Site inspection Form

Sequence No.

Date D M Y

Contractor / Contract No.

Line Number

S = Satisfactory / N = Need Improvement / U = Unsatisfactory

No. Items To Be Inspected S N U

1. Trafficking in person (TIP).

1.1. Are MCC's Trafficking In Persons (TIP) Policy implemented?

2. Environmental issues.

2.1. Are dust abatement measures implemented?

2.2. Are there any hydrocarbon substance leaks on the ground? From containers and or equipment?

2.3. Is equipment being maintained in a proper manner and records of all maintenance available?

2.4. Is the site tidy and clean?

2.5. Are excavated materials disposed of at an approved location?

3. General Issues

3.1. Do equipment operators have the proper licenses to operate equipment safely and efficiently?

3.2. Are high visibility clothing and all necessary PPE equipment provided to workers and visitors?

3.3. Are site specific traffic management plans, prepared, submitted to the PMC and approved prior to the start of work?

3.4. Are all necessary barricades, traffic cones, warning signs, lights and other safety devices available?

3.5. Did the contractor prepare and submit a Job Hazard Analysis? Has it been reviewed and approved by the PMC?

3.6. Are all mitigation measures mentioned in the ESMP and the Job Hazard Analysis implemented?

3.7. Are portable fire extinguishers and first aid kits provided in adequate number and type and mounted in readily accessible locations?

3.8. Is equipment being fueled in a safe manner with engines switched off?

4. Rigging and Material Handling

4.1. Are slings and rigging equipment inspected and marked for safe loads?

4.2. Are safety latches on hooks?

4.3. Do hoist ropes and slings have any visible damages (even if minor)?

4.4. No one is present under suspended loads.

4.5. Are cranes properly supported on outriggers?

4.6. Is the swing radius protected by barricades?

4.7. Are lifting operations within proximity of overhead power lines being carried out in a safe manner and a qualified signal man is available?

5. Excavation / Earth works

5.1. Are trench lengths limited to 150 m.?

5.2. Are excavations deeper than 1.5 meters conformant to the design and use of an anti-collapse measure?

5.3. Are excavated materials being removed from site immediately?

6. Fall Protection

6.1. Is a written site specific fall protection program in place?

6.2. All workers are protected at heights exceeding 182.88 centimeter or 6 feet?

6.3. Are excavation protected with fall protection systems?

6.4. Are all ladders maintained in good condition, joints between steps and side rails tight, all hardware and fittings securely attached, and moveable parts operating freely without binding or undue play?

7. Excavation Operations

7.1. Have a specific Activity Hazard Analysis or TMP been completed?

7.2. Does the contractor have competent person to test and certify the soil type for each excavation?

7.3. Has the competent person properly identified the soil type and provided guidance on proper protection systems?

7.4. Is adequate ventilation provided? Does the contractor have a mean for atmospheric testing?

7.5. Are means of entry and exit provided every 15 meters for excavation deeper than 1.2 meters?

7.6. Are excavations kept free of standing water?

7.7. Are excavations inspected prior to the start of each shift?

7.8. Are anti collapse measures available and used as and when necessary?

7.9. Are the public provided with sufficient access over and around the excavations?

8. Confined Space

8.1. Did the contractor provide proper confined space entry training to the staff?

Site inspection Form

No. Items To Be Inspected S N U

8.2. Did the contractor provide all the equipment required for confined space work? Such as Tripods, full body harness, ventilation fans and blowers, ladders…etc.

8.3. Did the contractor implement a work permit and a confined space permit system?

8.4. Did the contractor conduct toxic gas and oxygen level testing before allowing workers to enter a confined space?

8.5. Is a hole watchman trained and available?

8.6. Is there a sign indicating confined space works in progress?

9. Electrical

9.1. Are portable generators grounded?

9.2. Is temporary electrical connections properly installed and in waterproof enclosures?

9.3. Are cords and plugs in safe work condition?

10. Compressed Gasses

10.1. Is compressed gas cylinders regularly examined for obvious signs of defects, deep rusting, or leakage?

10.2. Is care used in handling and storage of cylinders, safety valves, relief valves, etc., to prevent damage?

10.3. Is red used to identify the acetylene (and other fuel-gas) hose, green for the oxygen hose and black for inert gas and air hoses?

