Excavation Adjacent To Underground Assets Swms 10285-8

Business Name:
Business Address: ABN/NZBN:
EXCAVATION (ADJACENT TO UNDERGROUND ASSETS) SAFE WORK METHOD STATEMENT (SWMS)

Business Contact: Phone #: Principal Contractor (PC):
Responsible person (for monitoring SWMS and work): Job address:
Signature: Date: PC Phone #: Date SWMS provided to PC:
Contact Phone #: Contact Phone #:
THIS WORK ACTIVITY INVOLVES THE FOLLOWING HAZARDOUS WORK AND ENVIRONMENTAL IMPACTS
Electrical equipment Elevated levels Slips, trips and falls Hazardous substances Silica dust
Hot Work Hazardous manual tasks Outdoor work Remotely &/or isolated work ?
Noise and vibration Native vegetation & weeds Air quality Waste Vehicle movement
Fuels, oils & chemicals Terrestrial fauna Waterways & soils Cultural heritage ?
THIS WORK ACTIVITY INVOLVES THE FOLLOWING “HIGH-RISK CONSTRUCTION WORK” (HRCW - IDENTIFIED IN THE JOB TASK COLUMN)
Confined spaces Mobile plant movement Demolition of a load-bearing structure Asbestos disturbance
Using explosives Diving work Artificial extremes of temperature Tilt-up or pre-cast concrete
Pressurised gas distribution mains or piping chemical, fuel or refrigerant lines energised electrical installations or services
Structures or buildings involving structural alterations or repairs that require temporary support to prevent collapse
Involves a risk of a person falling from 2m or more, including work on telecommunications towers
Working at depths greater than 1.5 Metres, including tunnels or mines Work in an area that may have a contaminated or flammable atmosphere
Work carried out adjacent to a road, railway or shipping lane, traffic corridor In or near water or other liquid that involves the risk of drowning
FOOT HEARING HIGH HEAD EYE FACE HAND PROTECTIVE BREATHING SUN SAFETY Do not wear rings,
PROTECTION PROTECTION VISIBILITY PROTECTION PROTECTION PROTECTION PROTECTION CLOTHING PROTECTION PROTECTION HARNESS watches or
jewellery that may
become
entangled. Long
and loose hair
must be tied back.
DOCUMENT #: VERSION #: 1 DEVELOPED BY SIGNATURE: REVIEW #:

EXCAVATION ADJACENT TO UNDERGROUND ASSETS © SafetyCulture All Rights Reserved ISSUE DATE: REVISION DATE: Page 1 of 13
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 Liaise with Principal Contractor to identify on-site safety systems and procedures
Planning/Preparation  Establish supervisory and communication arrangements
 Principal contractor to confirm emergency response procedures are in place.
Hold Points  Hold points identified and signed off before continuing work. Specify?
 All workers to have a General Construction Induction Card
 Relevant workers have relevant certificates of competency, licenses, and training. Specify on the SWMS Sign-off for each worker.
Training/Licence
 Trained First Aider on site
 All workers trained in site-specific emergency and evacuation procedures, SWMS, safe work procedures, and safety data sheets.
 Fit condition for work, i.e. no signs of fatigue, alcohol or drugs
 Attend all site inductions/briefings
Worker duties and
 Comply with all site requirements, e.g. PPE, Traffic Management Plans (TMP)
responsibilities
 Only carry out work related to the contract
 Inspect completed work and report possible safety, environmental and quality matters to the supervisor.
 All persons involved in the task must have this SWMS communicated to them before work commences
 SWMS to be reviewed and amended if necessary, in consultation with relevant persons after any near miss or incident
 If additional site hazards identified, review this SWMS and amend control measures to suit
 People, including workers, contractors and sub-contractors, affected by the revisions to this SWMS, must be informed ASAP
Monitor/Review  Give the principal contractor a copy of the revised SWMS
 The site supervisor to monitor works against the controls stated in this SWMS
 SWMS must be kept on-site and made available for inspection or review
 Keep a record of this SWMS until the job is complete or for two years if involved in a notifiable incident
 Regardless of any other factor, the person in control of the workplace must review this SWMS at least annually.
Site-Specific Notes: Act, Regulations, Codes of Practice References:
Refer to your tax invoice for your free download.

