Acadian Contractors, Inc.

• Client / Site

• Location
  Address

• PIC

• Conducted on

  Date

• Prepared by

• Location of Inspection
  Address

• List personnel present during observation:

SAFETY MEETING

• Is a completed daily safety meeting form present

  Yes

  No

  N/A

• Does the form identify a task overview <br>

  Yes

  No

  N/A

• Are the topics adequate to the task and environment of work

  Yes

  No

  N/A

• Add media

  Media

• Comments

JSEA

• Is a JSEA present for the task being performed

  Yes

  No

  N/A

• Is the JSEA signed by all personnel involved in the task including the PIC (Person in Charge)

  Yes

  No

  N/A

• Have all risks identified been properly mitigated

  Yes

  No

  N/A

• Has each mitigation been assigned to an individual or group

  Yes

  No

  N/A

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  Media

• Comments

BEHAVIOR BASED SAFETY

• Is the TAKE 5 process being utilized

  Yes

  No

  N/A

• Are all personnel participating

  Yes

  No

  N/A

• Are the cards being properly completed

  Yes

  No

  N/A

• Is the PIC reviewing the observations daily

  Yes

  No

  N/A

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• Comments

SHORT SERVICE EMPLOYEE

• Has each SSE been assigned a mentor identified on the JSEA as well

  Yes

  No

  N/A

• Can each SSE identify their mentor

  Yes

  No

  N/A

• Do total number of SSE's exceed 20% of crew (1 to 5 ratio) shall not exceed unless a variance approved by the client

  Yes

  No

  N/A

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• Comments

FIRE PROTECTION

• All fire extinguishers inspected, charged and accessible

  Yes

  No

  N/A

• Combustible and flammable material properly stored

  Yes

  No

  N/A

• Exit routes clear and marked

  Yes

  No

  N/A

• Evacuation routes posted and accurate

  Yes

  No

  N/A

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• Comments

FALL PROTECTION

• All practical options to eliminate the need to perform elevated work from heights have been explored

  Yes

  No

  N/A

• Fall protection risk and hazards have been identified on the task related JSEA

  Yes

  No

  N/A

• A rescue plan has been developed and all equipment needed to execute is readily available and on site

  Yes

  No

  N/A

• All fall arrest equipment/ systems being utilized are in good condition and have been inspected prior to use

  Yes

  No

  N/A

• Fall protection system(s) being utilized allow workers to tied off 100% of the time

  Yes

  No

  N/A

• Anchor point(s) are capable of supporting 5000lbs

  Yes

  No

  N/A

• Anchor point vertical of the user

  Safe

  At Risk

  N/A

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• Comments

OPEN HOLE: Openings 2" or greater located in any walking or working surface

• Open holes have been properly barricaded and/or covered

  Yes

  No

  N/A

• Barricades have a top rail and middle rail: top rails of each barricade are at least 42" in height and are capable of withstanding a load of at least 200lbs applied in any direction

  Yes

  No

  N/A

• A 4" kick plate, or third rail no more than 4" above the decking is installed if personnel are working below<br>

  Yes

  No

  N/A

• Open holes that cannot be immediately barricaded after exposure are monitored by an attendant (hole-watch) with no other duties and is equipped with fall protection at all times

  Yes

  No

  N/A

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• Comments

DROPPED OBJECTS

• Dropped objects risk and hazards have been identified on the task related JSEA

  Yes

  No

  N/A

• Suitable bins are provided for small, loose objects such as off-cuts, welding rod stubs, nuts and bolts, etc.

  Yes

  No

  N/A

• All hand tools are secure and restrained from free falling

  Yes

  No

  N/A

• The area below is adequately barricaded and personnel have visual warnings to increase awareness to anyone wanting to enter

  Yes

  No

  N/A

• The upper level work area is tidy and all loose material, pieces of scrap, unwanted tools and equipment are removed and positioned safely out of the way

  Yes

  No

  N/A

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• Comments

ELECTRICAL

• Power panels, controls, receptacles and wiring covered

  Yes

  No

  N/A

• Are all components free of missing or loose parts

  Yes

  No

  N/A

• Are all electrical cords in use clear of damage

  Yes

  No

  N/A

• Do extension cords have a grounding conductor

  Yes

  No

  N/A

• Any extension cords through walls, doors, ceilings, under rugs or mats

  Yes

  No

  N/A

• Electrical panels marked to indicate service and voltage

  Yes

  No

  N/A

• Emergency Exits are labeled and illuminate

  Yes

  No

  N/A

• Are electrical tools marked with a sticker that reads- IGNITION SOURCE

  Yes

  No

  N/A

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• Comments

GRINDERS

• Do all grinders being utilized have the manufactures guards in place: control handle, disc guard and auto shut-off switch

  Yes

  No

  N/A

• Is double eye protection being utilized when grinding

  Yes

  No

  N/A

• Is the work rest and adjustable tongue on pedestal grinders properly set: 1/8" work rest and 1/4" tongue

