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Document HSE-FOR-006 · Fire Fighting Prevention Equipment Inspection Record & Register

Fire Equipment Register

Equipment items

#SizeAgentLocationDueNote

Note codes: 1 Due/needs maintenance · 2 Instruction label damaged · 3 Pressure gauge faulty · 4 Seal/pin missing · 5 Hose damaged · 6 Corrosion visible · 7 Signage missing/damaged · 8 Access obstructed · 9 Wrong location · 10 Bracket broken/missing

Inspected by

Date

Noted by

Date

For action by

Action due date

Recent registers

0

Recent Stop Cards

0

Recent Safe Cards

0

Document HSE-H.I.R.A.-01 · SHEQ Department · matches the printed HIRA / Job Safety Analysis form

Job Safety Analysis (H.I.R.A.)

Job name

Job no.

Site name

Date

3. Risk / hazard evaluation

A. Planning — task steps

Task stepHazardControl / corrective action

B. Tools & equipment

Tool / equipmentHazardControl / corrective action

Have all the relevant control measures been put in place and implemented, so the task can be completed safely and without risk?

Yes — continue with task No — stop all work & notify supervisor

4. Names of persons / crew members performing task

Everyone listed here must sign on screen before this JSA can be submitted.

NameSignature

5. Acknowledgement by supervisor or person in charge

I declare that I have conducted all the assessment/s and evaluation/s of the task and work site. The information noted on this form is accurate and a true reflection of all circumstances I/we have encountered during the time of assessment.

Name

Designation

Your signature

Not signed

Recent JSAs

0 logged

Document VMFHSE026 Rev A · Hot Works Checklist

Hot Works Checklist

Date

Time

Location

Completed by

Ignition source

Minimum requirements

Mark each item Pass / Fail / N/A

1. Fire extinguisher / fire equipment available at the work area

2. Combustible materials removed or covered within 10m radius

3. Floors swept clean of combustible debris

4. Openings, cracks and holes covered to stop sparks passing through

5. Gas cylinders (if used) upright, secured, valves in good condition

6. Welding / cutting equipment inspected and in good condition

7. Fire watcher designated and remains for the duration of the work

8. Fire watcher equipped with a suitable extinguisher

9. Isolation / lock-out-tag-out (L.O.T.O.) completed where required

10. Area adequately ventilated (confined space precautions where relevant)

11. Nearby flammable / explosive atmospheres tested and cleared

12. PPE (welding shield, gloves, apron) worn by operator

13. Hot work permit completed and signed before work starts

14. Fire watch to continue for at least 30 minutes after work stops

Area safe for hot work?

Yes — proceed No — do not proceed

Supervisor name

Designation

Supervisor signature

HSE officer name

Designation

HSE officer signature

Person performing hot work

Designation

Signature

Recent Hot Works checklists

0

Document VMFHSE017 Rev A · First Aid Treatment Report

First Aid Treatment Report

Date

Time

F.A.R. #

Casualty’s personal information

Name

Identity no.

Age

Gender

Refusal of treatment (if applicable — signature)

Survey

Symptoms

Allergies

Medications

Past medical history

Last meal

Events — what happened

Vital signs

Time checked

Level of consciousness

Skin condition

Breathing rate

Rhythm

Depth

Pulse rate

Treatment given

Fit for duty?

Yes No

First aider name

Contact no.

Recent First Aid reports

0

Document VM-F-WS-002 · Compressor & Dryer Checklist · weekly

Compressor & Dryer Checklist

Equipment name

Type

Location

Date

Inspector name

Compressor

1. Oil level correct

2. Drive belts condition

3. Air/oil separator condition

4. Safety relief valve function

5. Pressure gauges functioning

6. Condensate drain operating

7. Unusual noise / vibration

8. Inlet filter clean

Chiller

1. Refrigerant level / no visible leaks

2. Condenser coils clean

3. Cooling fan operating

Air line

1. Fittings & couplings secure

2. Hoses free of damage

3. Line filters clean

4. Regulator / pressure setting correct

5. No visible air leaks

Comments & remedial actions

Signed (responsible manager)

