INFORMATION:

1- Fill in sheet 2-Checks only.

2- Sheet (Final L3 Report) is formulated and protected.

3- Critical (Go-No-Go) requirements are highlighted in

YELLOW
4- In tab "2- Checks" Hover over column cells to see reference
is made available, for more references refer back to relevant
Specification/Procedure.

5- Result of L3 assurance is auto assessed following this Risk

assessment matrix (RAM)"
 Inspection Date:
Inspection Location:
Contractor Name:
Contract Number:
Area Supervisor: Name & Ref. Ind.

Sr No. Assurance on How / What to check

Control measures related to
1 potential fall areas (Work at Height) Assessment, check 5 controls implemented at site.
identified in Risk Assessment.
Scaffolding working platforms and
2 constituent parts are as per the
minimum requirements.
Hazards of working at height identified in Risk
Assessment, check the knowledge of 5 worker involved in
such activity.
Controls of working at height hazards identified in Risk
Fall protection installed for any heights above 300mm.
All operatives using Personal Fall Protection Equipment
(PFPE) trained in their use. Equipment is inspected.
Sample 5 worker involved.
Guardrails and handrails are secured.
There is no lateral gaps in guardrails except for access
and egress.
Housekeeping is maintained on the platforms at all times.

Evidence of Inspection done by the authorised person is

in place.
Inspection taking place minimum every 7 days , sample 2
Scaffolding working platforms area.
3
inspected and records in place.
Scaffold Tagging System for all scaffolds is implemented,
sample 2 area.
Inspections are taking place and recorded.
Staff working on Scaffolding are Sample 5 Scaffolder to demonstrate evidence of training
4
trained. achievement (Scaffolder Card).
Barriers and warning signs to identify the danger areas
are installed.
Falling Objects Protection are in
5 There is no opening on the platform or/and between the
place.
boards.
Scaffolders are taking precaution to avoid falling objects.
Drill conducted to test Rescue Plan as stated in risk
Rescue plan of scaffolding activity in assessment and/or method statement.
place and materials are available at Rescue equipment available at the workplace and
6
site and scaffolders trained to use maintained in good order.
it. Scaffolders trained in its use, sample 3 scaffolders to
check their knowledge.
No damaged or defective equipment in use with working
Damaged or Defective Equipment at height activities.
7 are removed from use and placed in
quarantine area. Designated area of Damaged or Defective Equipment
clearly identified and/or labelled ‘Do not use’.
 Inspector (Lead): Name & Ref. Ind.
Name & Ref. Ind.
Inspection Team: Name & Ref. Ind.
Name & Ref. Ind.

YES/NO STATUS Comments

Not checked

Not checked

Not checked

Not checked

Not checked

Not checked

Not checked
 HSE Tracker

* Verification of compliance to requirements and procedures in processes.

No. Requriment Status Comments Mandatory action

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