COVER SHEET
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Document No.
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Inspection Title (Squadron)
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Program Inspection
- Completed
- N/A
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Facility Inspection
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Squadron Commander (Rank, Full Name)
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Safety Inspection Personnel (Rank, Name)
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Prepared by (Rank, Name, Unit, Office Symbol)
EXECUTIVE SUMMARY
EXECUTIVE SUMMARY
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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
- Highly Effective
- Effective
- Marginally Effective
- Non-Effective
- N/A
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Commander's Score
- Highly Effective
- Effective
- Marginally Effective
- Non-Effective
- N/A
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Unit Supervisor's Score
- Highly Effective
- Effective
- Marginally Effective
- Non-Effective
- N/A
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Unit Safety Representative's Score
- Highly Effective
- Effective
- Marginally Effective
- Non-Effective
- N/A
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Motorcycle Safety Representative's Score
- Highly Effective
- Effective
- Marginally Effective
- Non-Effective
- N/A
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Additional Duty Weapons Safety Representative's Score
- Highly Effective
- Effective
- Marginally Effective
- Non-Effective
- N/A
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Squadron Flight Safety Officer's Score
- Highly Effective
- Effective
- Marginally Effective
- Non-Effective
- N/A
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Unit Safety Culture Score
- Highly Effective
- Effective
- Marginally Effective
- Non-Effective
- N/A
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Best Practices
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Inspection Start Date
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Inspection Completion Date
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Inspection Report Sent to Unit
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Inspection Follow-up Due to Wing Safety
IN-BRIEF
IN-BRIEF RECAP
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In-Brief Date/ Time
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In-Brief Attendees (Rank, Name, Unit)
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FY Mishap Trends (Past Year - Current Year)
- Positive Trend
- Average Trend
- Negative Trend
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Mishap Trend Comments
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Open Discrepancy Comments
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Flagged MUSTT Rider Comments
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Hazard Abatement Comments
AREAS INSPECTED
Program Elements Assessed
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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.
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Hangar Door Operations and Training
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Hangar Door Operations and Training
Hangar Door Op
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Hangar Number
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Program Reviewed
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Training
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Hazardous Energy Control Program (HECP)
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Hazardous Energy Control Program
HECP
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Shop/Building
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Procedures
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Training
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Self-Inspection
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Confined Space Program
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Confined Space Program
Confined Space
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Section/Building
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Training Plan
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Master Entry Plan
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MEP Expiration Date
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Fall Protection
Fall Protection
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Does unit fall protection program plan include a rescue plan?
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Does supervision ensure all PFAS components receive a thorough inspection at least<br>quarterly and keep the record of inspection for at least one year?
PROGRAM INSPECTION
OCCUPATIONAL SAFETY
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OCCUPATIONAL SAFETY: APPLICABLE/NON-APPLICABLE
- Applicable
- Non-Applicable
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UNIT SAFETY REPRESENTATIVE (USR)
USR Overview
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Has the Unit Commander appointed a primary and alternate Unit Safety Representative (USR)?
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Has USR been trained within 30 days of appointment?
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Is the USR appointment letter accurate and up-to-date?
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ADD USR
USR
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USR:
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When was USR appointed?
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When was USR trained?
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When did USR last receive annual Privilege Brief?
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MOTORCYCLE SAFETY REPRESENTATIVE (MSR)
MSR Overview
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Has the Unit Commander appointed at least one Motorcycle Safety Representative (MSR) in writing coordinate the Motorcycle Safety Program?
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Has the MSR been trained within 30 days of appointment?
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Is the MSR appointment letter accurate and up-to-date?
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ADD MSR
MSR
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MSR:
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When was the MSR appointed?
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When was the MSR trained?
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DISCREPANCY
Discrepancy
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Reference
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Work Order#
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Database Reference # (For Internal Use Only)
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Open/Closed
- Open
- Closed
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Date Closed
WEAPONS SAFETY
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WEAPONS SAFETY: APPLICABLE/NON-APPLICABLE
- Applicable
- Non-Applicable
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ADDITIONAL DUTY WEAPONS SAFETY REPRESENTATIVE (ADWSR)
ADWSR Overview
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Has the Unit Commander appointed a primary and alternate Additional Duty Weapons Safety Representative (ADWSR) in writing?
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Has the ADWSR been trained within 30 days of appointment?
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Is the ADWSR appointment letter accurate and up-to-date?
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ADD ADWSR
ADWSR
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ADWSR:
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When was the ADWSR appointed?
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When was the ADWSR trained?
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EXPLOSIVES SAFETY TRAINING
Explosives Safety Training
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Are ADWSRs ensuring accurate training documentation and tracking mechanisms are in place at the appropriate unit/field management level?
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Are ADWSRs assuring initial and reoccurring explosives safety training of unit personnel associated with explosive operations is being conducted?
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SPOT INSPECTIONS
Spot Inspections
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Are ADWSRs conducting and documenting correctly monthly spot inspections?
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WRITTEN PROCEDURES
Written Procedures
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Are written procedures available at work site? Are they posted with any explosives facility license?
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Are locally written procedures developed for explosives operations IAW AFMAN 91-201 Section 7B?
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Are local written procedures affecting weapons safety coordinated with the weapons safety office?
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DISCREPANCY
Discrepancy
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Reference
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Work Order#
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Database Reference # (For Internal Use Only)
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Open/Closed
- Open
- Closed
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Date Closed
FLIGHT SAFETY
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FLIGHT SAFETY: APPLICABLE/NON-APPLICABLE
- Applicable
- Non-Applicable
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SQUADRON FLIGHT SAFETY OFFICER (SFSO)
SFSO
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Has the Unit Commander appointed at least one Squadron Flight Safety Officer (SFSO) in writing coordinate the Flight Safety Program?
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Has the SFSO been trained within 30 days of appointment?
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Is the SFSO appointment letter accurate and up-to-date?
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ADD SFSO
SFSO
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SFSO:
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When was the SFSO appointed?
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When was the SFSO trained?
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DISCREPANCY
Discrepancy
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Reference
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Work Order#
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Database Reference # (For Internal Use Only)
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Open/Closed
- Open
- Closed
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Date Closed
FACILITY INSPECTION
OCCUPATIONAL SAFETY
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DISCREPANCY
Discrepancy
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Reference
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RAC Code
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Work Order#
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Database Reference # (For Internal Use Only)
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Open/Closed
- Open
- Closed
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Date Closed
WEAPONS SAFETY
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DISCREPANCY
Discrepancy
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Reference
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RAC Code
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Work Order#
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Database Reference # (For Internal Use Only)
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Open/Closed
- Open
- Closed
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Date Closed
FLIGHT SAFETY
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DISCREPANCY
Discrepancy
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Reference
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RAC Code
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Work Order#
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Database Reference # (For Internal Use Only)
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Open/Closed
- Open
- Closed
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Date Closed
OUT-BRIEF
OUT-BRIEF
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Out-Brief Date/ Time
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Out-Brief Attendees (Rank, Name/ Unit)
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Total Findings
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Findings Breakdown
SIGNATURES
SIGNATURES (e-SSS)
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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
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60 AMW/SE Occupational Safety Manager
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60 AMW/SE Chief of Safety
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Unit Commander