Date

Recent checklists

0

Document VM-F-WS-001 · Overhead Crane Checklist · weekly

Overhead Crane Checklist

Equipment name

Type

Location

Date

Inspector name

Inspection items

1. Hook — no cracks, deformation or excessive wear

2. Hook safety latch functioning

3. Wire ropes — no fraying, kinking or broken strands

4. Wire rope end connections secure

5. Load block and hook block free of damage

6. Upper and lower limit switches functioning

7. Hoist brake functioning correctly

8. Travel / bridge brakes functioning correctly

9. Control pendant / pushbuttons labelled and functioning

10. Emergency stop functioning

11. Warning horn / alarm functioning

12. Rail / runway condition (no obstructions)

13. Bridge and trolley travel smooth, no binding

14. Electrical cables and festoon system in good condition

15. Load chart / rated capacity plate visible and legible

16. Gearbox / motor — no unusual noise or overheating

17. Structural members — no visible cracks or corrosion

18. Housekeeping — area under crane clear of obstructions

19. Fire extinguisher accessible near crane operating area

20. Last inspection / maintenance tag current

Comments & remedial actions

Signed (responsible manager)

Date

Recent checklists

0

Form VM-F-HSE-023 · Rev A · Ladder Register and Inspection Checklist

Ladder register & inspection checklist

Department

Date of inspection

Inspected by

Open a ladder below to record it. Leave unused ladders blank — only ladders with something filled in are saved.

Ladder 1 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 2 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 3 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 4 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 5 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 6 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 7 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 8 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 9 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 10 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 11 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 12 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 13 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 14 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Ladder 15 — tap to fill in

Usual location

Ladder type (step ladder, extension, etc.)

Construction material

Is the ID number present and legible?

Are any of the stiles twisted, cracked or missing?

Are any of the rungs twisted, cracked or missing?

Are any of the rungs loose?

Are ladder feet present and in good condition?

Is the ladder Class 1 or EN131?

Is the ladder free of any other defects?

Comments

Recent ladder registers

0

Form VM-F-HSE-002 · Rev A · Incident Report

Incident Report

Report number

Date of incident

Time of incident

Incident type

Operational area

Task being performed

Responsible person of the incident

Designation

ID number

Names of witnesses

Description of incident (what happened prior to the incident and afterwards — effect, treatment etc.)

Photos (the area where the incident took place, the injured employee, the employee performing the task)

Incident investigation information

Investigator

Investigation date

Investigation time

Findings (what your interviews / witness statements revealed and what you observed on the scene)

Immediate / direct cause/s (without one of these causes the incident would not have occurred)

Underlying / indirect cause/s (the reasons “why” the incident happened)

S.M.A.R.T. action recommendations

S.M.A.R.T. = Specific, Measurable, Achievable, Realistic, Timely. What can be done to improve current methods, procedures or policies to prevent a similar occurrence?

Improvement opportunities

Improvement opportunityResponsibility ofTarget date

Corrective actions

Corrective actionResponsibility ofTarget date

Acknowledgement and acceptance

We the undersigned acknowledge and accept the above findings, improvement opportunities and corrective actions as a truthful, fair and accurate representation of the events.

Name/s of person/s involved in incident

Supervisor [Construction Reg. 8(7)]

Safety Officer [Reg. 8(5)]

Responsible Person [OHS Act 16(2)]

Employer [OHS Act 16(1)]

Recent incident reports

0

Form VM-F-HSE-003 · Rev A · Incident / Accident Cost Analysis

Incident / Accident Cost Analysis

Date of incident / accident

Incident / Accident Register number (I.A.R.)

Enter the rand amount for each line. Section totals and the grand total are worked out automatically.

Dealing with the incident

First Aid Treatment - Labour

First Aid Treatment - Consumables / Equipment Used

Transport - Taking Injured Person/s to Medical Facility

Securing Area - Making the area safe

Securing Area - Extinguishing Fires

Property Damage - Damage to structures or assets

Total

Investigation of incident / accident

Time for Staff to Report, Record & Investigate incident

Meeting/s to discuss incident

Time spent with DOL Inspector

Time Spent with Client's HSE Officer

Consultant's fees to assist with investigation

Other

Total

Productivity cost

Assessing and Rescheduling Work Activities

Recovering Work / Production (Including Staff Costs)

Cleaning Up Site / Area and Disposal of Waste, equipment etc.

