12-Hour Service and Work-Over Site Safety Report

• Conducted on

  Date

• Location:

• AFE #:

• Statoil Site Representative:

• Statoil Safety Representative:

• Contractors Working on Location:

• Status of Operations:

Applicable Permits:

• JSA / SJA Completed for Each Contractor on Location with Contractor Sign-In Sheet?

  Yes

  No

  N/A

• Hot Work Permit Completed?

  Yes

  No

  N/A

• Confined Space Permit Completed and Posted?

  Yes

  No

  N/A

• Critical Lift Permit Completed?

  Yes

  No

  N/A

• Ground Disturbance Permit Completed?

  Yes

  No

  N/A

Signage:

• Proper Signage in Place at the Entrance to Location?

  Yes

  No

  N/A

• Designated Smoking Area Assigned?

  Yes

  No

  N/A

• Proper PPE Signage posted at entrance?

  Yes

  No

  N/A

• Warning Signs Clean and Visable?

  Yes

  No

  N/A

• Tank Battery Signs Posted?

  Yes

  No

  N/A

General Site Inspection:

• Safety Data Sheets (SDS) and Shipping Papers are on Location and Easily Accessible?

  Yes

  No

  N/A

• There are No Fluid Leaks, Discharges or Spills on Location?

  Yes

  No

  N/A

• Interior / Exterior Berms Present on Location?

  Yes

  No

  N/A

• There are No Trip Hazards?

  Yes

  No

  N/A

• All Vessels Labeled as to their Contents?

  Yes

  No

  N/A

• Proper PPE/FRC being worn by all personnel on Location?

  Yes

  No

  N/A

• Is a Clean and Sanitary Portable Restroom Facility provided in close proximity to the location?

  Yes

  No

  N/A

• Erected Windsock Visable?

  Yes

  No

  N/A

• Production Equipment Set?

  Yes

  No

  N/A

• Fall Protection being utilized when Required?

  Yes

  No

  N/A

• First Aid Kit and Blood Born Pathogen Kit available on Location?

  Yes

  No

  N/A

• Are Proper Tools being Utilized for the Job at Hand?

  Yes

  No

  N/A

• Are all Tools in Proper Working Condition?

  Yes

  No

  N/A

• Adequate Handrails provided on stairs with 4 or more Risers?

  Yes

  No

  N/A

• Stairs have Non-Skid Steps and are uniform size?

  Yes

  No

  N/A

• Proper Lifting Mechanics are being Used by Personnel?

  Yes

  No

  N/A

• Housekeeping is Good in all Work Areas?

  Yes

  No

  N/A

• Backup Alarms are Working Properly on Material Handling Equipment?

  Yes

  No

  N/A

• Daily Inspection of Material Handling Equipment (Forklift / Loader) has been completed?

  Yes

  No

  N/A

• Operator of Material Handling Equipment (Forklift / Loader) has Proper Certification?

  Yes

  No

  N/A

• Material Handling Equipment (Forklift / Loader) is Parked with it Forks in the Down Position?

  Yes

  No

  N/A

• Seat-belts are being Used by Operator of Material Handling Equipment?

  Yes

  No

  N/A

• Dead-Men are Properly Marked?

  Yes

  No

  N/A

• All Parked Vehicles are Properly Chocked?

  Yes

  No

  N/A

• Back-In Parking is being Utilized on Location?

  Yes

  No

  N/A

• Spotters are being Utilized on Location?

  Yes

  No

  N/A

• Fire Extinguishers are Properly Placed and have Current Inspection Tags?

  Yes

  No

  N/A

• Whip-Check are in Place and Cement Blocks are Set on High Pressure Lines?

  Yes

  No

  N/A

• Trucks Observing 5mph Speed Limit on Location?

  Yes

  No

  N/A

Electrical:

• All Electrical Equipment, Trailers, Generators, Accumulators, and Pipe Wrangler are Properly Grounded?

  Yes

  No

  N/A

• All Electrical Equipment Properly Marked as to its Function?

  Yes

  No

  N/A

• "High Voltage" Warning Signs Properly Posted?

  Yes

  No

  N/A

• LOTO Devices Provided and Available?

  Yes

  No

  N/A

• All Electrical Wiring is off the Ground?

  Yes

  No

  N/A

• All Electrical Cords, Receptacles, and Plugs in Good Working Condition?

  Yes

  No

  N/A

• All Exterior Electrical Outlets are Covered?

  Yes

  No

  N/A

• Is Rig Grounded to Well-Head?

  Yes

  No

  N/A

• Are Pumping Unit Weights Secured with Chain and Binder?

  Yes

  No

  N/A

Rig Inspection:

• Wind Walls are Erected and Placed Properly?

  Yes

  No

  N/A

• Locking Nuts are Properly Tightened on All Hydraulic Leveling Jacks?

  Yes

  No

  N/A

• Safeguards Properly Installed over all Moving Parts?

  Yes

  No

  N/A

• Pipe Racks are Level and Secured with Chocks in Place for Pipe?

  Yes

  No

  N/A

• Pipe Wrangler is Level and Secure?

  Yes

  No

  N/A

• Danger Area around Pipe Wrangler is Properly Marked?

  Yes

  No

  N/A

• All Fuel Tanks are Stored at the Proper Distance from Ignition Sources?

  Yes

  No

  N/A

• Guy-lines are Properly Connected to Tested Ground Anchors?

  Yes

  No

  N/A

• Guy-Lines are Properly Clamped?

  Yes

  No

  N/A

• Safety Banners are Clean and Attached to Guy-Lines?

  Yes

  No

  N/A

• Operator is at Controls?

  Yes

  No

  N/A

• Tool Pusher is Present on Location?

  Yes

  No

  N/A

• All Equipment with Motors are Located at Least 50ft from Well-Head or Ignition Source?

  Yes

  No

  N/A

• Pump is Located at Least 50ft from Well-Head?

  Yes

  No

  N/A

• Accumulator has No Leaks, and has been Properly Charged?

  Yes

  No

  N/A

• Accumulator has Whip-Checks that are Properly Placed?

  Yes

  No

  N/A

• Is there a Clear Means of Egress from Rig and Floor?

  Yes

  No

  N/A

• Is Emergency Escape in Place for Derrick Man?

  Yes

  No

  N/A

Additional Findings / Issues or Concerns:

• Issue #1:

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• Issue #9:

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• Issue #10:

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• Safety Representative:

  Sign

• Company Man:

  Sign

• Tool Pusher:

  Sign

• Contractor Supervisor / Foreman:

  Sign