11. Scaffolding

11.1. Are scaffolds erected in accordance to the scaffold design plan?

11.2. Are scaffolds erected by approved scaffolders?

11.3. Are scaffolds safe?

11.4. Is the entire width of the scaffold covered with walking platforms (timbers)

11.5. Are toe boards installed?

11.6. Are SCAF-TAGS being used indicating (RED) for unsafe scaffold, (GREEN) for safe scaffold?

11.7. Are scaffolds secured to the structure properly?

11.8. Are scaffolds inspected by a competent person on daily basis? And are the inspections documented.

INSPECTOR COMMENTS AND RECOMMENDATIONS

Inspection Conducted By

Name Job Title Signature

Attach Site photographs to the following page (Photographs must have date & time stamps)

ACTIVITY HAZARD ANALYSIS

Contractors Logo

Date prepared Prepared By Job description

Project Location Reviewed by

No. Job Step No. Hazard No. Remedial action to eliminate or minimize

hazards

No. Equipment No. Training No. Inspection

Contractor logo

INCIDENT REPORT FORM

Page 1 of 2

Reference No.

Date of Incident

Personal information of person(s) involved in the incident:

Last Name

Fist Name

MI Time of Incident

ID No. D.O.B. / /

Date of Report

M F

Home Address

Mobile No.

Incident Type Work No.

Personal Injury / Illness Affiliation

Property Damage MCC General Public

Environmental Incident MCA-Jordan Other Specify

Vehicular Incident PMC Project Manager Name & Signature

Near Miss Contractor

Other Specify : Visitor

Incident Summery (Provide detailed description & Photographs of the incident – attach additional pages if necessary )

Witness Name(s) Signature(s) Phone Number(s) 1

2

3

Classification First Aid Injury Illness Non-occupational Fatality

OSHA Recordable Yes No

Incident Type Injury Type Body Part Illness Type

Slip/Trip/Fall Abrasion Eye(s) L-R OCC Skin Disorder

Struck by/ Against Contusion Head/Neck Dust Disease - Lungs

Caught In/Between Laceration Arm(s)/Wrist(s) L-R Respiratory - Toxic Agent

Overexertion Puncture Hand(s)/Finger(s) L-R Systemic Poisoning

Repetitive Strain/Sprain Back Disorders - Physical

Foreign Body Fracture Trunk Disorders – Repetitive Trauma

Hand Tool/Equipment Irritation Leg(s)/Ankle(s) L-R Other :

Animal/Insect Bite Burn (Thermal/Chemical) Feet/Toes L-R

Other : Other : Multiple

I hereby certify that all of the above information is true and correct facts.

Contractor logo

INCIDENT REPORT FORM

Page 2 of 2

Prepared By / HSE Mgr. Approved By Project Mgr.

Name

Signature

Complete Details of the Incident & Photographs

Non-Compliance Notice ESMP

Page 1 of 1

Reference

Date Contract No.

Location HSE Specialist Signature

Notice: Pursuant to our site HSE inspection, this is an advisory notice of non-compliance with the mitigation measures specified in the ESMP during the implementation phase of the compact. Our HSE inspection report of the site is attached. The following needs your immediate corrective action. A re-inspection of the site will be done in 24 hours. The Engineer requests that you bring the site into compliance with the ESMP by correcting the noted violations.

HSE Measures Needing Correction:

Dates and Times of Re-inspection:

Violations Corrected: Yes No

HSE Inspector/Specialist: Signature:

نموذج شكاوى

الرقم المرجعي

التاريخ اعد بواسطة

تقديمه إلى تم التاريخ

معلومات الشكوى

تاريخ وصول الشكوى

اسم المشتكي

موضوع الشكوى

اسم المشروع

التفاصيل

القرارات

االجراءات المتخذة

التاريخ صادق عليها

مالحظات أخرى

.

.

.

.