Bringing Work Up To Standard (Product Reworking Time / Costs)

Hiring of Tools, Equipment, Plant, Services

Repairs to Damaged - Equipment

Repairs to Damaged - Structures / Building

Repairs to Damaged - Work-piece

Purchasing of Replacement Tools, Equipment, Plant, Services

Other

Total

Business costs

Salary - Injured Person/s

Salary - Contractor

Recruitment Costs

Productivity - Waiting to Resume Work

Productivity - Reduced Due to Delays

Productivity - Late Delivery, Affected Other's Productivity

Income - Penalties for Late Delivery

Income - Lost Due to Cancellation of Order

Other

Total

Customer relations

Reassuring Customers

Providing Alternate Source/s of Supply for Customers

Other

Total

Legal sanctions & related penalties

C.O.I.D. Claim Payments

Lawyer's Fees and Related Legal Expenses

Staff Time & Resources to Deal with Legal Cases

Fines and Costs Imposed Due to Legal Proceedings

Increase in Insurance Costs - C.O.I.D.

Increase in Insurance Costs - Liability

Other

Total

Other unaccounted for costs

Totals for incident / accident

Grand total

Notes / specify “Other” items

Recent cost analyses

0

Form VM-F-HSE-004 · Rev A · Annexure 1 — Recording and Investigation of Incidents (OHS Act Reg. 9)

Annexure 1 — Recording and Investigation of Incidents (OHS Act Reg. 9)

Occupational Health and Safety Act, 1993 (Act No. 85 of 1993) — Regulation 9 of the General Administrative Regulations: Recording and Investigation of Incidents.

B. Investigation of incident

Name of investigator

Date of investigation

Designation of investigator

Short description of incident

Suspected cause of incident

Recommended steps to prevent a recurrence

C. Remarks by Health and Safety Committee

Remarks

Chairperson

Date

Recent Annexure 1 records

0

Form VM-F-HSE-005 · Rev A · Incident / Accident Report Checklist

Incident / Accident Report Checklist

Incident / Accident Register number (I.A.R.)

Date

Name/s of person/s involved

Time

PHASE 1: Completion of Incident Report, COID Documentation and Treatment of Injured Person (H.S.E. Dept. / H.R. Dept.)

HSE-FOR-002 — Incident/Accident Report (“Reporting” stage completed)

HSE-FOR-018 — First Aid Treatment Report

WCL. 2 — Employer’s Report of an Accident (if referred to Doctor)

WCL. 4 — Doctor’s First Medical Report (if W.Cl.2 is submitted)

I hereby confirm that “Phase 1” of the checklist was completed by me and that all the above-mentioned information has been correctly completed and is attached to this checklist.

Name

Designation

Date

PHASE 2: Investigation of Incident/Accident (Incident Investigator)

HSE-REG-050 — Incident / Accident Investigation Attendance Register

HSE-FOR-002 — Incident/Accident Report (Completed Document)

HSE-FOR-013 — Witness Statement/s

None — Copies of relevant Qualifications and/or Certifications

Various — Copies of Risk Communication Documents — Toolbox Talk, HIRA, SWMS, JTA, SWP

None — Photographs of Scene

HSE-FOR-034 — “Why” Tree / Root Cause Analysis

I hereby confirm that “Phase 2” of the checklist was completed by me and that all the above-mentioned information has been correctly completed and is attached to this checklist.

Name

Designation

Date

PHASE 3: Follow-up C.O.I.D. Documentation / Return to Work (H.R. Dept)

W.Cl.5 — Doctor’s Follow Up/Progress Medical Report/s

HSE-FOR-036 — Return to Work Evaluation

I hereby confirm that “Phase 3” of the checklist was completed by me and that all the above-mentioned information has been correctly completed and is attached to this checklist.

Name

Designation

Date

PHASE 4: Close-out C.O.I.D. Documentation (H.R. Dept)

W.Cl.5 — Doctor’s Final Medical Report

W.Cl.6 — Resumption Report

I hereby confirm that “Phase 4” of the checklist was completed by me and that all the above-mentioned information has been correctly completed and is attached to this checklist.

Name

Designation

Date

PHASE 5: Verification and Close-out of Incident/Accident (H.S.E. Dept.)

HSE-FOR-035 — Implementation of S.M.A.R.T. Recommendations and Corrective Actions as detailed on HSE-FOR-002

HSE-REG-009 — Copies of Training Registers for Implementation of above

None — Photographic Evidence of Implementation

I hereby confirm that “Phase 5” of the checklist was completed by me and that all the above-mentioned information has been correctly completed and is attached to this checklist.

Name

Designation

Date

Recent incident checklists

0

Recent tool lists

0

Form VM-F-HSE-009 · Rev A · Breathalyser Test Results

Breathalyser Test Results

Employee

Date

Department

Initial reading

Reading

Time

Tester name

Designation

2nd reading taken by

Reading

Time

Tester name

Designation

Test witnessed by

Name

Designation

Acknowledgement

I hereby acknowledge that a breathalyser test was conducted on me on the suspicion that I was and/or may have been under the influence of alcohol during working hours at my place of employment. I further acknowledge and agree that, should the result of the breathalyser test reflect a reading above the minimum permitted limit, I may be subjected to the relevant disciplinary action in accordance with company policy.

