Contractor Name: SAFE PLAN OF ACTION 08A WMI-SPA-JSA Form.pdf PROJECT NO.

___________

Job/Task: Work Area: Date:

The following Tasks will include the “OSHA Big Four”: ✔ Falls/Elevated Work, ✔ Struck By, ✔ Caught In/Between, ✔ Electrical

Steps of Task Hazard/Reaction to Change Safe Plan Resources

TEAM MEMBERS’ SIGNATURES

The signature of the supervisor confirms the completion of the hazard assessment and Safe Plan of Action by the crew.
Supervisors Signature: Reviewed By PM/CM:____________________________________
INSTRUCTIONS: 1. Write name of the job or task in the space provided. 2. Conduct a walk-through survey of work area. 3. Write the steps of the task in a safe sequence. 4. List all possible hazards
involved in each step and reaction to change. 5. In the Safe Plan column, state the actions that will be taken to prevent the hazards and injury from reaction to failure. 6. In the Resources column, list
safety equipment and tools, etc. needed to do the job. 7. Ask each team member, who helped develop and will use this SPA, to sign in the spaces provided. 8. Review the SPA at the end of the task for
improvements. 9. PM/CM/CA will review and sign the SPA. 10. Other Foremen and Visitors review and acknowledge with initials in the lower margin potential Hazards and Controls in the work space
NOTE: Work shall stop when conditions change, the job changes, or a deficiency in the plan is discovered, and the current SPA will be modified or a new SPA created.
Foremen and Visitors Acknowledgement Initials: _____________________________________________________________________________________________________________________
 Safe Plan of Action Checklist (check all that apply)
Review checklist while completing back page Safe Plan of Action A new SPA is required if the job scope or work conditions change.
Required Permits Hazards Safe Plan
 Confined Space  Overhead Utilities Power de-energization required Insulation blankets required Wire watcher
 Critical Lift  requiredRequired clearance distance = _______Ft.  Safe work zone marked
 Hot Work  Crane or other  Signalman assigned  Tag lines in use  Area around crane barricaded
 Lock Out/Tag Out  Lifting Equipment  Lifting equipment inspected  Personnel protected from overhead load
 Soil Disturbance (Over 12”)  Underground Utilities  Reviewed as-builts  Subsurface surveys  Received dig permit 
 Utility Clearance  Required clearance distance = _______ Ft.  Safe work zone Marked
Required PPE  Electrical  Lock Out/Tag Out/Try Out  Permit required?  Confirm that equipment is de-
 Hard Hat, Class C  energized  Reviewed electrical safety procedures 
 Hard Hat, Class E (Elect. Protect)  Excavations  Permits  Inspected prior to entering  Proper sloping/shoring 
 Ear Plugs/Ear Muffs   Barricades provided  Access/egress provided  Protection from accumulated water
Eye Protection:  Fire Hazard  Hot Work Permit  Fire Extinguishers  Fire watch 
 Safety Glasses   Adjacent area protected  Unnecessary flammable material removed 
 Face Shield  Vehicular Traffic or  Traffic Barricades  Cones  Signs  Flagmen  Lane closure
 Chemical Goggles  Heavy Equipment  Communication with equipment operator 
 Welding Hood  Noise >85 dB Hearing protection is required:  Ear plugs  Ear Muffs  Both
Hand Protection:  Hand & Power Tools:  Inspect general cond.  GFCI in use  Identified PPE required for each tool
 Cut Resistant Gloves   Reviewed safety requirements in operators manual(s)  Guarding OK 
 Welders Gloves  Hand Hazards List sharp tools, material, equipment: ____________________________________
 Nitrile Globes   PPE gloves, etc.  Protected sharp edges as necessary
 Surgical Gloves  Manual Lifting  Reviewed proper lifting tech.  Identified material requiring lifting equipment
 Rubber Gloves   Hand protection required  Back support belts 
 Elect. Insulated Gloves  Ladders  Inspect general cond. before use  Ladder inspected within last quarter 
 Arm Sleeves   Ladder tied off or held  Proper angle and placement  Reviewed ladder safety
Foot Protection:  Scaffolds Inspect general condition before useTags in place Properly secured 
 Sturdy Work Boots  Toe boards used  Footings adequate  Materials properly stored on scaffold
 Safety Toe Boots  Slips, Trips Falls  Inspect for trip hazards  Hazards marked  Tools & material properly stored
 Rubber Boots   Extension cords properly secured  Work zone free of debris 
 Rubber Boot Covers  Pinch Points List potential pinch points: _________________________________________________
fitting the pipe together, man lift, moving material

 Dielectric Footwear   Working near operating equipment  Hand/Body positioning

Respiratory. Protection:  Working w/ Chemicals  The task creates potential for direct contact with hazardous chemicals.
Reviewed MSDS hazards and precautions  Have proper containers and labels.
 Dust Mask Have identified proper PPE (respirators, clothing, gloves, etc.)
 Air Purifying Respirator  Heat Stress Potential  Heat stress monitoring (>85o) Liquids available  Cool down periods
 Supplied Air Respirator   Sun Screen  Reviewed Heat Stress symptoms 
 SCBA  Cold Stress Potential  Proper clothing (i.e.. gloves, coat, coveralls)  Wind chill <32o
 Emergency Escape Respirator   Reviewed Cold Stress symptoms  Warm up periods 
 Environmental  Air emissions  Water discharge  Hazardous wastes  Other wastes 
Special Clothing:
  Pollution prévention Waste minimisation
 Tyvek ®  Natural or Site Hazards Weather Terrain Adjacent operations or processes Biological hazards
 Poly Coated Tyvek ®  Animals/reptiles/insects hazards
 Fire Resistant Coveralls  Adjacent Work/Processes Notified them of our presents Other workers adjacent, above, or below.
 Rain Suit and/or co occupancy Coordinated with adjacent work supervisor/customer operator Can work safely
 Safety Vest Caution barricade tape required Danger barricade tape required Rigid
 Barricades/covers railing required
Fall Protection: Covers over opening Warning signs required

 Double Lanyard Required SANITATION / FOOD SAFETY FOR CONSTRUCTION

 Anchorage Point Avalable  Pre-Construction Risk Assessment completed per Contractor Work Rules
Additional Anchorage Connector Needed  Requirements of Food Safety for Construction & Major Maintenance Activities are included and adopted for the work

e.g. Cross Arm Strap, etc.  Segregate construction from open product and other activities within the facility
 Retractable Device Needed  Atomizing dust or water
 Horizontal Life Line System Req’d.  Microbiological Risk
 Fall Clearance Distance Adequate  Equipment / material being transported thru facility
 Fall Rescue/Retrieval Plan Set Up  Waste contained
  Work done on potable water meets applicable codes
  Hollow areas sealed / no niches
Y Does project affect Combustible Dust  Wood not mobilized into the construction area
N system?  Pipe and conduit mobilized into the construction area is clean (ID & OD) and capped
  Construction materials have appropriate packaging
Design reviewed & approved by  Sanitizing Protocol

GE Technical Services  Personal Hygiene
 

82