GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.

DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT

Document No:045 Revision No: 00 Date:23.11.2010

DAILY EXCAVATION CHECKLIST

Location: From (km) To(km)
Subcontactor: Time/Date to be done:

No Items to be checked Yes No Comments

1 Is Excavation work permit exist ?

2 Tool box talks completed commercing the job?/ records
3 Is Excavator machine checklist completed?
4 Excation to be done proper slope according to soil type
Operation is suitable to risk assessment
5 /JSA/Method Statement
6 Oxygen level in acceptable scale in trench?
Are testing and controls used to prevent exposure to
7 hazardous atmospheres

Are excavation or other materials kept at least two feet (60

8 cm) from the edge of excavations?
Are emergency evacuation plans and procedures developed
9 and made?
10 Any water in trench?
11 Dewatering system if there is water in the trench
12 Is Physical barrication around excavation area exist?

In the trench more than 1.20 cm has ladder for

13 access/egress placed properly?
14 Is Flagman exist for excavation operation?
15 Cave in/ Demolition in trench or slope
16 Is Proper sign placed to warn people?
17 Overhead connection throught excavation road
18 Is there enough bridge placed to Public enrterance?
19 Any violator for smoking in trench?
Proper Watering at site to prevent from
20 dust/ registration form
21 PPE for all workers (will include dust mask)
22 Housekeeping
23 Other
This form will be submit daily basis to HSE office whether there is any condition which is unsafe will be notify related
party to take necessary action immediately

Name & Surname of Inspector :

Position:

Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No: 046 Revision No: 00 Date: 23.11.2010

DAILY HOT WORK CHECKLIST

Location: From (km) To(km)
Subcontactor: Date/Time :
No Items to be checked Yes No Comments

1 Is Hot Work Permit exist ?

2 Tool box talks completed commercing the job?/ records
3 Hot work equipment check
4 Fumes/by products prevented from traveling to other areas
5 Guards/Barricades placed
Is Operation suitable to risk assessment
6 /JSA/Method Statement?
7 Adequate and sufficient Fire extinguisher

8 Is Safety officer exist to working area?

9 Are emergency evacuation plans and procedures developed and made?

10 Is Oxygen level detected if operation in confined space?
Keep combustible material away working area from 11 m
11 (no oil;grease ; paint;tinner etc)
12 Is Cable management satisfactory?/cable conditions
13 Is Ventilation exist (If applicable)?
14 Combustible gases checked ?If it is in confined space
15 Housekeeping
GRINDER MACHINE
1 Properly guarded/ color coded
2 Cable conditions
3 Proper disc usage
GAS CYLINDERS
1 Gas cylinder conditions/ color coding/ connections/hoses
2 Regulators compatible with gas cylinder
3 Gauges/ Hoses conditions
4 Cylinders secured from tipping while in use
5 Cylinders have double flash back arrester
6 Cylinders are keep away ignition source
7 Cylinders are keeping under shadow? No direct sunlight

8 Is hose conditions of cylinders proper?

9 PPE(welding shield, ladder apron,glovers,face shield)

10 Other

This form will be submit daily basis to HSE office whether there is any condition which is unsafe will be notify related party to take
necessary action immediately

Name & Surname of Inspector :

Position:

Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No: 047 Revision No: 00 Date:23.11.2010

DAILY LIFTING-HOISTING/LOWERING CHECKLIST

Location: From (km)
Subcontactor: Time/Date to be done:
No Items to be checked Yes No Comments

1 Is a lifting operation plan exist?

2 Are risk assessment and JSA/JHA are exist in lifting plan?
3 Tool box talks completed commercing the job?/ records
4 Is Mobile Crane/Side boom DAILY checklist completed?
5 Are lifting gears certified?
6 Is Operation running according to Risk assessment-JSA ?
Is an appointed Person in charge (PIC) of lifting operation available ?
7
8 Is Riggerman available?
9 Is Lifting area barricated properly to prevent unauthorised entry?
10 Are warning signs located in proper number and place?
Is there any concurrent or similtaneous operation that
9 may affect or be affected by lift?
Is there any specific lifting equipment/gear usage?
10 If yes is it certified?

Is there any overhead connection around lifting area?