Zarqa Water & Wastewater Program INCIDENT INVESTIGATION REPORT

Date of Incident Time Of Incident Location of Incident Report Completed By

August 28th 2013 Between 10:30 & 11:00 am. Contract 83 / Hashimieah December 31st 2013

A full description of the incident including all activities taking place leading up to and during the incident:

Based on statements by Foreman Sameeh Z. Abu Al Ata Dated December 28th 2013 (copy attached) he instructed the worker Mr. Ali Abdul Majeed Amro hereinafter referred to as (the injured employee) on the said date and time to climb on the water tank located on a scaffold behind the portable cabin belonging to BOSHEH Contracting Est. and fill it with water. According to statement by Mr.Ahmad Naser Al Alian dated December 8th 2013 (copy attached) when the worker climbed on the scaffolding, the whole thing collapsed and the worker fell breaking his left leg. Based on statement by Mr. Ali Al Khawaldeh (Safety Officer) dated December 8th 2013 (copy attached) he was contacted and informed of the incident; Mr. Khawaldeh took the injured employee to Zarqa Government Hospital for treatment.

----------END----------- Impact to (mark as appropriate):

Air Seawater Ground Water

Soil X Other

Source of Incident Water tank.

Sensitive Receptors Not applicable

Affected Persons Name Ali Abdul Majeed Amro Gender M X F Age

Medical and/or Police Reports (please attach)

Medical report attached. Police report not available.

Training records Not provided / an incident report was requested from BOSHEH Contracting Est. but was not provided.

Witnesses (please attach statements)

Name Organization Contact

Ahmad N. Al Omoush BOSHEH Contracting Est. N/A

Samih Abu Al Atta BOSHEH Contracting Est. 079-560-2447

Ali Al Khawaldeh BOSHEH Contracting Est. 079-597-9738

Names and telephone numbers of MoE, other government agencies and ENGINEER personnel contacted in relation to the incident.

Name Organization Contact

Non Non Non

The contractor did not report the incident to the Engineer; the PMC was contacted directly by the injured employee.

Identified non-compliances with regulations, project procedures and systems.

The employee did not use a ladder to climb on an elevated platform.

Identified deficiencies within project procedures and systems

The project procedure does not address situations related to working at heights and scaffolding.

Immediate controls implemented.

Non

Lessons Learned 1. All incidents must be reported accurately and on time. 2. Do not move anyone who suffered a severe fall, wait for paramedics. 3. Regularly inspect equipment and machineries.

Zarqa Water & Wastewater Program INCIDENT INVESTIGATION REPORT

PREVENTATIVE ACTIONS PROPOSED

SN ACTION TO BE TAKEN RESPONSIBLE PERSON TARGET DATE STATUS

01 Prepare a solid platform for the tank.

Ghassan Salameh January 2014 Open

02 Provide training. Ghassan Salameh January 2014 Open

03 Regularly inspect equipment Ghassan Salameh January 2014 Open

Investigation Team

Name Title & Organization Signature

Haymour, Ali M. HSE Specialist / PMC

Mahmoud Asi HSE Officer / MCA-Jordan

Report Distribution list

Name Title and Organization

Eng. Kamal Al Zoubi CEO (MCA-Jordan)

Eng. Shajan Joykutty Program Manager (PMC)

Eng. Khamis Al Omari Acting Program Manager (PMC)

Eng. Mai Abu Tarboush CEO (MCA-Jordan)

Eng. Mohammed Ababneh CEO (MCA-Jordan)

Eng. Sami Al Shamali Waste Water Network Construction Manager (PMC)

Instruction For Remedial Work Sub-Clause 7.6(c)

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Reference

Date Contract No.

Location

HSE Inspector/Specialist Signature

Resident Engineer Signature

Construction Manager Signature

Instruction: In accordance with sub-clause 7.6 (c) of the General Conditions of your Contract with MCA-Jordan, you are hereby instructed to execute the work that is urgently required for the safety of the Works (trench safety) and the protection of the public and/or workers. Specifically, the following work shall be implemented. If applicable, photographs of the site are attached. The Engineer will inspect the site in 24 hours to verify the installation of the works. Please note that if the urgently required works are not installed in 24 hours, the Engineer will further issue a Suspension of Part of the Works for this location per sub-clause 8.1. If applicable in your contract, the Engineer will remove applicable item of payment dedicated to trench safety from the monthly Interim Payment Certificate as specified.

Work to be implemented

1.

2.

3.

4.

5.

6.

7.

