Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Section A: Project Details & Personnel Involved
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Date & time audit performed
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Driller signature
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Assistant driller signature
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EIT signature
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Auditor signature
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Project site name/#? (see Driller's log)
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Physical address if known? (see drillers log)"
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Work being performed & method (be specific, see drillers log)
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Job hazards noticed at this site? {Identified by tech(s) & auditor}
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Photo (optional)
Section B: Communication
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Discussed with supervisor/engineer before mobilization and or has clear direction about project
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Have a valid utility one call ticket? (We are in violation of state law w/o this)
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Utility locates sheet verifies all clear?
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Driller reviewed utility markings upon site arrival prior to drilling?
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Daily safety pre-task planning form & drivers log filled out
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Copy of JHA available
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Last time reviewed
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Feedback/observations/comments:
Section C: Technician Training
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Driller trained
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How
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How long has driller been performing this task/procedure?
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Current DOT medical examiners certificate
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Driller asst trained
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How
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How long has driller asst been performing this task/procedure?
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Current DOT medical examiners certificate
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EIT trained
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How
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How long has EIT been performing this task/procedure?
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Photo (optional)
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Feedback/observations/comments:
Section D: PPE
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Hard hat (Z89.1 / Z94)
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Type?
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Reflective outerwear?
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Type
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Safety eyewear (Z87)
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Type
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Safety footwear? (PR ASTM F2412/2413 or US ANSI Z41, section 5 standards or CSA Z195 Grade One Green Triangle
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Describe
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Hearing protection
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Type
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Gloves
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Type
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Other (respiratory, fall, H2S etc)
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Describe
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Photo(optional)
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Feedback/observations/comments:
Section E: Equipment & Supplies
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Shovels, 1 pointed & 1 flat
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18, 24 (two each) & 36" pipe wrench(one)
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Air powered or battery powered torque wrench w/charger
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Spare battery available
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Ratchet w/breaker bar, 1 1/4" & 1 1/8" sockets
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Set of hand tools & hacksaw/wood saw
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3lb maul
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Equipment in good condition
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Equipment stored neatly
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Water (job specific)
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Sample jars & labels
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3" x 30" thin wall tubes & caps
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Boring log forms & production sheets
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Fuel for drill rig
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Bituminous patch / quick grout, or other (job specific)
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Photo (optional)
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Feedback/observations/comments:
Section F: Rig Safety Requirements
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Rig on level surface or otherwise leveled?
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Drill indicators & warning lights clean
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Emergency kill switches operable (should be tested weekly at very least)
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Back-up warning indicator operable (mine sites only, rig & support truck)
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Any excess oil / grease
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Cables, chain guards, mast condition
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General overall condition
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Photo (optional)
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Feedback/observations/comments:
Section G: Body Use Movements
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Lifting, body mechanics
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Line of fire
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Eyes on task
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Pinch points minded
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Stretching performed today
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When was stretching performed
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Describe observed safe behaviors.
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Any supplies/equipment issued to tech(s) during audit?
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Photo (optional)
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Feedback/observations/comments:
Section H: Job Site Conditions / Safety Knowledge
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Severe weather / site emergency procedures known?
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Today's weather condition:
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Barricades / signage in place?
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Proper lighting
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Photo (optional)
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Feedback/observations/comments:
Section I: Required Braun/DOT Equipment & Documents(Drill Rig & support trucks 1 ton & up)
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Drill Rig# & milage
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U.S. DOT Stickers on Door (371094)?
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Any warning indicators lit up on dashboard?
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Emkay maintenance up to date?
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Windshield, windows & mirrors?
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Windshield wipers & fluid work?
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Horn functional?
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Seat belts work?
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Seat belt required sticker?
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Lights functional?
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Tires satisfactory (no uneven wear, bulges, etc)?
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Door, tailgate & vehicle # stickers in place & legible?
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Any body damage?
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Any visible leaks?
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Current DOT Annual Inspection?
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DOT pre-trip & log book filled out
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Current insurance card?
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Registration Current?
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Accident reporting kit?
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Emergency response guide book?
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Spare fuses?
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Spill response kit?
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Warning triangles?
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Jack & spare in place?
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1st aid kit?
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Fire extinguisher on board? (min 5lb for a mine site per MSHA)
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Secured/mounted?
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Size?
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Housekeeping (in & out)?
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Photo (optional)
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Feedback/observations/comments:
Section J: Required DOT Equipment & Documents(Support Truck)
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Support Truck# & milage
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U.S. DOT Stickers on Door (371094), for vehicles over 10K lbs GVW
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Any warning indicators lit up on dashboard?
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Emkay maintenance up to date?
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Horn functional?
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Windshield, windows & mirrors?
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Windshield wipers & fluid work?
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Seat belts work?
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Seat belt required sticker?
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Lights functional?
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Jack & spare in place?
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Tires satisfactory (no uneven wear, bulges, etc)?
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Any body damage?
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Any visible leaks?
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Door, tailgate & vehicle # stickers in place & legible?
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Current DOT Annual Inspection?
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Current insurance card?
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Registration Current?
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Accident reporting kit?
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Emergency response guide book?
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Spill response kit?
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1st aid kit?
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Fire extinguisher on board? (min 5lb for a mine site per MSHA)
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Secured/mounted?
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Size?
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Housekeeping (in & out)?
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Photo (optional)
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Feedback/observations/comments:
Section K: Vehicle (EIT Support Truck)
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EIT Support Truck# & milage
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Any warning indicators lit up on dashboard?
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Emkay maintenance up to date?
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Windshield, windows & mirrors?
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Windshield wipers & fluid work?
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Horn functional?
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Seat belts work?
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Seat belt required sticker?
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Lights functional?
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Jack & spare in place?
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Door, tailgate & vehicle # stickers in place & legible?
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Tires satisfactory (no uneven wear, bulges, etc)?
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Any body damage?
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Any visible leaks?
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Current insurance card?
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Registration Current?
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Accident reporting kit?
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1st aid kit?
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Fire extinguisher on board? (min 5lb for a mine site per MSHA)
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Secured/mounted?
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Size?
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Housekeeping (in & out)?
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Photo (optional)
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Feedback/observations/comments:
