Company name

Date

Health, Safety, and Environment (HSE)

Management Plan
PURPOSE OF THIS DOCUMENT

The purpose of this document is to provide guidance and supporting information to enable Suppliers to meet
Water Corporation’s requirements for HSE qualification.

Note: a HSE Management Plan is an organisational document that describes the supplier’s processes
to manage their risk and meet its objectives. The HSE Management Plan is submitted for
prequalification only. A HSE or OSH Management Plan, specific for the scope of works, must be
submitted when participating in the tendering process.

How to use this document:

Read the requirements of each section

Use the provided templates as a guide and prepare your own company specific documents
Collate your documents and submit when you complete the supplier registration form

If you believe a section is not applicable please state N/A and include a supporting statement as to why it does
not apply.
Note: Should you require any guidance on your HSE submission contact the Pre-Qualification team:

[email protected]

(08) 9420 2266

1 Leadership and Planning04

1.1 Company Organisational Structure

1.2 Management HSE Commitment and Expectations

1.3 HSE Responsibilities and Accountabilities

2 Compliance04

2.1 HSE Legal Compliance

2.2 Document Control

3 HSE Risk Management05

3.1 HSE Risk Management Tools

3.2 HSE Risk Register

3.3 Safe Work Method Statements (SWMS)

3.4 Stop Work

3.5 Job Safety and Environmental Analysis (JSEA)

3.6 Personal Protective Equipment (PPE)

3.7 Management of Change (MOC)

4 Systems of Work06

4.1 Environmental Management

4.2 Chemical Management

5 Stakeholders, Consultants & Communication07

5.1 HSE Communications and Consultation

6 Contractors and Suppliers07

6.1 Sub-Contractor Safety Management

7 People07

7.1 Alcohol and Other Drugs

7.2 Fatigue Management

7.3 Pre-Employment Medicals

7.4 Injury Management

7.5 Training and Competency Management

8 Incident Management, Reporting and Investigation08

8.1 Emergency Response and Management

8.2 Hazard/ Incident Reporting

8.3 Hazard/ Incident Investigations

9 Assets, Plant and Equipment08

9.1 Vehicle, Plant and Equipment

10 Performance, Monitoring. Audit & Improvement08

10.1 Review and Evaluation

10.2 Workplace Inspections

11 Reference Documents10

Appendices10

Appendix AOrganisational StructureAppendix BRisk Management Procedure

Appendix CRisk RegisterAppendix DWork Management System

Appendix EJSEAAppendix FChemical Register

Appendix GToolbox MeetingAppendix HTraining Register

Appendix IIncident Investigation Appendix JAudit & Improvement

Appendix KWorkplace Inspection

1 Leadership and Planning

1.1 Company Organisational Structure

Define all levels of personnel working within your Company, including:

Each position title.

Who each role reports to.
Contact details (key personnel).

Refer to Appendix A. You can complete and refer to Appendix A here

1.2 Management HSE Commitment and Expectations

How is HSE Commitment and expectations demonstrated in your Company? Include examples such as:

HSE Policy.
Identification of the activities that are monitored monthly for HSE compliance (e.g. Workplace
Inspections, Safe Work Method Statement (SWMS) / Job Safety and Environmental Analysis (JSEA)
reviews, Daily prestart, HSE meetings, training and compliance).
How personnel are made aware of their HSE responsibilities when joining the Company.

1.3 HSE Responsibilities and Accountabilities

1. Define HSE responsibilities and accountabilities for all levels within your organisation.
2. Management communicate expectations to reinforce HSE responsibilities and accountabilities.
3. Management have processes to assign and monitor adequate Supervision in the field.

2 Compliance
2.1 HSE Legal Compliance

1. Define how your Company identifies and meets its HSE legal obligations.
2. List the HSE legal obligations that affect your scope of work (e.g. Codes of Practice, Australian
Standards, etc.).

2.2 Document and Records Management

Define your process for document control and records management that includes:

A number system for HSE documents.

Creation date.
Document creator.
Approver of document.
Next review date.

3 HSE Risk Management

3.1 HSE Risk Management Tools

1. Define the processes / tools used by your Company to identify and manage risk (e.g.: Risk Register,
SWMS, JSEA, Step Back/ Take 5, etc.).
2. Outline how each risk tool is applied (e.g. what tool gets used and when).