Date and Time of Re-inspection:

Urgently Required Works Installed: Yes No

HSE Inspector/Specialist: Signature:

Resident Engineer: Signature:

Construction Manager: Signature

Instruction For Remedial Work Sub-Clause 7.6(c)

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Boxes highlighted with this color contain formulas ((DO NOT MAKE ENTRIES))

HSE Statistics Report Project Name:

Project Number:

Area:

Project Start Date:

Project Manager Report Number:

HSE Manager: Period Ending:

NO. DESCRIPTION

LAST PERIOD

THIS PERIOD

TOTAL TO-DATE

NA

TU

RE

OF

IN

JU

RY

TYPE

First Aid Recordable

LAST PERIOD

THIS PERIOD TOTAL

TO-DATE LAST PERIOD

THIS PERIOD

TOTAL TO-DATE

1

EM

PLO

YE

ES

No. of Employees (overall) 0.00 00.00

0.00

Fracture Hand 0.00 0.00 0.00 0.00 0.00 0.00

Cut / wound 0.00 0.00 0.00 0.00 0.00 0.00

2

RE

CO

RD

AB

LE

CA

SE

S

No. of Lost Time Incidents LTIs "Days Away from Work (DAFW) Cases"

0.00 0.00

0.00

Sprain / Strain 0.00 0.00 0.00 0.00 0.00 0.00

3 No. of Restricted Work Cases 0.00 0.00

0.00

Asphyxiation 0.00 0.00 0.00 0.00 0.00 0.00

4 No. Occupational Illnesses 0.00 0.00

0.00

Skin Injuries 0.00 0.00 0.00 0.00 0.00 0.00

5 No. of Occupational Fatalities 0.00 0.00

0.00

Electric shock 0.00 0.00 0.00 0.00 0.00 0.00

6 No. of Medical Treatment Cases 0.00 0.00

0.00

Head injury 0.00 0.00 0.00 0.00 0.00 0.00

7 No. of Loss Consciousness Case 0.00 0.00

0.00

Arms / hand 0.00 0.00 0.00 0.00 0.00 0.00

8

NO

N-R

EC

OR

DA

BLE

No. of First Aid Cases 0.00 0.00 0.00

Knee / Ankle 0.00 0.00 0.00 0.00 0.00 0.00

9 No. of Near Misses 0.00 0.00

0.00

Eye 0.00 0.00 0.00 0.00 0.00 0.00

10 No. of Non-Occupational Fatalities 0.00

0.00 0.00

Neck 0.00 0.00 0.00 0.00 0.00 0.00

11

IND

UC

TIO

N / T

RA

ININ

G

No. of HSE Staff inducted 0.00 0.00 0.00

Finger 0.00 0.00 0.00 0.00 0.00 0.00

12 No. of Project Personnel inducted 0.00

0.00 0.00

Foot / Leg 0.00 0.00 0.00 0.00 0.00 0.00

13 No. of Employees Trained (other than Induction)

0.00 0.00 0.00

Back 0.00 0.00 0.00 0.00 0.00 0.00

14 Total Man-hours for HSE Induction

0.00 0.00 0.00

Torso 0.00 0.00 0.00 0.00 0.00 0.00

15 Total Man-hours for Training

0.00 0.00 0.00

Groin 0.00 0.00 0.00 0.00 0.00 0.00

16

INS

PE

CT

ION

No. of HSE Meetings 0.00 0.00 0.00

Others(specify) 0.00 0.00 0.00 0.00 0.00 0.00

17 No. of HSE Inspections

0.00 0.00 0.00

Others(specify) 0.00 0.00 0.00 0.00 0.00 0.00

18

EN

VIR

ON

ME

NT

& S

EC

UR

ITY

No. of Fires 0.00 0.00 0.00

Others(specify) 0.00 0.00 0.00 0.00 0.00 0.00

19 No. of Thefts

0.00 0.00 0.00

NA

TU

RE

OF

IL

LN

ES

SE

S

TYPE

First Aid Recordable

20 No. of Property Damage

0.00 0.00 0.00

LAST PERIOD

THIS PERIOD TOTAL

TO-DATE LAST PERIOD

THIS PERIOD

TOTAL TO-DATE

21 No. of Alcohol Intoxication Cases

0.00 0.00 0.00

Malaria 0.00 0.00 0.00 0.00 0.00 0.00

22 No. of Drugs Abuse Cases

0.00 0.00 0.00

HIV 0.00 0.00 0.00 0.00 0.00 0.00

23 No. of Spills / Leaks

0.00 0.00 0.00

Avian Flu 0.00 0.00 0.00 0.00 0.00 0.00

24 No. of Chemical Releases

0.00 0.00 0.00

Hearing Loss 0.00 0.00 0.00 0.00 0.00 0.00

25

VE

HIC

LE

S No. of Vehicles

0.00 0.00 0.00

Carpel Tunnel 0.00 0.00 0.00 0.00 0.00 0.00

26 Total Kms. Driven

0.00 0.00 0.00

Heat Exhaustion

0.00 0.00 0.00 0.00 0.00 0.00

27 No. of Vehicle Accidents

0.00 0.00 0.00

Skin Disorders 0.00 0.00 0.00 0.00 0.00 0.00

28