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LIKELIHOOD INSIGNIFICANT MINOR MODERATE MAJOR CATASTROPHIC

SCORE ACTION
ALMOST CERTAIN 3 - HIGH 3 - HIGH 4 - ACUTE 4 - ACUTE 4 - ACUTE
LIKELY 2 - MODERATE 3 - HIGH 3 - HIGH 4 - ACUTE 4 - ACUTE 4A - ACUTE DO NOT PROCEED.
POSSIBLE 1 - LOW 2 - MODERATE 3 - HIGH 4 - ACUTE 4 - ACUTE 3H - HIGH Review before commencing work.
UNLIKELY 1 - LOW 1 - LOW 2 - MODERATE 3 - HIGH 4 - ACUTE 2M - MODERATE Maintain control measures.
RARE 1 - LOW 1 - LOW 2 - MODERATE 3 - HIGH 3 - HIGH 1L - LOW Record and monitor.
MOST LEAST
HIERARCHY OF CONTROLS EFFECTIVE EFFECTIVE
RESPONSIBLE
JOB TASK HAZARDS RISK CONTROL MEASURES PERSON
1. Provide Exposure to 3H  Training and information provided to workers on RCS should include: Supervisor
training on respirable o Information on the health effects associated with respirable crystalline silica dust (Provide
the health crystalline silica workers with a copy of ‘Health Monitoring for Exposure to Hazardous Chemicals - Guide for
effects (RCS) – dust workers’: Safe Work Australia)
associated inhalation o Identification of RCS dust through Safety Datasheet (SDS) or labels
with o Dust exposure prevention
respirable o Checking controls are working and using them
crystalline o When and how to use any respiratory protective equipment provided and what to do if
silica dust something goes wrong (Including worker respirator fit and check processes).
2. Planning - Contact with 4A  Location (roadside, residential, waterway.) Supervisor to
Assess underground  Route (length/depth) undertake all
intended utilities -  Soil type (seek geological surveys where required to ensure suitable excavation equipment – planning
excavation personal injury, clay/sand/rocks. processes
site property  Identify the presence of all underground, aboveground or overhead utilities or services at the
damage &/or proposed excavation site:
environmental o Dial Before You Dig (Telephone Service 1100) as a minimum
incident. o Site surveys
o Checks with all utility providers for the presence of services at the proposed excavation site
 If identified, ensure the location, clearance distances, alignments and other relevant information is
shown on utility drawings for the work:
o All details clearly marked on these documents
 If drawings are not available, or work is an unscheduled emergency or other unforeseen work,
identify indicators of underground services on site. Take note of:
o Poles supporting powered services/equipment
o Alignment markers
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RESPONSIBLE
o Pit overs
o Underground service signage
 Ensure contact details for all authorities responsible for the utilities at the site are listed and kept
on-site during operations
 Liaise with owners of the utility services to discuss precautions to be undertaken to avoid damage
and disruption of services.
o Maintenance hole/confined space entry requirements; ensure permit system in place if
applicable.
3. Working Extreme 3H  Check weather conditions – do not work in extreme conditions Supervisor to
outdoors weather  Reschedule works to work in more moderate temperatures. maintain
awareness of
Hyperthermia 3H  Ensure that workers trained to recognise the symptoms of hyperthermia and hypothermia weather
 Hot conditions. Ensure:  Cold conditions. Ensure: conditions
Hypothermia o Suitable protective clothing o Schedule warm-up breaks
o Sun brim on hard hats o Hold breaks inside Operator to
o Safety glasses - UV rated o Dress warmly in layers follow controls
o Use 30+ sunscreen on exposed o Stay dry (wet clothing chills the body rapidly)
skin o Workers must get out of the cold as soon as they
o Adequate drinking water can if starting to feel symptoms
o Access to shade on breaks o Alcohol, cigarettes, caffeine and certain
o Adequate breaks. medications increase susceptibility to cold.
4. Arrival on-site Personal injury, 3H  The vehicle should be positioned in a safe location, clear of traffic/vehicles/pedestrians during Supervisor to
& assess property equipment delivery and materials removal (deploy physical barriers, caution signs as necessary) check the site
onsite damage &/or  Do not park illegally and conduct
conditions environmental  Identify and obey all safety-related signage (check site entry requirements) JSA where
incident  Report to Site Supervisor necessary
 Ensure site-specific induction undertaken
 Assess mobile phone reception
 The worksite is exactly as detailed in Terms of Agreement or contract
 Complete a JSA specifying the control measures of unanticipated hazards.
5. Conduct a Lack of a clear 4A Risk Assessment Step 1 Supervisors
risk assessment  Identify all potential hazards identified at the excavation site. Hazard Assessments should and workers
assessment may lead to consider: ensure
personal injury, o Overhead electrical services controls
property followed
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RESPONSIBLE
damage &/or o Movement of traffic or powered mobile plant
environmental o Pedestrian access
incident. o Falls hazards
o Drainage and pits
o Exposures to essential services, i.e. fuel and refrigerant in pipes or lines, gas, electricity,
communications, sewerage, chemicals
o Exposure to hazardous chemicals
o Damage to adjacent or adjoining buildings
Risk Assessment Step 2
 Conduct a risk assessment and consider the likelihood of an incident occurring for each hazard,
and consequences of the incident.
Risk Assessment Step 3
 Use the most effective method to eliminate the risk. If this is not possible, then reduce (minimise)
the risk by working down the hierarchy of controls (Page 2). Using more than one of these
controls in combination is usually necessary. The selected controls must be:
o Fit for the purpose; and
o Suitable for the nature and duration of the work; and
o Installed, set up and used correctly; and
o Monitored for effectiveness.
If required by the risk assessment, arrangements should be made with the utility service
owners to disconnect or isolate the service before the commencement of any work that may
cause a transfer or release of energy.
If a risk assessment identifies that damage to any overhead or underground services is
possible and could result in an energy transfer or release, emergency response plans
prepared. The emergency response plans must cover:
 Evacuation of the site
 Protection of other persons in the vicinity
 Safety equipment and PPE (ensure equipment is in place before the excavation
work commences).
6. HRCW Unauthorised 3H  Erect secure impassable barricades with adequate signage: Supervisors
Work area access to the o Erected before the commencement of work to check all
set-up work area o Kept in position at all times until the work is completed and it is safe to remove controls in
o Regularly inspected and maintained place and
 Use lockout procedures to prevent unauthorised use of plant followed

