Pre-Task Safety Analysis (Word Document)

PRE-TASK SAFETY ANALYSIS

Supervisor: _____________________Company Name: _________________________ Date: __________________ Location of Task: _______________________________________________________________________________ Task Activity-List Basic Job Steps: __________________________________________________________________

Potential Hazards:

A- Electrocution/Shock Hazard H- Hot Surfaces

O- Excavations

V- Chemicals (SDS Review)

B- Falls From Heights

I- Pinch Points

P- Lead Exposure

W- Lifting (Manual/Mech.)

C- Overhead Work/Loads

J- Flying Particles

Q- Silica Exposure

X- Environmental (Hot/Cold)

D- Poor Lighting

K- Vehicle Traffic

R- Asbestos Exposure

Y- Compressed Air

E-Rough/Sharp Materials

L- Impalement

S- Poor Work Position

Z- Other:

F- Slippery Surfaces

M- Toxic Atmosphere

T- High Noise Area

G- Rotating Equipment

N- Welding Arc/Flash

U- Flammable Materials

(Enter Letter of Potential Hazard and Corrective Action for Each)

Letter

Corrective Action

PPE NEEDED

Safety Glasses W/Side Shields Hard Hats Face Shield Proper Work Gloves Hearing Protection Rubber Boots Chemical Suits

Full Body Harness / Lanyard

Foot Guards Sleeves for Hot Work Respiratory Protection Electrical Flash Gear Eye Wash Located

Safety Shower Located

WORK PLATFORMS

Scaffolds Inspected

Ladder Secured/ Inspected Boom Lift Inspected Scissor Lift Inspected

Safety Checklist

*Check all items required for your task*

REQ

PERMITS REQUIRED

REQ

FIRE PROTECTION

Confined Space Permit Hot Work Permit Line Breaking Permit Excavation Permit Roof Work Permit Critical Lift Checklist Railroad/Blue Flag

BARRICADES/COVERS

Yellow (Caution) Tape Red (Danger) Tape Hard Barricades Required Hole Covers Required Flashing Lights Required

HOUSEKEEPING

Cords/Leads Elevated

Walk Ways Clear

Trash/Scrap Secured Work Area Kept Clean

Tools are Secured

Welding Shields in Place Flammables Removed Fire Blankets Needed Fire Extinguishers Inspected Fire Watch Posted Sparks Contained

ENERGIZED EQUIPMENT

Lockout/Tag out Required

Electrical Tools Inspected Power Tool Guards in Place GFCI Required High Voltage Lines Identified

EQUIPMENT

Rigging Equipment Inspected

Mobile Crane Inspected

Overhead Cranes Inspected

Boom Trucks Inspected Fork Truck / Forklifts Inspected

Operators are Certified

REQ

Specific Remarks to Crew

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

*All crew members must sign in and out on the back of this form daily*

Crew Sign-In Before Work Shift Begins

I understand the safety precautions and have the training necessary to perform this task incident free

NAME

1

TIME

9

NAME

2

10

3

11

4

12

5

13

6

14

7

15

8

16

Crew Sign-Out After Shift

I have worked safely today and have not been injured

TIME

NAME

1

TIME

9

NAME

2

10

3

11

4

12

5

13

6

14

7

15

8

16

Post Task Follow Up

TIME

Y/N/NA

Y/N/NA

Y/N/NA

Locks Removed

Rail/Railway Clear

Injuries/Near Misses Reported

Barricades Removed

Equipment/Material Secured

Fire Watch Posted for 30 Min.

Barricades Erected

Gas Bottles Secured

Air Monitor Returned to Safety

Open Holes Secured

Work Area Clean

Employees Signed Out

*All injuries and near misses must be reported to the supervisor or safety director the day that they happen*

Signature of Supervisor: _________________________________________________________

*Describe all Reported Injuries Below*

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Signature of Injured Employee(s): _________________________________ Date: ___________

Additional Crew Sign-In Before Work Shift Begins (If Needed)

NAME

17

TIME

24

NAME

TIME

18

25

19

26

20

27

21

28

22

29

23

30

Additional Crew Sign-Out After Shift (If Needed)

NAME

17 18 19 20 21 22 23

TIME

24 25 26 27 28 29 30

NAME

TIME

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