, implemented controls and communicated to employees affected?
Design excavation and controls reviewed and signed off on?
Excavation equipment inspected, in good condition, operator trained and current and appropriate for task?
Employees working in vicinity prevented from entering area?
Any scaffolds being built, standing or being removed?
Licensed engineer designed and licensed person erecting scaffold?
Scaffold Work Load Limit visible and not exceeded? (tools, stored materials, number of persons)
Safe and complete scaffold (certified)?
Inspection protocol for scaffold in place and implemented?
Incompatible scaffold components?
Work at height (incl. roof), elevated work platforms, electrical work, hot work, line breaking, cranes, excavation, or confined space entry taking place?
Fire extinguisher (fire blanket, fire watch)?
First Aid Kit and Attendant(s)?
Eye-wash station and/or safety shower?
Extraction equipment inspected, readily available, and rescuers competent?
Air monitoring devices?
Respirators readily available, appropriate, and competent person present?
Emergency rescue protocols understood and participants competent and current?
Alarm numbers available and displayed?
Communication devices readily available, functionality tested, communication protocol understood?
Permit conditions met and implemented?
Driving, Traffic and Interfaces with moving equipment
Are you driving for work, working alongside or near traffic, or moving heavy equipment with no physical separation (barriers)?
Current driver license, vehicle preventive maintenance completed, no known vehicle issues?
Driving required in adverse conditions (rain, hail, snow, high wind, high / low sun, dark, wildlife, high mountain roads, high congestion, after extended shift, winter conditions, remote areas)?
Congestion in / near work area or road construction with changing conditions?
Working around operating trains, public transit, ATVs, helicopters/planes, boats / bodies of water?
Traffic control plan in place and implemented?
Hand tools and equipment
Powered hand tools (electric, pneumatic) to be used?
Completed pre-use inspection of tool?
Unsafe or damaged tools or equipment? (including missing or damaged guards)
Appropriate tools and equipment for job? (e.g. grinding discs for cutting)
Safe and compatible attachments used with tools and equipment? -guards in place-
Hot Work, Line Breaking, Confined Spaces
Hot work will be performed or is performed nearby? -permit
Hot work permit completed and controls implemented?
Ignition sources eliminated or controlled?
Line breaking? hazardous materials, high temperature, high pressure --permit?
Line breaking permit completed and controls implemented?
Any confined space entry required?
Permit required confined space has completed permit and implemented controls?
Non-permit required: hazards have been identified, risks assessed and controls implemented?
Any awkward body position or tight spaces to perform work?
Any excessive reaching required?
Any prolonged bending or twisting?
Any manual handling of materials / awkward objects >10Kg (22lbs)?
Any kneeling, squatting or sitting on ground?
Any repetitive motion, especially in combination of excessive force?
Any work where hands / fingers not in line of sight?
Any work above head?
Any heavy or awkward lifting (>10Kg / 22lbs)?
Any high temperature and / or in combination with humidity? heat stress risk assessment?
Any cold temperature with potential for frostnip or frostbite?
Visibility related gear? specify high-visibility vest, arm/leg reflective bands, other?
Protection Against the Elements
Adverse weather clothing? specify: raingear, cold-weather gear, etc.
Hot or cold temperature kit/gear?
Are all applicable work authorizations / permits appropriately completed, controls implemented, posted and reviewed with our company and sub-contractor employees involved in or affected by the work activities? -complete prior to starting work-
Are you performing the work with another employee participating or affected by the work activities?
Have you reviewed and discussed all the hazards identified, risks and agreed upon the appropriateness of the controls associated with the work activity? -contact supervisor if disagreement on controls- speak up if you feel not quite right about the approach!
Do you have all the appropriate tools, equipment, PPE, and control methods available, put in place and effectively implemented? -if not, address the issues or call supervisor if need supplies or clarification-
Are (sub)-contractor employees participating in, affected by, or performing this work activity?
A signed and dated (1 year or less) safety declaration is available for each sub-contractor involved in the work activity? --obtain via supervisor if not available-
The sub-contractor employees involved in the work have completed training in our company work-related HSE procedures? -complete prior to starting work activity-
The sub-contractor employees have taken and fully implemented appropriate measures to control the risks for their and our company employees? -must be done prior to starting work-
Authorized Person: I have reviewed this FLRA and agree that it is a fair assessment of the job and I authorize this work to proceed.
Instructions: Step 1. Complete FLRA prior to starting task and/or prior to changes in the work environment, work activities, equipment/tools, and people. Review the FLRA with co-workers/sub-contractors involved in the work activity or affected by it. Step 2: Identify each hazard present as either:a) present and safe if LOW RISK defined as the probability is rare/unlikely/likely AND severity is negligible/minor (first aid), b) present and at risk if MEDIUM RISK defined as the probability is rare/ unlikely/ likely / highly likely / almost certain AND severity is serious (medical aid required/major/catastrophic), or c) Present and Unsafe: if HIGH RISK defined as the probability is almost certain and minor, serious, major or catastrophic).Step 3: For each hazard identified, two options 1) use the action button at the bottom of the screen to describe the control you will put in place using the hierarchy of controls, or 2) select the controls further down in the toolStep 4: AFTER CONTROLs ARE PUT IN PLACE: if any residual risks identified remain MEDIUM or HIGH: they MUST be reviewed with Supervisor PRIOR to starting work activity. This MUST be documented by text/email / verbal approval of supervisor.Step 5: Email the completed FLRA to your supervisor after completion of the work.
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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