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RESPONSIBLE
 Provide information to workers and other persons on-site advising them of the exclusion zones
 Delivery of goods, materials and equipment should only be made through the public areas during Workers to
off-peak periods follow controls
 Provide supervision so that no unauthorised person enters an exclusion zone. and make
Work adjacent 4A  Where setting up on a road or other public place an alternative footpath provided supervisor
to road & public  Where necessary, traffic control put in place to provide safe road use aware of any
safety  If setting up roadside – comply with local laws and permits issues
 Erect any barriers & signage necessary to keep others safe and aware
 A spotter should be used to assist drivers reversing in the dark, low clearance or high traffic areas
 If temporary road traffic control is required (e.g. parking on-road or pedestrian management):
o Approvals and permits are sought from the local council and/or state road transport
departments where necessary
o Only accredited traffic controllers are to perform traffic control duties
o All traffic control measures put in place implemented as per Australian Standard AS 1742.3–
2009: Manual of Uniform Traffic Control Devices, Part 3: Traffic Control for Works on Roads
(‘AS 1742.3-2009’) or other requirements as per permit conditions
o Traffic controllers must have the required accreditation to perform traffic control duties
o Traffic controllers must have sufficient experience to set-up and control traffic safely.
Contact with 4A  Ensure work not conducted in close proximity to electrical power lines. Check for:
electricity - o Overhead power lines (including high and low voltage distribution conductors
overhead o Single wire earth return (SWER)
services o Service cables to premises
o Communications cables
o Electrical transformers (mounted lower than cables).
 Identify the maximum range of equipment and how close equipment or load can come to an asset
(known as design envelope). The following dimensions are taken from the closest point of an
extended component of the machine
 In general: o 3m above, either side and below power lines is No Go Zone
o Between 3-6.4m of power lines, a Spotter is required
o Further than 6.4m of power lines is an open area
o No work to be conducted within a 10m radius of SWER transformer.
Spotter required where any part of the truck is within 6.4m of a power line.
7. Environment Environmental 3H  Noise & vibration - Be aware of maximum noise levels at the site Supervisors
impact  The plant is maintained to minimise noise to check all
 No noise produced outside council approved hours of operation controls in
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 Engineering controls fitted to equipment (e.g. silencers) place and
 Air quality - Water sprays or dust suppressants methods are in place followed
 Fuels, oils & chemicals - Minimum amounts of hazardous substances kept on site
 Labelled and securely stored Workers to
 Refuelling of vehicles/equipment undertaken at least 6m from drains and waterways follow controls
 Follow SDS directions for disposal of chemicals in approved waste containers and make
 A spill kit is available at all times & spills cleaned up immediately follow SDS directions supervisor
 Waterways & soils - Do not wash out plant, equipment or containers where residue can enter aware of any
waterways or drains issues
 Native vegetation & weeds - Ensure that plant is washed free of dirt, vegetation, debris before
travelling between sites.
 Vehicle movement - Follow the TMP, only travel on established tracks and roads
 Use designated entry and exit points.
8. House  Slips 3H  Maintain housekeeping throughout the shift & clean-up Supervisor
keeping  Trips  Ensure sufficient lighting to detect changes in level (using temporary lighting as required) and workers
 Falls  Do not jump from elevated edges >180mm, step carefully and use prepared access areas to ensure
 The work area is clean and uncluttered as possible control
 Do not place equipment where it could become a trip hazard measures
 Check for stored items, corners or other obstructions that could cause tripping followed
 Ensure there is room to manoeuvre and no obstacles in the way
 Check the end destination is prepared correctly for placement of the materials/equipment
 Clean spills immediately
 Footwear is suitable. Snug-fitting shoes/boots with flat, non-slip soles, no loose soles, long laces,
oily soles, or caked with mud or other contaminants.
9. Manual tasks Musculoskeletal 3H  Materials/equipment placed as close to the work area as possible Supervisor
(MSD) injuries  Weight of an object should be known; avoid lifting loads more than 1/4 of your body weight and workers
 Do not use extreme force to move items to ensure
 Hold lifted items close to the body whenever possible: control
o Keeping knees bent and back straight and lift, unload keeping knees bent measures
 Use team lifts and mechanical means for heavy items followed
 Schedule regular breaks and practice job rotation
 Avoid overreaching, long periods of repetitive movements, awkward and sustained positions,
twisting and side-bending.
10. Conduct a Contact with 4A  Consider the location of other services both vertically and horizontally Supervisors
site survey underground  Verify the actual position of utility services at the site: to check all

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RESPONSIBLE
assets  Carry out potholing with hand tools, shovels. (Insulated if working near electrical services) or with controls in
approved non-destructive means such as hydro-vacuum systems, e.g. hydro jet/vacuum place and
o Mark line of excavation and identify exact entry locations (using paints/colour-coding as followed
required)
 Note the actual location on working documentation if any variations noted from that specified in Workers to
the working documents follow controls
 Advise the utility service providers of actual locations of services when variations are detected, and make
or alterations made supervisor
aware of any
If using hydro excavation techniques (potholing) utilising own or hire equipment, refer to issues
Hydro excavation SWMS for controls
If using sub-contract Hydro Excavation company, ensure sub-contractor has safe work
methods in place or refer to Hydro excavation SWMS for controls.
Inappropriate / 3H  Conduct underground detection utilising appropriate detection equipment and use this to locate
malfunctioning utilities, where independently capable
equipment  Ensure correct equipment provided, e.g.:
o For metallic properties – use an electromagnetic locating device
o For non-metallic – use Ground Penetrating Device (GPD), mini cameras or sonar technology
o Ensure all equipment is serviced, calibrated as per manufacturer’s instructions and
functioning correctly
 Follow all operating and safety instructions supplied with the equipment
 Ensure that operators are skilled in the use of the equipment.
11. Check Hazardous 4A If work involves entering an identified Confined Space, refer to ‘Confined Spaces SWMS.’ Supervisors
maintenance atmospheres  Allow air to vent from pits when opening covers before commencing work to check all
hole/pit  Do not enter any pit controls in
safety  Note: A confined space is an enclosed or partially enclosed space that is likely to be a risk to place and
health and safety, when a person’s head or upper body is within the boundary of the confined followed
space, because of:
o An atmosphere that does not have a safe oxygen level, or Workers to
o Contaminants, including airborne gases, vapours and dust that may cause injury from fire or follow controls
explosion, or and make
o Harmful concentrations of any airborne contaminants supervisor
 Note: Do not enter any maintenance hole/pit in which a person’s head or upper body within the aware of any
space without ensuring a confined space entry permit issues
If a person has entered or fallen into a maintenance hole, DO NOT ENTER THE
MANHOLE TO ATTEMPT A RESCUE. Contact the appropriate emergency personnel and
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RESPONSIBLE
the appropriate supervisor immediately if the person cannot be retrieved without
entering.
 Struck by 4A  Follow traffic management plan requirements
mobile plant  Lift pit/maintenance hole cover with a crane as required. When having to lift a pit/maintenance
hole cover using a crane. Check constantly for changing hazards while working and monitor work
 Crush injuries position at all times. Ensure:
 Amputation o Do not stand behind reversing vehicles
 Entanglement o Allow sufficient distance from plant during operation (allow sufficient room for equipment
 Fatality failures – such as arm/boom failure or plant rollover)
o No work conducted in established "no-go zones" for pedestrians
o Alertness at all times. Listen for reversing alarms/beepers and calls from Plant Operators
o Safety/warning signs, Spotters, traffic barriers, must be obeyed as required
o Work positions should be in clear sight of plant operators
 All ground workers must wear a hard hat and high vis clothing.
Crush Injuries 3H  Never place your hand in the opening to grasp a cover. Get help and use a tool
 Use blocks/shims where appropriate to avoid crushing
 Wear gloves and steel-cap boots for protection.
Musculoskeletal 3H  Pit/maintenance hole lid lift – lid may be jammed due to an accumulation of material or damage:
(MSD) injuries o Be aware of sudden unexpected movement if cover dislodging from the lid
o Do not use excessive force
o Use appropriate tool for cover removal or use mechanical means to assist in a lift of heavy
lids.
Snake/spider 3H  Be aware of surroundings - snakes and spiders can be found anywhere
bite  Never put your hands or feet somewhere where you can’t see them
 Check all drain covers after removal.
12. HRCW  Powered 3H Refer to applicable Plant SWMS, e.g. Excavator or other, for controls Supervisors
Excavation & mobile plant Refer to Working in Excavation SWMS for controls relating to the actual excavation work to check all
contact with movement including battering and shoring, emergency response, falls, hazardous atmospheres and controls in
assets  Engulfment working near machinery. place and
followed
Contact with 4A  Where mechanical excavation is undertaken in the vicinity of underground assets ensure:
assets o Prevent damage to the cables Workers to
o All persons are kept well clear of the excavator while it is operating follow controls

