Title Page
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Group
- Air Wing
- Maintenance Group
- Mission Support Group
- Operations Group
- Combat Com Group
- Medical Group
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Squadron
- Maintenance Sq.
- Aircraft Maint. Sq.
- Maint. Operations Flt.
- Operations Support Sq
- Contingency Readiness Flt.
- Air Squadron
- Logistics Readiness Sq.
- Security Forces Sq.
- Comm. Flight
- Force Support Sq.
- Civil Engineering Sq.
- Comptroller Flt
- Combat Com Sq.
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Section (i.e. Avionics, Propulsion, Air Trans)
- Air Trans
- Supply
- Vehicle Operations
- 531st Band
- POL
- Fuels
- Avionics
- Propulsion
- ISO
- NDI
- Metal Tech
- Elect/Enviro
- Hydrualics
- AGE
- Munitions
- CBCS Supply
- Power Pro
- Vehicle Maint. CBCS
- Communication CBCS
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Building Number
- 1669
- 1670
- 1671
- 1672
- 1673
- 1674
- 1675
- 1676
- 1677
- 1680
- 4175
- 4160
- 1101
- 1191
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
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Room Number
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Conducted on
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Prepared by
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Location
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USR:
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Occupational Safety Assessor
- SMSgt Donald Seymore
- Donnie Seymore
- MSgt Porfirio Diaz
- TSgt Zach Northcutt
- TSgt Brandon Galusha
- Maj Kurt Anderson
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Commander
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Governing regulation include AFI 91-203, AFI 91-202, OSHA 29 CFR 1910 and 1926, OSHA 29 CFR 1960, and all National Consensus Standards incorporated by reference i.e. NFPA, NEC, ANSI
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136th AW Safety Program Assessment Reviewed June 6 2018 By Donald Seymore
Safety Management Program
Unit Safety Representative (USR)
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Has the commander appointed a primary and alternate USR in writing? AFI 91-202 1.8.21.2
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Does the USR brief their commander quarterly on the units safety program? AFI 91-202 2.2.2.1
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Has the USR attended or completed USR training? AFI 91-202 2.2
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If deficient select the appropriate designator below.
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Remarks :
Management Commitment
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Is leadership actively involved in safety? AFI 91- 202 1.4.1.4
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Ask personnel about theit Commander's/Supervisor's take on safety.
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Do commanders ensure discrepancies are completed within 30 days or tracked and reported to the safety office every 30 days until complete? AFI 91-202 1.8.21.6
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If deficient select the appropriate designator below.
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Remarks :
Safety Bulletin Board
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Is a safety board available and visible?
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Is the required information posted?
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Af 457, Af 457 directions, AFVA 91-307, commanders safety endorsement, mishap prevention brief, CA-10, mishap reporting procedures, SEG-15, SEW-15
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If deficient select the appropriate designator below.
Emergency Procedures AFI 91-203 6.2.15 OSHA 1910.38
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Ask personnel if they know: Emergency phone numbers, emergency EXIT locations, fire extinguishers and pull stations location and operation, location of the rally point, and location of the severe weather shelter in place locations.
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Do personnel know emergency procedures for their area?
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Has an emergency action plan been developed?
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Has a written emergency action plan been written that meets the requirement of 29 CFR 1910.38
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Are emergency procedures briefed annually?
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Are briefings documented?
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If deficient select the appropriate designator below.
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Remarks :
Workplace Safety Inspections/Meetings
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Is the Supervisor or USR conducting monthly workplace inspections? AFI 91-202 2.2.2.2
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Are inspections documented IAW AFI 91-202 3.7?
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Are emergency light tests being conducted monthly? OSHA 1910.37 & NFPA 101
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Are they documented?
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Are fire extinguishers inspected and signed off monthly? 91-203 41.2.2.2 and NFPA 10
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Is the Supervisor or USR conducting monthly safety meetings? AFI 91-202 2.2.2.5
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Are on and off duty safety items briefed?
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Are safety meetings documented?
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If deficient select the appropriate designator below.
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Remarks :
Safety Training
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Has a Job Safety Train Guide (JSTG) been developed for this section? AFI 91-202 Attachment 4
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Does the JSTG meet AFI 91-202 Attachment 4 requirements?
