COVER SHEET
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Document No.
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Inspection Title (Group/ Squadron)
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Program Inspection
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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 AFI90-201, 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. Observations do not require reply, but 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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Best Practices
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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
- 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
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
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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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Primary USR:
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When was primary USR appointed?
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When was primary USR trained?
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When did primary USR last receive annual Privilege Brief?
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Alternate USR:
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When was alternate USR appointed?
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When was alternate USR trained?
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When did alternate USR last receive annual Privilege Brief?
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MOTORCYCLE SAFETY REPRESENTATIVE (MSR)
MSR
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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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Primary MSR:
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When was the primary MSR appointed?
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When was the primary MSR trained?
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Alternate MSR:
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When was the alternate MSR appointed?
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When was the alternate MSR trained?
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HIGH RISK ACTIVITIES PROGRAM
HRAP
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Has the Unit Commander provided a Risk Activity Briefing to all unit personnel whether they chose to participate in high risk activities or not?
MICT
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Has squadron accomplished the following MICT checklists: 1. Unit Safety Representative (USR) Responsibilities/ 2. Supervisor Occupational Safety Responsibilities (within the squadron)/ 3. Commander below Installation Level Responsibilities Communicator/ 4. RM (RM-01) - AFI90-201, Para. 5.4.
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DISCREPANCY
Discrepancy
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Open/Closed
- Open
- Closed
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Reference
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Work Order#
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Date Closed
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Database Reference # (For Internal Use Only)
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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
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Has the Unit Commander appointed at least one Additional Duty Weapons Safety Representative (ADWSR) in writing coordinate the Weapons Safety Program?
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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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Primary ADWSR:
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When was the primary ADWSR appointed?
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When was the primary ADWSR trained?
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Alternate ADWSR:
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When was the alternate ADWSR appointed?
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When was the alternate ADWSR trained?
MICT
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Has squadron accomplished the following MICT checklists: 1. SEW-3 Weapons Safety program Management - AFI90-201, Para. 5.4.
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DISCREPANCY
Discrepancy
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Open/Closed
- Open
- Closed
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Reference
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Work Order#
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Date Closed
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Database Reference # (For Internal Use Only)
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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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Primary SFSO:
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When was the primary SFSO appointed?
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When was the primary SFSO trained?
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Alternate SFSO:
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When was the alternate SFSO appointed?
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When was the alternate SFSO trained?
MICT
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Has squadron accomplished the following MICT checklists: 1. SE F01 - Aviation Safety/ 2. AMC SEF Sup - Aviation Safety - AMC Sup - AFI90-201, Para. 5.4.
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DISCREPANCY
Discrepancy
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Open/Closed
- Open
- Closed
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Reference
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Work Order#
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Date Closed
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Database Reference # (For Internal Use Only)
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Date Closed
FACILITY INSPECTION
OCCUPATIONAL SAFETY
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SAFETY CULTURE
1 - VERY POOR - i.e., Personnel are unyielding/defiant toward safety issues/inspectors.
2 - POOR - i.e., Evident by lack of engagement in protecting people/assets. Slow to abate hazards.
3 - OK - i.e., Safety is not a priority, but personnel display a willingness to abate hazards/issues.
4 - GOOD - i.e., Personnel are willing to take initiative/action to abate hazards & protect ppl/assets.
5 - EXCELLENT - i.e., Personnel are deeply engaged in safety culture; preventing/abating hazards.
Section
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DISCREPANCY
Discrepancy
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Open/Closed
- Open
- Closed
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Reference
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Work Order#
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Date Closed
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Database Reference # (For Internal Use Only)
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Date Closed
WEAPONS SAFETY
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SAFETY CULTURE
1 - VERY POOR - i.e., Personnel are unyielding/defiant toward safety issues/inspectors.
2 - POOR - i.e., Evident by lack of engagement in protecting people/assets. Slow to abate hazards.
3 - OK - i.e., Safety is not a priority, but personnel display a willingness to abate hazards/issues.
4 - GOOD - i.e., Personnel are willing to take initiative/action to abate hazards & protect ppl/assets.
5 - EXCELLENT - i.e., Personnel are deeply engaged in safety culture; preventing/abating hazards.
Section
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DISCREPANCY
Discrepancy
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Open/Closed
- Open
- Closed
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Reference
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Work Order#
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Date Closed
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Database Reference # (For Internal Use Only)
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Date Closed
FLIGHT SAFETY
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SAFETY CULTURE
1 - VERY POOR - i.e., Personnel are unyielding/defiant toward safety issues/inspectors.
2 - POOR - i.e., Evident by lack of engagement in protecting people/assets. Slow to abate hazards.
3 - OK - i.e., Safety is not a priority, but personnel display a willingness to abate hazards/issues.
4 - GOOD - i.e., Personnel are willing to take initiative/action to abate hazards & protect ppl/assets.
5 - EXCELLENT - i.e., Personnel are deeply engaged in safety culture; preventing/abating hazards.
Section
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DISCREPANCY
Discrepancy
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Open/Closed
- Open
- Closed
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Reference
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Work Order#
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Date Closed
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Database Reference # (For Internal Use Only)
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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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Unit Commander signatures are collected as acknowledgment of having received their inspection out-brief. Out-Briefs are given to unit commanders at the 80% inspection completion point as to inform unit commanders of their standing. Out-Briefs are designed to share the direction of the final inspection results per discussed issues, highlighted best practices, and unit observations, etc. Should a significant difference present itself, unit commanders will be notified by SEG immediately.
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60 AMW/SE Chief of Safety
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60 AMW/SEG Occupational Safety Manager
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Unit Commander
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60 AMW/SEG Occupational Safety Specialist