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RESPONSIBLE
 Service infrastructure is not to be used as hand or footholds when climbing into or out of and make
excavations supervisor
 Use correct backfilling methods to maintain the structural integrity of the system aware of any
 If underground service is accidentally uncovered, displaced or struck during the excavation, all issues
work in the direct area is to stop immediately
 The incident should be reported immediately to the asset manager (if there is any risk of energy
release from the damage, a request made to isolate the service in that area)
 Ensure a risk assessment retaken after any incident before work commencing.
Contact with 4A  Electrical cables ensure:
electricity/ o Treat all cables as ‘live’, until proven otherwise
communication o Maintain a careful watch for evidence of further cables. Use location devices to determine
cabling precisely the position of any additional cables
 Support all cables exposed for greater than 1 metre using non-conductive supports
In the case of machine contact with electrical cables:
1. Try to break the mobile plant’s contact with the line by moving the mobile plant clear only if safe
to do so
2. If moving not possible, they should remain inside the cabin. (If it is essential to leave the cab
due to fire or other reasons, jump clear of the equipment)
3. If essential to leave, do not touch the equipment and ground at the same time if jumping clear.
When moving away from the equipment, the operator should hop slowly, shuffle or jump away
from the plant (with feet together). Do not run
4. If the operator falls to the ground, ensure they roll clear. They should not try to get up by
pushing off with their hands as the electricity may pass through the arms and legs in contact
with the ground
5. Warn all other personnel/public to keep 8 -10 m clear from equipment. Do not touch any part of
the equipment or victim(s) and do not attempt to approach or re-enter the vehicle.
6. Call for emergency assistance on 000 at the earliest opportunity
7. Begin First Aid treatment if the operator is clear of the area (Do not place yourself in danger)
8. Initiate the company emergency management plan
9. Await confirmation by the power company that the power is turned off before commencing any
recovery of persons’ plant or equipment.

