EXECUTIVE SUMMARY

EXECUTIVE SUMMARY

Summary

** This annual safety program assessment and facilities inspection meets and satisfies the mandatory safety requirements of AFI 90-201, Attachment 3. **

1. Upon completion of the inspection, 60 AMW Safety has 15 days to complete the inspection report for Commander coordination.

2. All noted program and facility (if applicable) findings from this report require corrective actions. Once the report is received by the unit, corrective actions must be sent to the safety office within 30 days.

3. Upon receipt of the report, the Unit Safety Representative (USR) will ensure all appropriate functional/facility managers receive a copy of the safety inspection report. Each noted finding requires a reply.

4. RIAs do not require a reply; however, should be addressed in a timely manner. The USR will consolidate responses and forward corrective actions taken or planned, along with an estimated completion date (ECD), to the safety office. If a work order request was submitted, enter the work order number, and the date the work request was submitted to base CE. Submission of a work request is NOT considered a closing action; only when the item is actually corrected.

5. Each open finding requires follow-up and a status sent to Wing Safety (60AMWSAFETYGround@us.af.mil) every 30 days until all actions are completed. Once item is corrected this will be verified by Wing Safety and officially closed in the report.

Overall Unit Score
Commander's Score
Unit Supervisor's Score
Unit Safety Representative's Score
Motorcycle Safety Representative's Score
Additional Duty Weapons Safety Representative's Score
Squadron Flight Safety Officer's Score
Unit Safety Culture Score

Best Practices

Inspection Start Date
Inspection Completion Date
Inspection Report Sent to Unit
Inspection Follow-up Due to Wing Safety

IN-BRIEF

IN-BRIEF RECAP
In-Brief Date/ Time

In-Brief Attendees (Rank, Name, Unit)

FY Mishap Trends (Past Year - Current Year)

Mishap Trend Comments

Open Discrepancies

Open Discrepancy Comments

Flagged MUSTT Riders

Flagged MUSTT Rider Comments

Open Hazards (Hazard Abatement)

Hazard Abatement Comments

AREAS INSPECTED

Program Elements Assessed

The following program elements; if applicable were assessed and found to be compliant unless otherwise noted in this report. Specific areas are broken down to provide additional guidance. Program elements requiring corrective actions are identified within this report as findings.

Hangar Door Operations and Training

Hangar Door Operations and Training

Hangar Door Op

Hangar Number

Program Reviewed

Training

Hazardous Energy Control Program (HECP)

Hazardous Energy Control Program

HECP

Shop/Building

Procedures

Training

Self-Inspection

Confined Space Program

Confined Space Program

Confined Space

Section/Building

Training Plan

Master Entry Plan

MEP Expiration Date

Fall Protection

Fall Protection

Does unit fall protection program plan include a rescue plan?

Does supervision ensure all PFAS components receive a thorough inspection at least
quarterly and keep the record of inspection for at least one year?

PROGRAM INSPECTION

OCCUPATIONAL SAFETY
OCCUPATIONAL SAFETY: APPLICABLE/NON-APPLICABLE

UNIT SAFETY REPRESENTATIVE (USR)

USR Overview

Has the Unit Commander appointed a primary and alternate Unit Safety Representative (USR)?

Has USR been trained within 30 days of appointment?

Is the USR appointment letter accurate and up-to-date?

ADD USR

USR

USR:

When was USR appointed?
When was USR trained?
When did USR last receive annual Privilege Brief?

MOTORCYCLE SAFETY REPRESENTATIVE (MSR)

MSR Overview

Has the Unit Commander appointed at least one Motorcycle Safety Representative (MSR) in writing coordinate the Motorcycle Safety Program?

Has the MSR been trained within 30 days of appointment?

Is the MSR appointment letter accurate and up-to-date?

ADD MSR

MSR

MSR:

When was the MSR appointed?
When was the MSR trained?