MA

N-

HO

UR

S

Total Man-hours Worked (Direct & Indirect) 0.00 0.00 0.00

Poisoning 0.00 0.00 0.00 0.00 0.00 0.00

29 Total Days Lost due to LTIs "DAFW cases"

0.00 0.00 0.00

Frost Bite 0.00 0.00 0.00 0.00 0.00 0.00

30 Total Man-hours from Last LTI "DAFW case" / Fatality

0.00 0.00 0.00

Others(specify) 0.00 0.00 0.00 0.00 0.00 0.00

31 RATES Total Recordable Injury rate (RIR) 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Prepared by: HSE Manager Name: Signature /

Date:

Approved by: Project

Manager Name:

Signature / Date:

Formula RIR = NUMBER OF RI’S X 200,000 ÷ TOTAL EMPLOYEE HOURS OF EXPOSURE

Suspension of Part of the Works Notice

ESMP Violations

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Reference

Date Contract No.

Location

HSE Specialist Signature

Resident Engineer Construction Manager

Approved Program Manager

Notice: Pursuant to our site HSE inspection reports, subsequent ESMP violation notice, and the Engineer’s Instruction for Remedial Action per sub-clause 7.6 (c) of the General Conditions of your contract; this notice serves as an Instruction to Suspend progress of part of the Works identified in the Location section of this notice per sub-clause 8.8 of the General Conditions. The cause of this notice is identified below and therefore sub-clauses 8.9, 8.10 and 8.11 shall not apply to this suspension.

Cause for Suspension of Part of the works: ESMP violations noted in the following prior notices.

1.

2.

3.

4.

5.

6.

Dates and Times of Re-inspection:

Resumption of Work Given per Sub-Clause 8.12: Yes No

HSE Inspector/Specialist: Signature:

Resident Engineer: Signature:

Construction Manager: Signature:

Program Manager: Signature:

Trafficking In Person (TIP) Audit Checklist

Date Time Contractor

# Aspect Yes No Comment

1 Do all foreign workers have a work permit?

2 At which date of the month is staff being paid?

3 Are contracts provided to workers? if yes are there copies?

4 How many hours are workers supposed to work in a single day?

5 How much overtime is being worked?

6 Is overtime being paid? At which rate?

7 Is there any incident of child labor?

8 Is there any incident of holding passports?

Prevention

1 Is a TIP Risk Management Plan developed?

2 Did workers and subcontractors sign the TIP statement?

3 Is the TIP provision included in the employment contract?

Awareness & Training

1 Construction workers are trained on TIP risk management.

2 Info with contacts where to refer victims / report TIP is on visible place for workers and communicated to project communities.

3

Availability of information materials on construction sites, such as posters or other appropriate information instruments which should contain contact details where to report incidences of TIP.

4

What kind of measures has been taken to raise awareness and mitigate potential risk of TIP among workforce? (e.g. Training workshop, cultural restriction and community values).

5 Are the workers aware of the MCC’s Zero tolerance policy on TIP?

Reporting

1 TIP Reporting system is in place.

2

Feedback of communities on the performance of the program. This will be in the form of informal discussions and organized focus group discussions with stakeholders and people from project communities.

3 Workers have access to a complaint mechanism where they can report complaints?

MCA-Jordan PMC Contractor acknowledgement