Azteca Energy Services Safety Audit

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

JSA

• Is JSA Complete?

  Yes

  No

  N/A

• Has Onsite Personnel Signed The JSA?

  Yes

  No

  N/A

Required PPE

• Hard Hat

  Yes

  No

  N/A

• Safety Glasses

  Yes

  No

  N/A

• Face Shield / Goggles

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Gloves

  Yes

  No

  N/A

• ANSI 107 Class II or III Safety Vest

  Yes

  No

  N/A

• Foot Protection / Safety Toe

  Yes

  No

  N/A

• FRC Clothing

  Yes

  No

  N/A

• Dust Mask

  Yes

  No

  N/A

Excavation

• Excavation Type:

  Stable Rock

  Type A

  Type B

  Type C

• Is the excavation less than 20' deep?

  Yes

  No

  N/A

• Documented Inspection by Competent Person

  Yes

  No

  N/A

• Benched or Sloped Properly = Class A -3/4:1 Class B -1:1 Class C-1 1/2:1

  Yes

  No

  N/A

• Access / Egress Within 25' Of Entrants?

  Yes

  No

  N/A

• Trench Box/Shoring Proper

  Yes

  No

  N/A

• Trench Box Certifications

  Yes

  No

  N/A

• Spoil Pile Minimum 2-Feet From Excavation

  Yes

  No

  N/A

• Signs, Signals & Barricades

  Yes

  No

  N/A

• One Call Valid

  Yes

  No

  N/A

• Utilities Identified

  Yes

  No

  N/A

Material Handling

• Body Mechanics

  Safe

  At Risk

  N/A

• Position of People

  Yes

  No

  N/A

• Manual Lifting Devices (Come-a-Longs, Chain falls, etc…)

  Safe

  At Risk

  N/A

• Safety Latch

  Safe

  At Risk

  N/A

• Slings

  Safe

  At Risk

  N/A

• Hooks & Shackles

  Safe

  At Risk

  N/A

• Wire Rope

  Safe

  At Risk

  N/A

• Lifting Chains

  Safe

  At Risk

  N/A

• Load Secure, Rigged Properly

  Yes

  No

  N/A

• Tag Lines Used

  Yes

  No

  N/A

Vehicle/Equipment/Crane

• Authorized/Qualified Operator

  Yes

  No

  N/A

• Designated Signal Person

  Yes

  No

  N/A

• Seatbelt Used

  Yes

  No

  N/A

• Daily/Weekly/Annual Inspection

  Yes

  No

  N/A

Housekeeping

• Dunnage

  Safe

  At Risk

  N/A

• Trash

  Safe

  At Risk

  N/A

• Trash Receptacles

  Yes

  No

  N/A

• Crew Trucks/Trailers

  Safe

  At Risk

  N/A

Material Storage

• Material Stored Properly

  Yes

  No

  N/A

• Flammable/Combustible Storage

  Safe

  At Risk

  N/A

• Pipe Chocked

  Yes

  No

  N/A

Electrical

• GFCI/Assured Grounding Program

  Yes

  No

  N/A

• Cords/Tools – Inspected

  Yes

  No

  N/A

• Cords Routed Properly

  Yes

  No

  N/A

Hot Work

• Permit

  Yes

  No

  N/A

• Permit Conditions Followed

  Yes

  No

  N/A

• Fire Watch

  Yes

  No

  N/A

Welding

• Grinder Condition

  Safe

  At Risk

  N/A

• Guards/Handles

  Yes

  No

  N/A

• Leads/Hoses/Gauges

  Safe

  At Risk

  N/A

• Bottle Storage

  Safe

  At Risk

  N/A

Fire Protection & Prevention

• Fire Suppression Equipment

  Yes

  No

  N/A

• Fire Extinguisher Inspection

  Yes

  No

  N/A

• Properly Rated/Size (BC versus ABC)

  Yes

  No

  N/A

• Combustible/Flammable Material Away from Hot Work

  Yes

  No

  N/A

Traffic Control

• Designated Flagger With Cones

  Yes

  No

  N/A

• Signs Posted per MUTCD

  Yes

  No

  N/A

• Escort Required/Used

  Yes

  No

  N/A

Signs/Barricades

• Condition

  Safe

  At Risk

  N/A

• Proper Type

  Yes

  No

  N/A

• Appropriate Location

  Safe

  At Risk

  N/A

• Marking Hazards

  Yes

  No

  N/A

Overhead Power Lines

• Power Lines Marked with Goal Post and/or Signs

  Yes

  No

  N/A

• Designated Spotter

  Yes

  No

  N/A

X-Ray

• Signs, Signals & Barricades

  Yes

  No

  N/A

Lock-Out/Tag-Out

• Potential Energy Sources Identified

  Yes

  No

  N/A

• Isolated

  Yes

  No

  N/A

• Verified

  Yes

  No

  N/A

• Affected Personnel Informed

  Yes

  No

  N/A

Miscellaneous

• Restrooms & Potable Water Available

  Yes

  No

  N/A

• First Aid Kit

  Yes

  No

  N/A

• Confined Space

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

Closing Comments