DISCREPANCY

Discrepancy

Reference

Work Order#

Database Reference # (For Internal Use Only)

Open/Closed
Date Closed
WEAPONS SAFETY
WEAPONS SAFETY: APPLICABLE/NON-APPLICABLE

ADDITIONAL DUTY WEAPONS SAFETY REPRESENTATIVE (ADWSR)

ADWSR Overview

Has the Unit Commander appointed a primary and alternate Additional Duty Weapons Safety Representative (ADWSR) in writing?

Has the ADWSR been trained within 30 days of appointment?

Is the ADWSR appointment letter accurate and up-to-date?

ADD ADWSR

ADWSR

ADWSR:

When was the ADWSR appointed?
When was the ADWSR trained?

EXPLOSIVES SAFETY TRAINING

Explosives Safety Training

Are ADWSRs ensuring accurate training documentation and tracking mechanisms are in place at the appropriate unit/field management level?

Are ADWSRs assuring initial and reoccurring explosives safety training of unit personnel associated with explosive operations is being conducted?

SPOT INSPECTIONS

Spot Inspections

Are ADWSRs conducting and documenting correctly monthly spot inspections?

WRITTEN PROCEDURES

Written Procedures

Are written procedures available at work site? Are they posted with any explosives facility license?

Are locally written procedures developed for explosives operations IAW AFMAN 91-201 Section 7B?

Are local written procedures affecting weapons safety coordinated with the weapons safety office?

DISCREPANCY

Discrepancy

Reference

Work Order#

Database Reference # (For Internal Use Only)

Open/Closed
Date Closed
FLIGHT SAFETY
FLIGHT SAFETY: APPLICABLE/NON-APPLICABLE

SQUADRON FLIGHT SAFETY OFFICER (SFSO)

SFSO

Has the Unit Commander appointed at least one Squadron Flight Safety Officer (SFSO) in writing coordinate the Flight Safety Program?

Has the SFSO been trained within 30 days of appointment?

Is the SFSO appointment letter accurate and up-to-date?

ADD SFSO

SFSO

SFSO:

When was the SFSO appointed?
When was the SFSO trained?

DISCREPANCY

Discrepancy

Reference

Work Order#

Database Reference # (For Internal Use Only)

Open/Closed
Date Closed

FACILITY INSPECTION

OCCUPATIONAL SAFETY

DISCREPANCY

Discrepancy

Reference

RAC Code

Work Order#

Database Reference # (For Internal Use Only)

Open/Closed
Date Closed
WEAPONS SAFETY

DISCREPANCY

Discrepancy

Reference

RAC Code

Work Order#

Database Reference # (For Internal Use Only)

Open/Closed
Date Closed
FLIGHT SAFETY

DISCREPANCY

Discrepancy

Reference

RAC Code

Work Order#

Database Reference # (For Internal Use Only)

Open/Closed
Date Closed

OUT-BRIEF

OUT-BRIEF
Out-Brief Date/ Time

Out-Brief Attendees (Rank, Name/ Unit)

Total Findings

Current Year (FY)
Last Year (FY)

Findings Breakdown

Critical
Significant
Minor

SIGNATURES

SIGNATURES (e-SSS)

1. Purpose. Provide the Unit Commander a written report of the annual safety program management assessment and facility inspection of the organization.

2. Background. IAW AFI 91-202, safety assessments and inspections are required and assist the commander with their safety and mishap prevention programs. The report consists of an executive summary, facilities inspected, program review, management to supervisor involvement, recommended improvement areas, trend analysis, and identified discrepancies. Actions to correct the identified areas have a 30-day suspense for corrective actions taken. Reply does not need to be delayed if identified items are not closed; rather, those items will be tracked at the unit level and reported to wing safety every 30 days until closed.

3. Recommendation. Wing CC review the annual safety assessment/inspection report.

60 AMW/SEG Occupational Safety Specialist
60 AMW/SE Occupational Safety Manager
60 AMW/SE Chief of Safety
Unit Commander
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.