Refer to Appendix B Risk Management Procedure. You can complete and refer to Appendix B here.

3.2 HSE Risk Register

Provide your current HSE Risk Register that identifies:

Key risks for the category of work you wish to provide.

Risks prioritisation (sorted high, medium, low).
 Control methods to reduce risk to as low as reasonably practicable (ALARP).
All High Risk Work (as per OHS Regulations 1996).
Identifies all Environment, Health and Hygiene risks (e.g. wastewater, dust, noise, heat exposure,
etc.).

Refer to Appendix C. You can complete and refer to Appendix C here.

3.3 Safe Work Method Statements (SWMS)

Provide an example of a SWMS for the type of work the company will be conducting.

Note: SWMS’s are required where work is deemed, by Division 12, Section 3.137 & 3.143 of WA
OSH Regulations 1996 as “Construction High Risk” or if requested by the Water Corporation.

Refer to Appendix D. You can complete and refer to Appendix D here.

3.4 Stop Work

Define the process that stipulates the right and obligation to stop work where personal safety or the
environment is at risk of harm for all personnel including Contractors.

Describe how this is communicated to all levels of the workforce, including Contractors.
Supports stopping work without fear of discipline or repercussions?

3.5 Job Safety and Environmental Analysis (JSEA)

Provide example JSEA’s for the type of works the Company will be conducting. The following requirements
are minimum expectations:

All JSEA’s MUST be developed prior to the task commencing.

All JSEA’s MUST be reviewed at the commencement of each shift.
All JSEA’s MUST remain at work front.
Copies of JSEA’s MUST be retained and made available to Company upon request.

Refer to Appendix E. You can complete and refer to Appendix E here.

3.6 Personal Protective Equipment (PPE)

Define how your personnel identify and maintain the correct PPE required for the tasks they are performing
(e.g. Work at height equipment, breathing apparatus, Hi-visibility clothing, steel capped boots, safety
glasses, ear plugs/muffs, hard hat, safety gloves, hat brim, sunburn cream, etc.).

3.7 Management of Change (MOC)

Define your process to manage changes to plant, equipment, process or procedure, including how:

Changes are identified and recognised.

 Changes are reflected in relevant documentation (e.g. Risk Register, SWMS, etc.).
Changes are communicated to personnel, including Sub-Contractors.

4 Systems of Work
4.1 Environmental Management

Define your process for the assessment and management of environmental impacts, including how you:

Reduce, Reuse and recycle waste materials where possible.

Manage and dispose of construction wastes in an acceptable approved manner.
All spills and releases must be reported immediately through to your Water Corporation
representative.
Spill prevention and response measures.

4.2 Chemical Management

Provide a Listing/ Register of all chemicals used by your Company and the PPE required to be worn during
use

The register must be readily available to workers.

Workers must have access to hardcopy Safety Data Sheets (SDS).
All containers must be labelled with name, risk and safety precautions.

Refer to Appendix F. You can complete and refer to Appendix F here.

5 Stakeholders, Consultants & Communications

5.1 HSE Communications and Consultation
1. Define your Company process to communicate and consultant with employees and Sub-Contractors
on HSE matters (e.g. HSE notice boards, meetings and toolbox topics).
2. Define how personnel are informed of hazards (including learnings from incidents), required safe work
practices and regulations associated with their work.

Refer to Appendix G. You can complete and refer to Appendix G here.

6 Contractors and Suppliers

6.1 Sub-Contractor Safety Management

Define how Sub-Contractors are engaged and managed. This shall include as a minimum:

HSE Contractor selection process.

Induction, training and competency requirements.
Monitoring the implementation Sub-Contractors HSE Management System Plan and systems of work.
Performance monitoring of Sub-Contractors.
Inclusion of Sub-Contractors in HSE Meetings.
7 People
7.1 Alcohol and Other Drugs

Describe how your Company manages alcohol and other drugs in the workplace. As a minimum:

All personnel must be advised to report to work in a condition capable of safely carrying out the
required tasks.
Any person considered being under the influence of alcohol or other drugs must be prevented from
commencing or continuing work.
Agree to participate in Client random drug and alcohol testing if completing duties at a Client
workplace.

7.2 Fatigue Management

Define your process for managing fatigue (e.g. what are your standard working hours, duration of each
shift, hours between shifts).

