Brigham Resources/ 24-Hour Service Rig Site Safety Report

• Conducted on

  Date

• Location:

• Well #:

• AFE #:

• Brigham Resources Site Representative (Day):

• Brigham Resources Site Representative (Night):

• Brigham Resources Safety Representative:

• Contractors Working on Location:

• Stage of Drill-Out:

• Weather Condition on Location:

  Select Wet Dry Frozen

  • Wet
  • Dry
  • Frozen

Applicable Permits:

• JSA / SJA Completed for Each Contractor on Location with Contractor Sign-In Sheet?

  Yes

  No

  N/A

• Hot Work Permit Completed?

  Yes

  No

  N/A

• Confined Space Permit Completed and Posted?

  Yes

  No

  N/A

• Critical Lift Permit Completed?

  Yes

  No

  N/A

• Ground Disturbance Permit Completed?

  Yes

  No

  N/A

Signage:

• Proper Signage in Place at the Entrance to Location?

  Yes

  No

  N/A

• No Smoking Signs and Designated Smoking Areas Signs posted?

  Yes

  No

  N/A

• Proper PPE Signage posted at entrance?

  Yes

  No

  N/A

• "Hearing Protection Required" Warning Signs are Properly Poseted?

  Yes

  No

  N/A

• Muster area Designated?

  Yes

  No

  N/A

• Warning Signs Clean and Visable?

  Yes

  No

  N/A

• Tank Battery Signs Posted?

  Yes

  No

  N/A

• Emergency Contact Information Posted on Location?

  Yes

  No

  N/A

• OSHA Poster Posted?

  Yes

  No

  N/A

General Site Inspection:

• LEL and H2S Monitors Deployed?

  Yes

  No

  N/A

• 350lbs Fire Extinguishers Deployed?

  Yes

  No

  N/A

• 30lbs Fire Extinguishers Deployed?

  Yes

  No

  N/A

• There are No Fluid Leaks, Discharges or Spills on Location?

  Yes

  No

  N/A

• Adequate Lighting Provided?

  Yes

  No

  N/A

• Interior / Exterior Berms Present on Location?

  Yes

  No

  N/A

• There are No Trip Hazards?

  Yes

  No

  N/A

• All Vessels Labeled as to their Contents?

  Yes

  No

  N/A

• Proper PPE/FRC being worn by all personnel on Location?

  Yes

  No

  N/A

• Is a Clean and Sanitary Portable Restroom Facility provided in close proximity to the location?

  Yes

  No

  N/A

• Erected Windsock Visable?

  Yes

  No

  N/A

• Production Equipment Set?

  Yes

  No

  N/A

• Hearing Protection Provided and Available?

  Yes

  No

  N/A

• Fall Protection being utilized when Required?

  Yes

  No

  N/A

• First Aid Kit and Blood Born Pathogen Kit available on Location?

  Yes

  No

  N/A

• Are Proper Tools being Utilized for the Job at Hand?

  Yes

  No

  N/A

• Are all Tools in Proper Working Condition?

  Yes

  No

  N/A

• Adequate Handrails provided on stairs with 4 or more Risers?

  Yes

  No

  N/A

• Stairs have Non-Skid Steps and are uniform size?

  Yes

  No

  N/A

• Proper Lifting Mechanics are being Used by Personnel?

  Yes

  No

  N/A

• Dead-Men are Properly Marked with Visible Yellow Stakes?

  Yes

  No

  N/A

• Housekeeping is Good in all Work Areas?

  Yes

  No

  N/A

• Backup Alarms are Working Properly on Material Handling Equipment?

  Yes

  No

  N/A

• Seat-belts are being Used by Operator of Material Handling Equipment?

  Yes

  No

  N/A

• All Parked Vehicles are Properly Chocked?

  Yes

  No

  N/A

• Back-In Parking is being Utilized on Location?

  Yes

  No

  N/A

• Spotters are being Utilized on Location?

  Yes

  No

  N/A

• Fire Extinguishers are Properly Placed and have Current Inspection Tags?

  Yes

  No

  N/A

• Whip-Check are in Place and Cement Blocks are Set on High Pressure Lines?

  Yes

  No

  N/A

• Trucks Observing 5mph Speed Limit on Location?

  Yes

  No

  N/A

• Water-Haul Supervisor Present on Location?