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RESPONSIBLE
Contact with 4A  Do not remove any thrust blocks or other supports on junction bends or other areas without
water pipes and providing alternative support
sewerage mains  Ensure pumping equipment is on standby in case of a breach.
Contact with gas 4A  Do not use mechanical excavation within one metre of gas lines
lines  No naked flame or other hot works conducted without a hot work permit in place (check with asset
owner regarding procedures)
 No hard material blocks, e.g. concrete is placed against the lines when backfilling
 Any damage to the line or support infrastructure, including coverings, must be reported to the
asset owner.
If a gas leak is detected or suspected do not attempt to repair the leak:
1. Remove everyone from the vicinity of the leak
2. Notify emergency services immediately
3. Notify members of the public in adjacent buildings and locations and advise to leave the area
4. Ensure all naked flames or sources of ignition extinguished or removed.
13. Emergency  Injury 4A  For police, fire or ambulance call ‘000.’  Refer to your SWMS Supervisors
response  Fatality  Follow site emergency and evacuation procedures implementing and workers
 Environmenta  A communication system is available, e.g. a mobile phone or radio instructions for further ensure
l damage  Check for dangers to self before helping others specific emergency controls
 Maintain control of the area and stabilise the situation responses. followed
 Apply first aid to the injured worker
 Complete an incident report.
OVERALL RISK RATING AFTER CONTROLS 1 - LOW 2 - MODERATE 3 - HIGH 4 - ACUTE
PERMITS Not applicable Hot Work Confined Space Local council ? ?

If yes – This SWMS must align with requirements of the Site
SITE MANAGEMENT PLAN Is the work associated with a Construction Project? Yes No Management Plan in place for the Construction Project.
PLANT & EQUIPMENT HAZARDOUS SUBSTANCES SUPERVISORY ARRANGEMENTS
Electrical tools and leads Tested and tagged quarterly List hazardous substances taken on-site Audits
and have the SDS on-site.
Hand tools - Meet AS/NZS Regular visual inspection 1. Spot Checks
Ladders - Meet AS/NZS Inspected and tagged out if damaged 2.

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Mobile plant-specify Inspected and tagged out if damaged 3. Reporting systems

4.
? 5. Suitably qualified supervisors for job
? 6. Direct on-site supervision
7.
? 8. Remote site: communication
9. systems/schedule
?
10.
This SWMS developed in consultation and cooperation with workers and relevant organisation representatives. I have read the above SWMS, and
SWMS SIGN-OFF I understand its contents. I confirm that I have the skills and training, including relevant certification, to conduct the task as described.
I agree to comply with safety requirements within this SWMS, including risk control measures, safe work instructions, and PPE described.
JOB ROLE / POSITION LICENCES, COMPETENCIES & QUALIFICATIONS (add as applicable)
WORKERS’ NAME DATE SIGNATURE
E.G. SUPERVISOR, WORKER, TRAINEE TYPE / DESCRIPTION CLASS NUMBER
Construction Card
Construction Card
Construction Card
Construction Card
Construction Card
Construction Card
Construction Card
Construction Card
Construction Card
Construction Card
Business Name:
This SWMS developed in consultation and cooperation with workers and relevant organisation representatives. I have read the above SWMS, and
SWMS SIGN-OFF I understand its contents. I confirm that I have the skills and training, including relevant certification, to conduct the task as described.
I agree to comply with safety requirements within this SWMS, including risk control measures, safe work instructions, and PPE described.
JOB ROLE / POSITION LICENCES, COMPETENCIES & QUALIFICATIONS (add as applicable)
WORKERS’ NAME DATE SIGNATURE
E.G. SUPERVISOR, WORKER, TRAINEE TYPE / DESCRIPTION CLASS NUMBER
Construction Card
Construction Card


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Business Address: ABN/NZBN:

EXCAVATION (ADJACENT TO UNDERGROUND ASSETS) SAFE WORK METHOD STATEMENT (SWMS)

DOCUMENT #: VERSION #: 1 DEVELOPED BY SIGNATURE: REVIEW #:

Business Address: ABN/NZBN:

DOCUMENT #: VERSION #: 1 DEVELOPED BY SIGNATURE: REVIEW #:

Business Address: ABN/NZBN:

LIKELIHOOD INSIGNIFICANT MINOR MODERATE MAJOR CATASTROPHIC

Business Address: ABN/NZBN:

Business Address: ABN/NZBN:

DOCUMENT #: VERSION #: 1 DEVELOPED BY SIGNATURE: REVIEW #:

Business Address: ABN/NZBN:

Business Address: ABN/NZBN:

DOCUMENT #: VERSION #: 1 DEVELOPED BY SIGNATURE: REVIEW #:

Business Address: ABN/NZBN:

Business Address: ABN/NZBN:

DOCUMENT #: VERSION #: 1 DEVELOPED BY SIGNATURE: REVIEW #:

Business Address: ABN/NZBN:

DOCUMENT #: VERSION #: 1 DEVELOPED BY SIGNATURE: REVIEW #:

Business Address: ABN/NZBN:

PERMITS Not applicable Hot Work Confined Space Local council ? ?

DOCUMENT #: VERSION #: 1 DEVELOPED BY SIGNATURE: REVIEW #:

Business Address: ABN/NZBN:

Mobile plant-specify Inspected and tagged out if damaged 3. Reporting systems

Business Address: ABN/NZBN:

DOCUMENT #: VERSION #: 1 DEVELOPED BY SIGNATURE: REVIEW #:

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