7.3 Pre-Employment Medicals

Describe how your Company:

Knows personnel are fit for work (e.g. pre-existing injuries).

How do you select and manage people who are unfit (e.g. restrict certain work activities)

7.4 Injury Management

Define your processes to prevent and manage workplace injuries/ illness, including:

Emergency procedures (e.g. first aid, first aid kits, trained first aid personnel).
Medical attention and follow-up.
Workers Compensation process.
Return to Work process.

7.5 Training and Competency Management

1. Provide a Training Needs Register/Listing that captures:
Name and description of the work activities to be undertaken.
The equipment to be used during each work activity.
Skills required.
Specific work activity training (e.g. WA Driver Licence, High Risk Licence and National Tickets).
2. Provide a Training Register/Listing that shows the following details:
Employee name.
Position held (e.g. fitter, excavator operator).
Skills / Competencies / Experience (e.g. tickets / qualifications).
Training provider.
Certificate/Licence number.
Certificate/Licence expiry date.

1. Define your process for the on-boarding/induction of personnel to your Company.

Refer to Appendix H. You can complete and refer to Appendix H here.

8 Incident Management, Reporting and Investigation

8.1 Emergency Response and Management
1. Define your processes to manage and respond to emergency situations (e.g. fire, medical emergency,
chemical spills, etc.).
 2. Include a listing of all your emergency equipment (e.g. First Aid equipment, fire extinguisher, etc.).

8.2 Hazard/ Incident Reporting

1. Define your process for Hazard, Near Miss and Incident Reporting.

Note: Verbal advice to the Water Corporation is required immediately following an incident (as a
minimum within two (2) hours) and a formal written incident report is required to be provided to the
Water Corporation within five (5) working days of the incident.

8.3 Hazard/ Incident Investigation

1. Define your process for Hazard, Near Miss and Incident Investigation, including how you:
Investigate incidents, near misses and hazards.
Track and close out actions.
Analyse hazard and incident trends.
Notification process to Worksafe of injuries/incidents reportable under OSH Regulations.

Refer to Appendix I. You can complete and/or refer to Appendix I here.

9 Assets, Plant and Equipment

9.1 Vehicle, Plant and Equipment

Define how you ensure vehicles, plant and equipment are safe to use. For example: Licensing and
inspection of equipment (e.g. pre-start checks) and maintenance/servicing of equipment.

Note: The following equipment is banned by the Water Corporation:

9” Angle Grinders
Concrete Cutting Saws (Quick Cut Saws), exception if trolley mounted for the purpose of ground
cutting.

10 Performance monitoring, Audit & Improvement

10.1 Review and Evaluation

Define your process for periodic review and evaluation of your Company’s compliance to this HSE
Management System Plan, including:

Audit and inspection schedule.

Key document reviews (e.g. Procedures, Risk Register, etc.).
Leadership Key Performance Indicators (e.g. leadership time on site).
How are Managers involved in the review process.

Refer to Appendix J. You can complete and/or refer to Appendix J here.

10.2 Workplace Inspections

Provide an annual inspection schedule that covers the following:

All the work categories you have listed on your Risk Register (e.g. chemical storage, general area
housekeeping)
All key equipment used for your work (e.g. vehicle, lawn mower, etc.)
The requirements for all personnel and management to conduct inspections

Refer to Appendix K. You can complete and/or refer to Appendix K here.

11 Reference Documents
Provide a list/register of documents (i.e. Plans, Procedures, Forms, Checklists, etc.) associated with
this Management Plan and Scope of Work.

Document Number Document Name

Appendix A – Organisational Structure & Roles (Refer section 1.1)
The following Organisational Structure outlines the roles that have a Health, Safety and
Environmental responsibility within INSERT ORGANISATION.

Roles and Responsibilities Defined

The following examples of roles and responsibilities for personnel within INSERT ORGANISATION
regarding HSE are below.

This list should reflect positions within your organisational structure. .