The employee acknowledges the above

Done and signed at (place)

Date signed

Team leader / manager

Recent breathalyser tests

0

Form VM-F-HSE-011 · Rev A · Safe Work Method Statement (SWMS)

Safe Work Method Statement (SWMS)

Job / task

Site / location

How to complete a SWMS — tap to read

A Safe Work Method Statement is a task- and site-specific document that identifies the hazards and risks and the controls to be implemented so each phase of the job is completed safely. It must be prepared, reviewed and approved before work commences.

List each task in the order it will be carried out (including preparation and clean-up), identify the hazards and risks of each task, then detail the controls: Elimination, then Substitution, Isolation, Engineering controls, Administrative controls and finally PPE (last resort).

Brief all team members before starting. Work must cease immediately if the SWMS is not being followed. If controls are inadequate, stop work, review and amend the SWMS, and re-brief the team.

Tasks, hazards & controls

Task descriptionHazards and risksMitigation controls

Tools, equipment & infrastructure that will be used (e.g. small tools, cutting torch, scaffold, painting)

Working environment & restrictions

Protection of others

Emergency procedures

Operatives / competence

Personal protective equipment

Plant & equipment

Materials handling / storage & safety information

Critical stages — work method (must be undertaken in the correct sequence)

Sign-off

The planning steps, responsibilities and controls necessary to complete this task safely have been communicated to all personnel involved. We the undersigned are obligated to call a “safety stoppage” for any condition perceived or otherwise regarded as an unsafe situation.

Date

Responsible person / Project manager

Team leader

HSE department

Team members

NameDesignation / employee no.

Recent SWMS

0

Form VM-F-HSE-013 · Rev A · Incident Investigation Witness Statement

Incident Investigation Witness Statement

Incident / Accident Register number

Date of interview

Time of interview

Place of interview

Interviewer

Interviewer designation

Witness details

Witness name

Contact number

ID / passport number

Designation

Age (years)

Experience (years)

Experience (months)

Time with the company (years)

Time with the company (months)

Immediate supervisor name

Immediate supervisor contact

What happened? (detail what happened from the start of your shift, the incident and afterwards — arrived on site at…, toolbox talk, incident, treatment etc.)

Scope of work

Was the task being performed according to an instruction from someone? If yes, who gave the instruction?

Did the task require any specific qualifications (e.g. Rigger, Boilermaker, Working at Heights)? If yes, attach copies for each person.

Communication of risks

Was a pre-shift toolbox talk held? By whom and where? If yes, attach copies.

What was discussed / what were some of the topics?

Are a documented Risk Assessment, Job-task Analysis, Safe Work Method Statement and/or Safe Work Procedure in place for the task? If yes, attach copies.

Were the conditions of these documents discussed with all personnel involved? Name some of the corrective actions.

Personal view regarding incident

In your opinion, what could have been done differently by the IP / team to prevent this from happening again?

In your opinion, what could have been done differently by the Company to prevent this from happening again?

Attachments (qualifications, toolbox talk, risk documents)

Acknowledgement and acceptance

I, the undersigned “witness”, declare that the above statement is a truthful, fair and accurate representation of the events leading up to the incident/accident as experienced by me. I understand that by submitting a false statement I am guilty of contravening Sections 14 and 37 of the Occupational Health and Safety Act 85 of 1993 and may be subject to prosecution.

The witness makes the above declaration

Signed at

Time

I, the undersigned “interviewer”, declare that the above statement is a truthful and accurate representation of the events surrounding the incident/accident as disclosed to me by the above-mentioned witness.

The interviewer makes the above declaration

Signed at

Time

Recent witness statements

0

Form VM-F-HSE-014 · Rev A · Personal Protection Equipment (PPE) Repayment Agreement

Personal Protection Equipment (PPE) Repayment Agreement

Date

Employee name & surname

Employee number

Repaid in how many parts

The Company has agreed to purchase PPE for staff in line with the PPE Policy. The employee agrees to pay the amount below off in the number of parts selected, for PPE purchased by the Company.

Total amount to be repaid (R)

Amount per week (R)

Number of weeks

Repayment commences

Repayment continues without break until

Should the employee’s services be terminated for any reason, by either party, the total outstanding amount will be immediately repayable. Such amount will be deducted from any remuneration owed to the employee if necessary.

The employee accepts the above conditions

Payroll

Payroll approved and loaded

Payroll signature (name)

Recent PPE repayment agreements

0

Form VM-F-HSE-018 · Rev A · Employee Cellphone Compliance Acknowledgment

Employee Cellphone Compliance Acknowledgment

To maintain a secure and distraction-free workplace, Via Maris Shipyard has established a policy regarding personal cellphones on company property. Cellphones are not allowed in company facilities or workspaces unless explicitly permitted by Team Leaders and the Production Manager. Designated, individually identified cellphone lockers are available for storage of your cellphone.

Employee name & surname

Department

Date

If you will not be using the designated cellphone locker, tick one:

My cellphone is at home My cellphone is in my car I do not have a cellphone I have been granted authorisation by my Team Leader and Production Manager to use my cellphone due to specific reasons

Authorised by (Team Leader / Production Manager) — if applicable

Compliance agreement

I agree to comply with this form and understand that failure to do so will result in immediate dismissal. I understand that Via Maris reserves the right to verify compliance with the Cellphone Policy, including inspections and searches of personal belongings in accordance with applicable laws.

I agree to all of the above and take full responsibility for my actions in accordance with the Via Maris Cellphone Policy

Security (name)

Recent cellphone acknowledgments

0

Form VM-F-HSE-021 · Rev A · Employee Labour Sign-on (PPE Issue)

Employee Labour Sign-on (PPE Issue)

Non-return of PPE will result in deduction off final salary to the value of the PPE that was issued.

Name of employee

Job title

Date received

F&A / Jacket

Description / size (New start / Annual PPE issue)

Received

Returned

Replacement required?

F&A Pants

Description / size (New start / Annual PPE issue)

Received

Returned

Replacement required?

F&A / One-Piece

Description / size (New start / Annual PPE issue)

Received

Returned

Replacement required?

Winter Jacket

Description / size (New start / Annual PPE issue)

Received

Returned

Replacement required?

T-Shirts

Description / size (New start / Annual PPE issue)

Received

Returned

Replacement required?

Protective footwear

Description / size (New start / Annual PPE issue)

Received

Returned

Replacement required?

Other

Description / size (New start / Annual PPE issue)

Received

Returned

Replacement required?

I confirm that I have received the above Personal Protective Clothing as part of my work uniform. I further confirm that if my PPE is damaged, lost or stolen, I am solely responsible for replacing said garments at my own expense.

The employee confirms the above

HSE department

HSE department signature (name)

Date

Comments

PPE returned / clearance

Employee (name)

Date of clearance

HSE (name)

Date of clearance

Payroll / HR (name)

Date of clearance

Recent labour sign-ons

0

Recent equipment requests

0

Form VM-F-HSE-027 · Rev A · Pre-Use Hand Tools Checklist

Pre-Use Hand Tools Checklist

Date

Area / department

Mark each tool Correct or Out of order, and add remarks where needed. One form per inspection day.

Flogger

Spanner

Hammer

Pliers

Chipping Hammer

Hand Drill

Stilson

File

Hacksaw

Crimping Tool

Grinder

Skill Saw

Inspection done by

Over-inspection done by

Safety tips: always wear correct PPE · use the correct tool for the job · inspect hand tools before using them · do not modify hand tools · report damaged tools to the Supervisor/Storeman.

Recent hand tool checklists

0

Form VM-F-HSE-028 · Rev A · Pre-Use Portable Electrical Equipment Checklist

Pre-Use Portable Electrical Equipment Checklist

Equipment no.

Date

Mark each item Correct or Out of order, and add remarks where needed. One form per inspection day.

Plug top

Connection to plug

Connection to unit

Switch of appliance

Earth continuity check

Core or cable insulation (no joints)

Guards on appliance

Appliances distinctly marked

General condition of appliances

Lock out devices (where applicable)