  Yes

  No

  N/A

• Material Safety Data Sheets (MSDS) and Shipping Papers are on Location and Easily Accessible?

  Yes

  No

  N/A

Fueling Vehicles:

• Is Fuel Transfer from Tanker Truck being Conducted Off Location?

  Yes

  No

  N/A

• Fuel Storage Tanks Properly Located and Labeled as to their Contents?

  Yes

  No

  N/A

• Grounding and Bonding is being Utilized when Refueling Equipment or Vehicles?

  Yes

  No

  N/A

• Discharge Valves, Nozzles and Hoses in Good Working Condition?

  Yes

  No

  N/A

• "Flammable" Warning Signs Properly Posted on All Sides of Storage Tanks?

  Yes

  No

  N/A

Electrical:

• All Electrical Equipment, Trailers and Generators are Properly Grounded?

  Yes

  No

  N/A

• All Electrical Equipment Properly Marked as to its Function?

  Yes

  No

  N/A

• "High Voltage" Warning Signs Properly Posted?

  Yes

  No

  N/A

• LOTO Devices Provided and Available?

  Yes

  No

  N/A

• All Electrical Wiring is off the Ground?

  Yes

  No

  N/A

• All Electrical Cords, Receptacles, and Plugs in Good Working Condition?

  Yes

  No

  N/A

• All Exterior Electrical Outlets are Covered?

  Yes

  No

  N/A

Cranes:

• Operator is Certified and the Certification is within its 3 year Validity?

  Yes

  No

  N/A

• Daily Inspection of Crane has been Completed?

  Yes

  No

  N/A

• Crane has Annual Inspection Certification?

  Yes

  No

  N/A

• Lines, Tanks, Valves, Pumps, and Other Parts of the Crane's Hydraulic System are in Good Working Condition?

  Yes

  No

  N/A

• Lifting Hooks and Lines are in Good Working Condition Free from Defects or Cracks?

  Yes

  No

  N/A

• Safety Latch on Hook is in Good Working Condition?

  Yes

  No

  N/A

• Crane's Control Levers are Clearly Marked?

  Yes

  No

  N/A

• Load Charts are Legible and Near Operator Controls?

  Yes

  No

  N/A

• Boom Angle Indicator is Working Properly?

  Yes

  No

  N/A

• Slings and Straps are in Good Working Condition and Free from Defects?

  Yes

  No

  N/A

Rig Inspection:

• Derrick Lights and Crown Light are in Good Working Condition?

  Yes

  No

  N/A

• Wind Walls are Erected and Placed Properly?

  Yes

  No

  N/A

• Locking Nuts are Properly Tightened on All Hydraulic Leveling Jacks?

  Yes

  No

  N/A

• Safeguards Properly Installed over all Moving Parts?

  Yes

  No

  N/A

• Pipe Racks are Level and Secured with Chocks in Place for Pipe?

  Yes

  No

  N/A

• Pipe Wrangler is Level and Secure?

  Yes

  No

  N/A

• Danger Area around Pipe Wrangler is Properly Marked?

  Yes

  No

  N/A

• All Fuel Tanks are Stored at the Proper Distance from Ignition Sources?

  Yes

  No

  N/A

• Guy-lines are Properly Connected to Tested Ground Anchors?

  Yes

  No

  N/A

• Guy-Lines are Properly Clamped?

  Yes

  No

  N/A

• Statoil Safety Banners are Clean and Attached to Guy-Lines?

  Yes

  No

  N/A

• Operator is at Controls?

  Yes

  No

  N/A

• Tool Pusher is Present on Location?

  Yes

  No

  N/A

• All Equipment with Motors are Located at Least 50ft from Well-Head or Ignition Source?

  Yes

  No

  N/A

• Pump is Located at Least 50ft from Well-Head and Rig Tank?

  Yes

  No

  N/A

Snubbing Unit:

• Snubbing Truck has Emergency Egress?

  Yes

  No

  N/A

• Snubbing Truck is Properly Chocked?

  Yes

  No

  N/A

• There are No Leaks on the Snubbing Unit?

  Yes

  No

  N/A

Additional Findings / Issues or Concerns:

• Issue #1:

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• Brigham Resources Safety Representative:

  Sign

• Company Man:

  Sign

• Tool Pusher:

  Sign

• Contractor Supervisor / Foreman:

  Sign