WORKS SUPERVISOR

INSERT NAME is responsible for HSE at the workplace and duties include:

implementing the HSE Management Plan

observing all HSE rules and regulations
making sure that work activities are carried out in a safe and environmentally sound manner
planning to do all work safely including any interface with other work activities;
providing advice and assistance on HSE matters to personnel
being part of the planning and design stages of trade activities
deciding when training on HSE is required
actioning HSE reports and carrying out workplace inspections
setting up HSE meetings and programs
 helping to prepare Job Safety Environmental Analysis / Step Back Forms for the organisation’s
work activities
investigating hazard reports and ensuring that they are completed and corrective actions
undertaken
carrying out project inductions, Toolbox Talks and team meetings
being a part of incident investigations
leading by example and promoting sound HSE practices at every opportunity;
undertaking inspection of the contracted or planned works to ensure that HSE control measures
are implemented and effective; and
other HSE duties as directed by the Works Manager.

EMPLOYEE

Are responsible for the following:

working in a safe manner without risk to themselves, others or the environment

complying with the HSE Management Plan including all Job Safety Environmental Analysis / Step
Back Forms
reporting all incidents to the Works Supervisor
reporting all injuries and illnesses to the designated First Aid Officer
reporting any HSE hazards to the Works Supervisor
providing suggestion, through agreed consultation methods, on how to improve HSE issues
seeking assistance if unsure of HSE rules
reporting any faulty tools or plant to the Works Supervisor
complying with site rules
correctly using all personal protective equipment; and
complying with emergency and evacuation procedures.

Appendix B – Risk Management Procedure (Refer section 3.1)

INSERT ORGANISATION uses the following Risk Tools to identify and record hazards associated with specific activities.
 Tool Description

Formally documented process that details the high risk construction

work activities and the agreed methodology to be carried out for a
Work Method Statement specific job. It clearly outlines the hazards that may arise and the
controls that must be put in place to mitigate and manage the identified
risks.

A documented risk assessment which breaks down the job into work
Job Safety Environment
steps with the identified hazards and required control measures
Analysis (JSEA)
formally recorded for each step.

A simple form for work team members to use for hazard identification
and control assessment by stopping, looking and discussing the
Step Back / Take 5
situation with colleagues before proceeding with any work. Primarily
used for Low – Medium risk activities, which do not require a JSEA.

Prior to commencement of works, INSERT ORGANISATION will:

Conduct a start-up meeting with all personnel involved in the works

Appoint a responsible person for the works and application of the Risk Tool
Break down specific work activities into job steps to identify all potential hazards associated with the works.
Record hazards identified in the applicable Risk Tool (JSEA, Step Back etc.)
Ensure all persons on site understand the requirements and application of the Risk Tool
Apply appropriate controls as identified on the Risk Tool.

During the works, INSERT ORGANISATION will review the Risk Tool:

At the commencement of each shift

New personnel are introduced to the worksite
Where on site conditions have changed (weather etc.)
Where there is a change in methodology or scope of works (change in machinery required, change in location of
works, additional activities required etc.)

For all high risk Works identified on the Risk Register, INSERT ORGANISATION will:

Conduct works in accordance with the applicable Work Method Statement

Is the activity a High Risk Construction Work task? Check the back page for a list of these activities.

☐ NO☐ YES If yes, JSEA is required.

Have you used the risk matrix on the inside cover to measure the level of risk of the task BEFORE

Putting any controls in place? Is the risk level high or extreme?

☐ NO ☐ YES If yes, JSEA is required.

Do you need to obtain a Permit for the task?

☐ NO ☐ YES If yes, JSEA is required.

I
/L)
Controls

Adequate breaks during task ☐

Air monitoring equipment ☐

Appropriate waste disposal (e) ☐

Barricading ☐

Bridging cables, rubber gloves ☐

Cable locator ☐

Communications ☐

Contact Supervisor or Environmental Advisor (e) ☐

Dewatering, divert water flow (e) ☐

Dial Before You Dig ☐

Dust / Face mask / SCBA (e) ☐

Edge protection ☐

Exclusion zone

Eye protection

First aid kit and water

Fuel, chemical spill kit (e)

Gloves

Hard-hat

Other:

Appendix C – Risk Register (Refer section 3.2)

INSERT ORGANISATION has identified, assessed and rated all risk associated with the activities that
we wish to provide for the Water Corporation (normal works portfolio).
 Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8

Existing Controls
Safety
Hazard(Top (Prevention/
EssentialHigh Action/ Action By &
Ref. Task/Job Event) Causes Detection/ Control/ C L R C L R
Risk Work Recommendations When
Mitigation)

EXAMPLE

1. Controls are to be
1. This is about specific, realistic,
Description of the
1. List the what will cause practicable, verifiable
required broad
relevant Water the most harm. and actual (e.g.
staged steps within 1. These are the
Corporation documented in
a task. causes of the 1. These are additional
Safety Essentials 2. There could be procedures, plans) or
The details Top Event(s), so controls that will be
associated with more than one, can be confirmed as in
provided shall: in considering if implemented and will
this task/job step. and we're only place by inspection /
• Be descriptive it's a cause, ask further reduce the risk
considering the audit). They do not
and use active the question, level identified.
2. Lists the Top Event(s), include actions /
wording /command does this cause
relevant High those things that recommendations -
language (e.g.: the Top Event to 2. An additional risk
Risk Work will cause you or Step 7).
lifting, entering and arise? ranking (Step 8) will
activities the environment 2.
applying). determine the
associated with the most harm. Elimination,
• Provide specific 2. Each cause is effectiveness this
this task/job step Substitution,
details (e.g.: what to be individually control (e.g.: will it
(As per OSH 3. Other events Engineering and/or
is the actual: numbered and actually reduce the
Regulations (hazards) are Isolation shall be given
type/model, on a separate risk).
1996, Division 12, typically preference over
location, weight, line.
section 3.317 and addressed in the identification of lower
height,volume,
3.143 WMS or the level controls
size, quantity ical).
JSEA. (Administration and
PPE).

Appendix D - Work Method Statement Template

Contractor

Contract #

SOW Title

Location

Document # Revision # Date

Contractor Name Signature Date

Completed by:

Authorised by:
 Water Corporation Name Signature Date

Accepted by:

1. Introduction
Provide background and description of the Project, including CRAW details.

CRAW Title Document Number Date

1. Schedule
Describe the proposed Project schedule for the activity (start / end dates, sequence of work activities and where this work activity fits into the overall
SOW schedule).

1. Roles and Responsibilities

List roles of those responsible for the safe execution of the work activity.
 Name Position Company Brief Outline of Role

1. Training and Competency Requirements

List minimum training and competency requirements required to safely complete the work activity described by the WMS.

Note: All personnel involved in the work activity must be trained and competent to perform their assigned roles.
 Position Licenses, qualifications and / or certifications

1. Work Methodology
Detail the work methodology in a logical sequence listing the step by step necessary for conducting the activity in a safe and sustainable manner.

1. Plant and Equipment

Identify plant and equipment (including type and capacity) necessary to complete the work activity described.

1. Hazards, Risk and Control Measures

Provide a list of all potential hazards, specific risk controls and residual risk scores.
 Inherent Risk Established Controls Residual
Item Hazard
Level Measures Risk Level

Use the hierarchy of controls

Elimination
Substitution
Isolate
Engineering
Administration
PPE

1. Emergency Response Requirements

Define the emergency response and rescue requirements for the work activity including any specialist personnel and equipment.

Emergency Contact Details

Contact Name / Resource Number

Emergency radio channel and/or

telephone number

Emergency Response Personnel

 Name Role

i.e. First Aid, Senior First Aid, Fire

Wardens

Emergency Response Equipment

Emergency Response Equipment Location

i.e. First aid kit, defibrillator, fire extinguishers emergency showers, eye wash station, etc

Project Specific Emergency Response Plans

 Emergency Response Plan Document

i.e. Confined Space, Spills, hazardous substances, medical emergency (first aid),etc.

1. Environmental Management Requirements

Define Environmental aspects and requirements for the work activity. Include reference to the Construction Environmental Management Plan, where
required.

Key Environmental Aspects associated with the SOW

Key Requirements as specified in the relevant Environmental approvals

Include work approvals and licenses, and Project Environmental Mitigation strategies (i.e. lighting, fauna / flora management and waste management)

Construction Environmental Management Plan Document Number Date

1. Hazardous Substances and Dangerous Goods Inventory

Identify by name all hazardous substances and dangerous goods associated with the work activity.
Note: transport, storage, use and disposal of any hazardous substances / dangerous goods associated with work activities shall be in compliance with
the requirements of the relevant SDS.

Hazardous Substances and Dangerous Goods SDS

1. Personal Protective Equipment

List any personal protective equipment required for the work activity that is additional to the minimum standard PPE.

1. Change Management

Identify the necessary tools or processes required to manage change to the work activity, location, conditions, or engineering and how changes shall be
communicated to project personnel and all other affected parties.

1. Simultaneous Operation (SIMOPS) Management and Planning

Identify any potential work activity interfaces, incompatible work activities and specify the minimum controls required to mitigate any risks associated with
these activities.
 SIMOPS Control measures Risk level

Work activity interfaces and/or

incompatible work undertaken at the
same time that the described work
activity.

1. Supporting Documents and Drawings

List supporting documentation associated with the work activity to be undertaken ( i.e. plans/elevations, schematics, P&IDs, photos).

Document number Document Title

1. Compliance Mapping

List statutory/regulatory requirements specific to the work activity eg. Australian / New Zealand Standards, Codes of Practice, and industry guidelines).
Appendix E – Job Safety Environment Analysis (Refer section 3.5)
Project Name / Site Address: ___________________________________________________________________________

Task Details: ________________________________________________________________________________________

Permits / Plan Required:

☐Clearance to Work Permit ☐Hot Work Permit ☐Complex Isolation Permit ☐Rescue Plan ☐Other:_____________

☒Confined Space Entry Permit ☐Grid Mesh Reinstatement Permit ☐Hazardous Gas Zone Permit ☐Traffic Management Plan

Equipment Used Qualifications, Licenses, Training Required

All site specific actions, identified hazards and control measures are to be detailed and assessed below:
 What could harm me or the What can I do to reduce
Initial Risk Residual Risk
environment? (Hazard) risk? (control measure) Person Responsible for
control
Low Low
Dust Schedule work for low wind
Action/Step
conditions Bill Mac – Supervisor
Mod Med
Damage to Traditional Land
Eg Clearing land surface
Obtain clearing permit Bill Mac – Supervisor
High High
Noise
Suppress with use of water Joe – Water Cart Op
Risk to the Public carts

Team Sign On

I have read the contents of and agree to work in accordance with this JSEA. Responsible person / Supervisor / Line Manager Review

ContractorInduct
Role Name Signature ion Card # Reviewed by Date Sign

Responsible person

Need more lines? Simply add another sign on page

Appendix F – Chemical Register (Refer section 4.2)

Chemical Register
 Chemical Manufacturer Use Quantity PPE requirements SDS Date

Safety glasses

Diesel Fuel BP Fuelling lawn mower 20 litres Viton / Nitrile gloves 9 Jan 2017

Appendix G – Toolbox Meeting (Refer section 5.1)

All Toolbox Talks undertaken on behalf of INSERT ORGANISATION are recorded on this form and
signed by participants.

All corrective actions noted on this form are implemented and signed by the nominated person. It is
the responsibility of the INSERT RESPONSIBLE POSITION to ensure that all corrective actions are
completed and reviewed for effectiveness.
Toolbox Talks

Workplace:

Subject of Talk:

Presented by:

Duration: Date:

Persons Present

Print Name: Signature: Print Name: Signature:

Points Raised / Comments

Action Complete

Corrective Action Action by

Sign off Date

Appendix H – Training Register (Refer section 7.5)

Having regard to the hazards and risks associated with the scope of work performed by the
contractor, INSERT ORGANISATION has assured that all personnel are trained and competent to
perform all tasks in a way that is safe and does not adversely impact on themselves, others or the
environment.
The following register contains details of the skills and competencies of the organisation’s personnel.

Skills /
Competencies /
Employee Experience Training Card No. /
Position Held Expiry
Name Provider Reg. No
(e.g. tickets /
qualifications)

Appendix I – Incident Investigation Report (Refer section 8.3)

 Date Reported Source of Completion
Description Planned Actions
Identified By Identification Date

Update
Organsational
Management Chart to reflect
Organisational chart new employees
Plan
13/01/16 J Darling does not reflect Update process for 10/02/16
Compliance on board new staff
current staff
Review to include change
on Organisational
Chart

Update training to
current status
Management Training register has Update processes
Plan not been updates to to ensure
13/01/16 J Darling 07/02/16
Compliance reflect training in the recording of new
Review past 3 months qualifications
gained is
completed

Recent change to
Prepare
Management fatigue communications to
Plan management inform workers of
13/01/16 J Darling 16/02/16
Compliance standards have not new rules
Review been communicated Present new rules
to the workforce at toolbox meeting