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Has the JSTG been reviewed annually and documented? AFI 91-202 1.8.22.4
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Is the safety training documeted on an AFTO 55 or electronic equivalent (i.e. ARCNET)? AFI 91-202 1.8.22.5.1
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Do NCO'S, Air Force civilians, and commissioned officers in a supervisory roll receive Supervisor's Safety Training (SST)? 91-202 1.8.22.13
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If deficient select the appropriate designator below.
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Remarks :
Personal Protection Equipment
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Has the supervisor assessed all PPE needs for the work area? AFI 91-202 1.8.18.11.5
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Are PPE inspections performed? AFI 91-202 1.8.23.5
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Was any unserviceable PPE found during the assessment?
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If deficient select the appropriate designator below.
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Remarks:
Industrial Work Center
Fall Protection Program AFI 91-203 13.2 & AFI 91-203 24.16
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Do workers perform duties at 4ft or greater?
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Has a fall protection program been developed? ANSI Z359.2
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Does program include an emergency primary and secondary plan if a worker falls? ANSI Z359.4
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Is the PFAS equipment inspected at least quarterly and records of the inspections kept for at least one year? ANSI Z359.2 Sec 5.5
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Do employees have documented training? 29 CFR 1926.503 (b)(1)
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Does the equipment have the manufacturers name, ID code, and date? AFI91-203 13.4.6.2
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Do all employees who perform work above 4ft, where PFAS systems are available have required training? AFI 91-203 13.5.1
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If deficient select the appropriate designator below.
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Remarks:
Lockout/Tagout Progam AFI 91-203 CH. 21,
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Does this section have a Lockout/Tagout Program?
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Has the Supervisor developed a Energy Control Program? 29 CFR 1910.147(c)(1)
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Is each piece of equiment/machinery reviewed annually and documented? 29 CFR 1910.147(c)(6)(I)
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If deficient select the appropriate designator below.
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Remarks:
Forklift/Powered Industrial Equipment AFI 24-301, 29 CFR 1910.178 (I)(1)
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Does the section use a forklift or any powered industrial equipment? 29 CFR 1910.178
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Does the section have a list of approved trainers on file?
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Are training programs available and do they meet the requirements in 29 CFR 1910.178(3)(I) for training program content?
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Are operators reevaluated every 3 years?
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Are training outline reviewed annually?
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If deficient select the appropriate designator below.
Industrial Work Centers
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Is this an Industrial area? (Assess items below and document findings)
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Compressed Air Lines
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Compressed Gas Cylinders
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Hand Tools
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Ladders
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Machines firmly secured to floors, bases, or stands
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Grinding Machines
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Machine Guards
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Hydraulic Floor Jacks - lubricated & inspected
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Remarks :
Hazardous Communication Program (HAZCOM) AFI 90-821, 29 CFR 1910.1200
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Does the shop maintain chemicals?
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Has a written hazard communication program been developed? AFI 90-821 CH. 3 and 29 CFR 1910.1200
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Are Safety Data Sheets (SDS) available?
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Are chemical inventories available?
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Are all chemicals label in accordance with the GHS system?
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If deficient select the appropriate designator below.
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Remarks :
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Add media
Confined Space Program AFI 91-203 CH 23, 29 CFR 1910.146
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Does the area have confined spaces?
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Is the written confined space program approved and signed by the commander? AFI 91-203 23.2.7
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Is the program reviewed and documented annually? AFI91-203 23.2.5.7
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Are the workers that enter the confined spaces adequately trained? AFI91-203 23.2.7.2
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Are AFTO form 1024's complete, with all of the information that is required? AFI 91-203 23.5.1
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Are AFTO form 1024's kept on file for one year? AFI 91-203 23.5.1.1
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If deficient select the appropriate designator below.
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Remarks :
MICT COMMUNICATOR REVIEW AFI 91-202 3.4.4.
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Supervisor's Occupational
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USR
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Commander
Mishaps over past 12 months
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Were any mishaps reported over the past 12 months? If yes add total number in notes.
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Number of mishaps
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Add signature
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