  Yes

  No

  N/A

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• Comments

CUTTING AND BRAZING

• Are cylinders legibly marked to clearly identify the contents or type of gas

  Yes

  No

  N/A

• Are compressed gas cylinders secure and safe for operation

  Yes

  No

  N/A

• Are cylinders, cylinder valves, couplings, regulators, hoses and apparatuses kept free of oily substances

  Yes

  No

  N/A

• Are cylinders properly stored at a minimum of 20' separation or by a non combustible barrier

  Yes

  No

  N/A

• Are cylinders kept clear of ignition sources

  Yes

  No

  N/A

• Are fittings inspected for leaks and properly tightened (confirm with soap and water solution in spray bottle)

  Yes

  No

  N/A

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• Comments

PAINTING AND BLASTING

• Are appropriate NIOSH approved respirators being used during painting, blasting and clean-up procedures

  Yes

  No

  N/A

• Are all respirators well maintained and properly stored when not in use

  Yes

  No

  N/A

• Is painting being performed in a well ventilated area

  Yes

  No

  N/A

• Is NO SMOKING signage posted in painting areas

  Yes

  No

  N/A

• Are environmental practices being followed

  Yes

  No

  N/A

• Are fittings and valves properly secure

  Yes

  No

  N/A

• Are blasting machines equipped with remote shut down switches (deadman switch)

  Yes

  No

  N/A

• Is the breathing air class D and filtered to remove moisture, oil mist and paticulates

  Yes

  No

  N/A

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• Comments

SCAFFOLDING

• Has the scaffolding been inspected and tagged approved for use

  Yes

  No

  N/A

• Is the scaffolding equipment equipped with the appropriate guard rails and work platforms

  Yes

  No

  N/A

• Is the staging surfaces level, smooth and free of obstructions (proper footing in place)

  Yes

  No

  N/A

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• Comments

LADDERS

• Are ladders in good condition with no missing or loose parts

  Yes

  No

  N/A

• Are the labels readable and legible

  Yes

  No

  N/A

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• Comments

HOSES

• Are hoses in good, safe working condition

  Yes

  No

  N/A

• Are secondary protectors in place, i.e. safety pins and whip checks

  Yes

  No

  N/A

• Are the gaskets for each connection inspected and replaced if worn, distorted or too soft

  Yes

  No

  N/A

• Are hoses laid out so that they will not obstruct employees

  Yes

  No

  N/A

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• Comments

SLIP, TRIP, FALL HAZARDS

• Are drain covers and grates in good repair and properly installed

  Yes

  No

  N/A

• Are walkways/ identified pathways clear of material, cords and hoses

  Yes

  No

  N/A

• Are steps and guardrails in place and properly secured

  Yes

  No

  N/A

• Is there adequate lighting in all areas including exterior

  Yes

  No

  N/A

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• Comments

PERSONAL PROTECTION

• Are all machine guards in place and properly set

  Yes

  No

  N/A

• Are eyewash stations capped and easily accessible

  Yes

  No

  N/A

• Is proper PPE being utilized according to the JSEA

  Yes

  No

  N/A

• Is PPE being used appropriate for the task

  Yes

  No

  N/A

• Are proper body mechanics being used

  Yes

  No

  N/A

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• Comments

NOISE

• Are noise levels continuously above 85 decibels

  Yes

  No

  N/A

• Are employees utilizing hearing protection

  Yes

  No

  N/A

• Comments

RIGHT TO KNOW

• Are SDS(s) present for all chemicals onsite

  Yes

  No

  N/A

• Are personnel aware of the location of the SDS(s)

  Yes

  No

  N/A

• Are personnel familiar with safety precautions regarding chemical usage

  Yes

  No

  N/A

• Is only the minimum amount of chemical in the area and/or properly contained

  Yes

  No

  N/A

• If chemicals are in use, was its safe usage included in the JSEA up to and including emergency procedures

  Yes

  No

  N/A

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• Comments

RIGGING

• Does all rigging have current tags attached

  Yes

  No

  N/A

• Is all rigging material inspected prior to use and the correct material for the task

  Yes

  No

  N/A

• Are proper rigging practices being followed

  Yes

  No

  N/A

• Are only qualified riggers performing rigging duties

  Yes

  No

  N/A

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• Comments

HOUSEKEEPING

• Pictures of the area are a requirement of this section

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  Media

• Does the environment offers a designated area for food and drink consumption out of the work area

  Yes

  No

  N/A

• Are all water coolers sealed and labeled with a date of liquid fill

  Yes

  No

  N/A

• Comments

SPECIALITY OR CRITICAL TASK

WORK AREA SAFETY DRIVEN

• O to 5 you have observed behavior and/or questioned personnel and decided the work area is Production Driven. 6-10 is you have observed behavior and/or questioned personnel and decided the work area is Safety Driven

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• Comments

SIGNATURES

• Person In Charge Name

  Sign

• Name of Facilitator

  Sign