Power cord Remove of damage

Workplace damaged on drill at tool, tag drill out of
14/02/16 N. Naitanui service, send tool 14/01/16
Inspection 12 Weaponess Rd
to manufacturer
Northam for repair

Dispose of lifting
21/02/16 J Kennedy On the job Lifting sling torn sling, order 22/02/16
replacement

Date Reported Source of Completion

Description Planned Actions
Identified By Identification Date

Appendix J – Management Plan Audit and Improvement (Refer

section 10.1)
General

Auditor

Other Attendees
Example Activities Reviewed Conforms

Yes ☐ No ☐ N/A ☐
Changes and distribution of the HSE Management Plan are recorded

Scope of works delivered by company and organisation details are current Yes ☒ No ☐ N/A ☐

HSE Policy signed and dated by Director/Manager Yes ☐ No ☐ N/A ☐

HSE Risk Register is maintained Yes ☐ No ☐ N/A ☒

Controls for high risk activities are documented Yes ☐ No ☐ N/A ☐

Training and Competency Register is current Yes ☐ No ☐ N/A ☐

Induction Training records are current Yes ☐ No ☐ N/A ☐

Roles and responsibilities are allocated and signed Yes ☐ No ☐ N/A ☐

Plant / Equipment Register is current Yes ☐ No ☐ N/A ☐

Hazardous Substances and Dangerous Goods Register is current Yes ☐ No ☐ N/A ☐

Waste Management is managed as per the Waste Management Procedure Yes ☐ No ☐ N/A ☐

Traffic Management is managed as per the Traffic Management Procedure Yes ☐ No ☐ N/A ☐

Public Safety is managed as per the Public Safety Procedure Yes ☐ No ☐ N/A ☐

Fitness for work is managed as per the Fitness for Work Procedure Yes ☐ No ☐ N/A ☐

Lifting activities are managed as per the Lifting Procedure Yes ☐ No ☐ N/A ☐

Working alone is managed as per the Lone Worker Procedure Yes ☐ No ☐ N/A ☐
Mobile Plant is managed as per the Mobile Plant Procedure Yes ☐ No ☐ N/A ☐

Excavation is managed as per the Excavation Procedure Yes ☐ No ☐ N/A ☐

Hazardous Substances and Dangerous Goods are managed as per the Hazardous
Yes ☐ No ☐ N/A ☐
Substances and Dangerous Goods Procedure

Work at heights is managed as per the Working at Heights Procedure Yes ☐ No ☐ N/A ☐

Work is confined space is managed as per the Confined Space Procedure Yes ☐ No ☐ N/A ☐

Workplace Inspections are conducted as per schedule Yes ☐ No ☐ N/A ☐

Register of Injuries is current Yes ☐ No ☐ N/A ☐

Incident Investigation Reports have been completed and corrective actions have been
Yes ☐ No ☐ N/A ☐
transferred to the Corrective Actions Register

Actions on the Corrective Actions Register are closed Yes ☐ No ☐ N/A ☐

Plant, tools and Equipment Register is current Yes ☐ No ☐ N/A ☐

Leadership activities are defined and measured Yes ☐ No ☐ N/A ☐

Workers Compensation Information is current Yes ☐ No ☐ N/A ☐

Work sites have appropriate emergency preparedness Yes ☐ No ☐ N/A ☐

Other: Yes ☐ No ☐ N/A ☐

Items Identified for Correction

Outstanding Issues and Recommendations
Follow up actions required Yes ☐ No ☐ When

Completed By

Name Position

Signature Date
Appendix K – Workplace Inspection (Refer section 10.2)

Freq 2017

ITEM
1M, 3M, 6M,
January February March April May June July August September October November December
12M

Date By who Date By who Date By who Date By who Date By who Date By who Date By who Date By who Date By who Date By who Date By who Date By who

Induction

PPE Compliance

Certified plant

Workplace Amenities

Chemicals

Mobile cranes

Site Address: __________________________________________________Date: ___ / ___ / ___ Job #:

______________________________________Task: ________________________________________________________Assess the
risk

Identify the hazards (e) = also an environmental hazard/control

Choose your controls: Choose all appropriate controls for all identified hazards.

I have read the contents of and agree to work in accordance with this Step Back. Responsible person
/ Supervisor / Line Manager ReviewTeam Sign On

Project #:__________________Job / Work Order #: _________Date Created:_______________Valid Until:

_________________JSEA prepared by: ___________