If yes Are crews aware it and is it mentioned in lifting
11 plan ?
12 Is Emergency escape route exist?
13 PPE for all workers
14 Housekeeping
15 Other
This form will be submit daily basis to HSE office whether there is any condition which is unsafe will be notify
related party to take necessary action immediately

Name & Surname of Inspector :

Position:

Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM
PROJECT

Document No: 048 Revision No: 00 Date: 23.11.2010

LIFTING PLAN
Exact Location

Lift category Routine Non-Routine

Weight of load
Lifting equipment&accessories to be used (Specify type,SWL and colour code)

Document attached
Diagram/sketch of lifting operation
Method Statement
Conditions to be observed
Culturel,communication and language differences
Environmental conditions (etc .weather cond. Wind)
Weight,size,shape and center of gravity of load
Lighting in the pick up and lay down on areas
Available of approved lifting point
Proximity hazards,obstruction,path of load
Method of slinging
Attaching Detaching
Working under suspended loads
Risk assessment
JSA/JHA
Access and emergency escape routes
Suitability and condition of lifting equipment to be used
Initial and final load positions and how it will get there
Number of the personnel required for task
Over head connection
Daily checklist completed by operator
Visibilty of load
Conflict task in area
Overturning of load/load integrity/need for tag line

Task Detail (Step by step)

Method(s) of communication to be used Radio Verbal Hand Signal

Step to be taken to eliminate danger to personnel involved others (including barriers where appropriate)

Debrief and learning points:

Prepared by: Signature Date

Reviewed by: Signature Date

Approved by: Signature Date

 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No: 049 Revision No: 00 Date: 23.11.2010

DAILY CONFINED SPACE CHECKLIST

Location: From (km) To(km)
Subcontactor: Date/Time :

No Items to be checked Yes No Comments

1 Is Confined Space Work Permit exist ?

2 Tool box talks completed commercing the job?/ records
Is job carrying out according to R.A.-JSA- MSDS-Method
3 Statement
4 Athmosphere is tested?
5 O2 level is acceptable?
6 Is watchman available?
7 Is Access/Egreess suitable?
Is there any flammable material exist or to be produced by
8 process?

9 Is Emergency vehicle exist?

Are emergency evacuation plans and procedures developed
10 and made?
If flammable material or gas exist adequate fire
11 extinguisher is available?

12 If there is harmful gas or fume adequate ventilation exist?

13 Is there enough action to prevent from extreme heat ?
Mechanical and electrical isolation completed prior the usage
14 of equipment in confined space?
15 Is there regular breaks for Employees who are working in C.S,
16 Illumination is enough?
17 Is gas purging necessary ?if necessary is it applying?
Is there appropriate communication with employees
18 who are working in Confined Space
19 PPE-If necessary RPE
20 Housekeeping
21 Other

This form will be submit daily basis to HSE office whether there is any condition which is unsafe will be notify related
party to take necessary action immediately

Name & Surname of Inspector :

Position:

Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No: 050 Revision No: 00 Date: 23.11.2010

DAILY RADIATIOGRAPHY ACTIVITY CHECKLIST

Location: From (km) To(km)
Subcontactor: Date/Time :

No Items to be checked Yes No Comments

1 Is Radiation Work Permit exist ?

2 Tool box talks completed commercing the job?/ records
Is job carrying out according to R.A.-JSA- Method
3 Statement?
4 Is Radiation safety officer exist?
5 Is safe distance calculated?
Is barication according to safe distance/
6 exposure time calculation?
7 Is portable shielding available?
8 Is Usage of dosimeter exist and under the record?
9 Warning sign conditions
Is Transportation of licienced sealed source and Radiactive
exposure device comply with procudure and Method
10 statement?
11 Is there necessary warning sign on transpotation vehicle ?
12 Emergency plan

13 Personal dose rate under record

14 Sealed source base under record
15 Sealed source site record
16 Are Emergency equipments at site?
Is thickness of shielded is proper? See radiography procedure
17 attachment C
18 Is survey meter available to check dose rate at barrier?
19 Other
This form will be submit daily basis to HSE office whether there is any condition which is unsafe will be notify related
party to take necessary action immediately

Name & Surname of Inspector :

Position:

Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No: 051 Revision No: 00 Date:23.11.2010

CONCRETE MIX & POURING OPERATION CHECKLIST

Location:
Subcontactor: Date/Time :

No Items to be checked Yes No Comments

PRE-OPERATIONAL PART
1 Toolbox talk is completed
2 Placement of truck is established
3 Accessibility of pump truck adequate
4 Accessibility of concrete truck adequate
5 Enough ground support for pump truck and concrete truck
6 Overhead structures or trees
7 Maintain minimum 10 (3m)ft distance from power lines
8 Work area clear
9 Clean out area established
Pre Operational -PUMP TRUCK
1 Hose connection
2 Controls clearly marked
3 Location of emergency shut off
4 Outrigger conditions of Pump truck
OPERATIONAL PART
1 Is there any man who appointed as a signalman

Is there adequate communication system between

2 operator and signalman
3 PPE (esp.: glovers , rubber boots,long sleeve shirt)
4 Are all trench excavats properly stepped, slopped or shored
5 Are ladders properly tied off & stairs secured
6 First aid kit is available
7 Emergency contact list is available
8 Emergency plan
9 Is fresh water available for concrete removal from skin
10 Is there traffical management at site for
This form will be submit to HSE office WHENEVER OPERATION IS EXIST ,whether there is any condition which
is unsafe will be notify related party to take necessary action immediately

Name & Surname of Inspector :

Position:

Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No: 052 Revision No: 00 Date: 23.11.2010

NIGHT WORK CHECKLIST‫جـدوـلاـلتأكد مناـلعملاـلليلي‬

Location:
Subcontactor: Time/Date to be done:
No Items to be checked Yes No ‫البنود التي يجب التاكد منها‬

1 PTW ‫هل يوجد تصريح للعمل لليلي‬

2 Toolbox talks ‫هل تم التحدث للعمال عن االعمال الليلية‬

3 Risk Assessment for night work ‫هل تم تحديد مخاطر العمل الليلي‬

4 Risk Assessment for activity ‫هل تم تحديد مخاطر الفعاليات الليلية‬

5 Is First aid kit available? ‫هل يوجد عدة اسعافات اولية‬

6 Is First aider available? ‫هل يوجد مسعف في الليل‬

7 Is Emergency plan exist? ‫هل توجد خطة للالسعافات‬

8 Is Emergency vehicle exist? ‫هل يوجد سيارة في حالة الطوارئ‬

‫هل يوجد الئحة باسماء االشخاص للالتصال بهم في‬
9 Is Emergency contact list exist? ‫حالة الطوارئ‬

10 Lighting/ILLUMINATION of emergency escape roads ‫اضاءة الشوارع المخصصة لحاالت الطوارئ‬

11 Isolation hazardous areas ‫منطقة المواد الخطرة معزولة‬

12 Traffic management at site ‫ادارة السير في الموقع موجودة‬

13 Food support prior to work ‫االكل في الليل تم تأمينة‬

14 Is Drinking water available? ‫مياة للشرب موجودة‬

Communication dayshift regarding equipment
and workplace hazards ‫تم التخاطب مع فرق العمل النهارية بخصوص‬
(update if any changing is exist)
15 ‫مخاطر العمل الليلي‬

16 Periodical breaks ‫سوف يعطى العمال فترات راحة‬

17 Proper reflective warning signs at site ‫يوجد لوائح عاكسة في الموقع‬

18 Is there any employee who has any health problem? ‫هل يوجد أي عامل لدية مشاكل صحية‬
19 PPE ‫هل الجميع لديهم ادوات الحماية الشخصية‬
20 Others
This form will be submit daily basis to HSE office whether there is any condition which is unsafe will be notify related
party to take necessary action immediately

Name of Operator :

Position:

Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No: 053 Revision No: 00 Date: 23.11.2010

DAILY TOWER CRANE CHECKLIST

Location:
Subcontactor: Time/Date to be done:
No Items to be checked Yes No Comments
Foundation bolts/anchors
Main power disconnect switch
PRELIMINARY

Hook sheaves/swilvel
Power contact grounding
Support guys/anchors
Riggerman
Ladders/Platforms
Section conncting bolts/pins
Safety rails/chains
Tie-in assembly(s)
Chord and lacing welds
Power cable
TOWER

