Broussard Brothers, Inc.

• Client

• Location

• PIC

• Conducted on

  Date

• Prepared by

SAFETY MEETING

• Is a completed safety meeting form present?

  Yes

  No

  N/A

• Does it identify a task overview?

  Yes

  No

  N/A

• Has it been signed by all personnel on site?

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

• Have all risks identified been properly mitigated?

  Yes

  No

  N/A

• Has each mitigation been assigned to an individual of group?

  Yes

  No

  N/A

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

SSE

• Are SSE's onsite?

  Yes

  No

  N/A

• Has each SSE been assigned a mentor?

  Yes

  No

  N/A

• Can each SSE identify their mentor?

  Yes

  No

  N/A

• Does total number of SSE's exceed 20% of total crew?

  Yes

  No

  N/A

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

ELECTRICAL

• Power panels, controls, receptacles and wiring covered

  Yes

  No

  N/A

• Any loose or missing parts?

  Yes

  No

  N/A

• Any damaged electrical cords in use?

  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

SLIP, TRIP, FALL HAZARDS

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

  Yes

  No

  N/A

• Are walkways clear of material, cords and hoses?

  Yes

  No

  N/A

• Are steps and guardrails in place and properly secured?

  Yes

  No

  N/A

• Are ladders in good repair with no missing or loose parts?

  Yes

  No

  N/A

• Is there adequate lighting in all areas including exterior?

  Yes

  No

  N/A

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

• Are all personnel wearing reflective vests?

  Yes

  No

  N/A

CHEMICAL SAFETY

• Are personnel aware of the location of the MSDS's?

  Yes

  No

  N/A

• Are MSDS's present for all chemicals on site?

  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?

  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

HOUSEKEEPING

• Select from range

RIGGING

• Does all rigging have current tags attached?

  Yes

  No

  N/A

• Is proper rigging practices being followed?

  Yes

  No

  N/A

• Are only qualified riggers performing rigging duties?

  Yes

  No

  N/A

CRANE

• Is crane operator's training current?

  Yes

  No

  N/A

• Is a complete and current pre-use crane inspection available for review?

  Yes

  No

  N/A

• Name of person completing the inspection form

• Is the operator the same person that completed the inspection form?

  Yes

  No

  N/A

• Were any deficiencies noted on the inspection?

  Yes

  No

  N/A

• Are pendant line tags present and current?

  Yes

  No

  N/A

• Is all wire rope properly lubricated?

  Yes

  No

  N/A

• Overall appearance of the crane

SIGNATURES

• PIC

  Sign

• Inspector

  Sign