Safety switches

No exposed open wires and connections

Operator’s name

Over-inspection done by

Recent portable electrical checklists

0

Recent ladder checklists

0

Form VM-F-HSE-030 · Rev A · First Aid Box and Equipment Checklist

First Aid Box and Equipment Checklist

Area

Inspector

Year

Month of inspection

Date inspected

Minimum contents of a first aid box — tap to read

As per OHS Act 85 of 1993, G.S.R. 3

Wound cleaner / antiseptic (100ml)
Swabs for cleaning wounds
Cotton wool for padding (100 g)
Sterile gauze (1 packet)
1 pair forceps (for splinters)
1 pair scissors, minimum size 100 mm
1 card safety pins
4 triangular bandages
4 roller bandages (75mm x 5m)
6 roller bandages (100mm x 5m)
1 roll elastic adhesive (25mm x 3m)
1 anti-allergenic adhesive (25mm)
1 packet adhesive dressing strips
4 first aid dressings (75mm x 100mm)
4 first aid dressings (150mm x 200mm)
2 straight splints
Disposable gloves (2 pr L & 2 pr M)
2 CPR mouth pieces / similar devices

As per Mine Health and Safety Regulations (Minerals Act 27 of 1956 and Act 50 of 1991, Chap. 24)

8 leg splints
4 joints for splints
2 arm/elbow splints
2 rubber tourniquets
2 stick improvised tourniquets
4 shell dressings
8 large dressings
12 small dressings
4 rolls of 50g cotton wool
18 triangular bandages
1 pair of scissors
1 neck brace
2 pairs surgical gloves
1 CPR mouthpiece
2 bottles of antiseptic solution
1 bottle eye drops

Do not tick. Select OK or the number of the specific deviation from the legend for each box.

ID no.LocationResult

Spot check / audit (date and initials)

Recent first aid box checklists

0

Form VM-F-HSE-032 · Rev A · Emergency Evacuation Drill

Emergency Evacuation Drill

Emergency contacts — SHE Officer: 069 510 8061 · Millerton Medi-Clinic: 021 529 9299 · Fire Department landline: 021 480 7700 · Fire Department mobile: 107 or 112 · Police: 10111 · Department of Labour: 021 468 5500. A site-specific First Aider is appointed in the SHE Site File.

Appointed emergency coordinator

Site / area

Emergency plan preparation / key features

List location of nearest emergency exits, fire extinguishers and other safety features available at the work site Describe one or more evacuation routes Determine the Emergency Meeting Location(s), places for staff to gather and wait for instructions (easily and safely accessible, outside the affected area) Inform all staff of the existing procedures Train the staff (e.g. best behaviour in case of emergency, first-aid treatment) and test the evacuation plan regularly

Date of emergency evacuation drill

Time the alarm was raised

Time roll call was completed

The next emergency evacuation drill must be done within six (6) months of this drill.

Emergency evacuation roll call register

NamePresent

Visitors to site (APS sign-in register)

NamePresent

Is all personnel present and accounted for?

Yes No

If not, find out the approximate last known position and notify the emergency response official. DO NOT enter the facility and attempt a rescue by yourself. If all personnel are accounted for and the facility has been given the all clear (by rescue workers or the emergency coordinator), resume work as normal.

Notes / missing persons

Sign-off

Fire Marshal

Date

HSE Officer

Date

Production Manager

Date

Recent evacuation drills

0

Recent scaffolding inspections

0 logged

Recent training requests

0 logged

My staff details

My leave days

My banking details

My training

Every department’s numbers, live, in one place.

Departments

Group companies

Asgard

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Department Statistics

Contract value, budget and progress for every current project.

Project Snapshot

Canteen Snapshot

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Leave application

My leave requests

Anonymous complaint

Personal details

Contact information

Next of kin

Banking details

Training Manual for now

My pending change requests

Bulk-link SimplePay employee numbers

Staff on record

Personnel intake & onboarding process

Recent onboarding records

Employee personal details record

Employee information

Contact details complete only if details have changed

Bank details

Clothing sizes

Emergency contact

Personal

Medical information

For office use

Recent records

Employment request

Recent employment requests

Exit interview

Recent exit interviews

Waiting on you

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Sick leave — pending HR verification

Staff detail changes — pending your approval

Disciplinary warning

Charges

Validity

Signatures

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Employee profile

My team

Company organogram

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Fire Equipment Register

Recent registers

Stop Card

Recent Stop Cards

Safe Card

Recent Safe Cards

Job Safety Analysis (H.I.R.A.)

1. Risk identifier mark every question — if you don’t know, mark it “No”

2. Task evaluation

3. Risk / hazard evaluation

4. Names of persons / crew members performing task

5. Acknowledgement by supervisor or person in charge

Recent JSAs

Hot Works Checklist

Ignition source

Minimum requirements

Recent Hot Works checklists

First Aid Treatment Report

Casualty’s personal information

Survey

Injury location

Vital signs