Hydraulic hoses for leaks

Gear boxes for oil level/leaks
Slewing ring bolts
Counterweights secure
Motor/winch hold-down bolts
Wire rope condition
Hoist drum spooling
Control function
Swing break
Moment overloads
CRANE OPERATION

Hoist overloads
Trolley cable/brake
Sheaves
Gear limits
Trolley limits
Luffing limits
Hoist limits
Proximity to power lines
Fire extinguisher
Load chart
CAB

Window glass
Operation manual
Others

This form will be submit daily basis to HSE office whether there is any condition which is unsafe will be notify related
party to take necessary action immediately

Name of Operator :

Position:
Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No: 054 Revision No: 00 Date:

DAILY SCAFFOLDING CHECKLIST‫جـدوـلاـلتأكد مناعماـلاـلسقـائـل‬

Location: MADABA BRIDGE STATION
Subcontactor: MADANAT CONTACTING CO Date/Time‫ اـلتاريخ واـلزمـن‬:

No Items to be checked Yes No ‫االعمال التي يجب التأكد منها‬

‫نعم‬ ‫ال‬
PRE-OPERATIONAL PART ‫اعمال يجب التاكد منها قبل التشغيل‬
1 All parts of scaffolding are free from corrosion ‫جميع قطع السقايل خالية من الصدأ‬
2 All members are straight. ‫جميع القطع مستقيمة‬
3 Welds are not damaged. ‫اللحامات غير معطوبة‬
4 Locking devices on frames and braces are in good working
order. ً ‫قطع التثبيت تعمل جيدا‬
5 Coupling pins effectively align the frame or panel legs. ‫براغي التثبيت تعمل على استقامة االرجل والقوائم‬
6 Pivoted cross braces have the center pivot securely in place. ‫المرابط العرضية مثبتة‬
7 Caster brakes are in good working order. ‫الكوابح تعمل جيدا‬
8 Base plate ‫يوجد قطع ارضية‬
9 Planking is scaffold grade and cleated. ‫الخشب المستعمل جيد‬
10 Leveling/compaction of ground previous installation of
scaffolding ‫االرضية التي يثبت عليها السقائل ذات سطح مستوي‬
11 Have competent persons been in charge of erection? ‫عمال مهرة مدربة تقوم بالتركيب‬
12 Training for erection/dismantling team ‫تدريب الطواقم على اعمال الفك والتركيب‬
AFTER ERECTION AND PRIOR TO OCCUPANCY ‫اعمال يجب التاأكد منها بعد التركيب وقبل االستعمال‬

1 There is proper support under every leg for the ground

conditions. The supports will not washout if rain occurs. ‫يوجد تثبيت جيد تحت كل رجل‬

All base plates or adjustment screws are in firm contact with

2
their supports. All adjustment nuts are snug against the legs of
the frame. ‫جميع البراغي والصواميل مشدودة‬
3 Sections fit tightly together ‫جميع القطع تركب بسهولة‬
4 Frames are properly braced. ‫جميع التجميعات لديها مرابط عرضية‬
5 All locking devices are properly locked. ‫جميع المرابط محكمة‬
6 Planking and all accessories are properly installed. ‫خشب واالكسوارت الالزمة للتثبيت موجودة‬
8 Anchors are secured between the structure and the
scaffolding. ‫الموابط بين السقائل والمبنى مثبت باحكام‬
9 Access/Egress ‫الدخول والخروج‬
10 Platform conditions ‫حالة الممرات‬
11 Toe board ‫قاطع سفلى على مستوى القدم‬
12 Knee rail ‫دربزين على مستوى الركبة‬
13 Hand rail ‫دربزين لليد‬
14 Scaff-tag available ‫يوجد قارمة لبيان فحص السقائل‬
15 Training for employee ‫تدريب العمال‬
16 Excavation around scaffolding area ‫حفريات حول السقائل‬
This form will be submit to HSE office WHENEVER OPERATION IS EXIST ,whether there is any condition which is unsafe will
be notify related party to take necessary action immediately
Name & Surname of Inspector :
‫اسم المفتش‬

Position:
‫الموقع الوظيفي‬
Signature:
‫التوقيع‬
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT

Document No: 055 Revision No: 00 Date: 23.11.2010

WEEKLY STRUCTURE- SAFETY CHECKLIST

Location:
Subcontactor: Date/Time :
No Items to be checked Yes No No Items to be checked Yes No
1
PTW 26 Acess/Egress

2
Toolbox talks/Induction / Training 27 Barricade

3
Daily Excavation checklist 28 Assembly point

4
Daily Concrete mix & pouring checklist 29 Hand tools

5
Daily Hot work checklist 30 Excavation slopes

6
Daily Confined space checklist 31 Oil leakage at site

7
Daily Heavy equipment checklist 32 Oil spill kit

8
Daily Scaffolding checklist 33 Ladder conditions

9 34 Taking precaution according to MSDS

Daily Lifting/Lowering checklist while Chemicals are using
10
Daily Working at height checklist 35 Nails at site

11 36 Fire extinguisher is available /

Daily Dust control registiration inspection
12
OHSE documents are availble 37 Illumination

13
Toilet/Changing room/rest room 38 Housekeeping

14
Proper ladder usage 39 Accident/Incident reports

15
Waste management/ its registration 40 Warning signs/arrows

16
Traffic management 41 Risk Assessment related work scope

17
ERP (Emergency Response Plan) 42 PPE

18
Emergency contact list 43 Site security is exist

19
First aider / Nurse 44 Visitors records are keeping

20
First aid kit 45 Visitor instruction is available

21
Emergency Car 46 Drinking water is available at site

22
Designated Material Storage area 47 Generator conditions

Chemical storage(Container, Labelling,

23 temprature control, warning sign, MSDS , 48 Refuelling of heavy equipment is
etc) appropiate/ Condition of diesel tank
24
Electrical cable management 49 Toilet cleaning registiration

25 50 Sewage water registiration

/ Water tank comsumption
Electrical connections/earthing/conducts registiration / First aid kit checklist

Yes :+2
N/A : Not Applicable : 0 Total Mark:
No: 0

Name & Surname of Inspector:

Position:

Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No:056 Revision No: 00 Date:23.11.2010

DAILY SAND BLASTING COATING/LINING CHECKLIST

Location: From (km)
Subcontactor: Time/Date to be done:

No Items to be checked Yes No Comments

1 Tool box talks completed commercing the job?/ records

WORK is executing according to risk assessment
2 /JSA/Method Statement
Is MSDS available in workplace and work comply with
3 MSDS
4 Storage materail comply with MSDS
5 Is Adequate fire extinguisher available
6 Proper warning signs are exist in workplace
7 Is confined space checklist is filled(if applicable)
1 Pressure relief valves operational
AIR COMPRESSOR

2 Air pressure gauges

3 Hoses & connections
4 Coupling safety wired
5 General conditions

6 Other

1 Operator's hood (Air supplied)

2 Air filters (to hood)
3 Air intake location
SAND BLASTING

4 Dead mans controls

5 Hoses property grounded
6 Operator protective cloting
7 Helper's protective clothing
8 Baaricade /warning signs
9 others

This form will be submit daily basis to HSE office whether there is any condition which is unsafe will be
notify related party to take necessary action immediately

Name & Surname of Inspector :

Position:
Signature:
 GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.
DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT
Document No:057 Revision No: 00 Date:23.11.2010

DAILY WORKING AT HEIGHT CHECKLIST

Location: From (km) To(km)
Subcontactor: Time/Date to be done:
No Items to be checked Yes No Comments
1 Tool box talks completed commercing the job?/ records

Every open side or opening into or throughtwhich

2 person may fall down is covered or guarded by an effective
barrier to prevent person

3 Every open side of staircase is provided by hand rail

and knee rail
Safety harness /Life line
Safety harness made available or supplied to
1 any person for his personal protection
2 Anchorage for safety harness is available
3 If number 2 is not available, life line should be available
4 Anchor point is higher than working position

5 Every employee aware of proper usage of safety harness

6 Pre-usage inspection is done for safety harness/life line

This form will be submit daily basis to HSE office whether there is any condition which is unsafe will be notify
related party to take necessary action immediately

Name & Surname of Inspector :

Position:

Signature: