C&C Oilfield Services Pipeline Construction Safety Report

• Conducted on

  Date

• Prepared by

• Location
  Address

• Contractor/Subcontractors

Work Permit/ JSA

• Appropriate for Task/Task Covered

  Good

  Fair

  Poor

  N/A

• Reviewed and Signed

  Yes

  No

  N/A

Environmental/Emergency Response

• Emergency Action Plan

  Yes

  No

  N/A

• Spill Response Kit

  Yes

  No

  N/A

• Certified Responders

  Yes

  No

  N/A

• First-Aid Kit

  Yes

  No

  N/A

Hazardous Communication

• Safety Data Sheet Available

  Yes

  No

  N/A

• Safety Data Sheet Reviewed

  Yes

  No

  N/A

• Containers Labeled Properly

  Yes

  No

  N/A

• Handling Procedures Followed

  Safe

  At Risk

  N/A

PPE

• Hard Hat

  Safe

  At Risk

  N/A

• Hard Hat worn correctly

  Safe

  At Risk

  N/A

• Eye/Face

  Safe

  At Risk

  N/A

• Hand

  Safe

  At Risk

  N/A

• Hearing

  Safe

  At Risk

  N/A

• Footwear

  Safe

  At Risk

  N/A

• Hi-Vis Vest

  Safe

  At Risk

  N/A

• FRC

  Safe

  At Risk

  N/A

• Monitors Available, In Use, Calibrated (4-Gas, H2S or Other)

  Safe

  At Risk

  N/A

• Other:

  Safe

  At Risk

  N/A

Material Handling

• Body Mechanics

  Safe

  At Risk

  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

  Safe

  At Risk

  N/A

• Tag Lines Used

  Safe

  At Risk

  N/A

• Other:

  Safe

  At Risk

  N/A

Vehicle/Equipment/Crane

• Authorized/Qualified Operator

  Safe

  At Risk

  N/A

• Designated Signal Person/ Spotter

  Safe

  At Risk

  N/A

• Seatbelt Used

  Safe

  At Risk

  N/A

• Backup Alarm

  Safe

  At Risk

  N/A

• Daily/Weekly/Annual Inspection

  Yes

  No

  N/A

• Inspection Completed Properly

  Yes

  No

  N/A

• Spill kits and containment

  Safe

  At Risk

  N/A

Material Storage

• Material Stored Properly

  Safe

  At Risk

  N/A

• Flammable/Combustible Storage

  Safe

  At Risk

  N/A

• Pipe Chocked

  Safe

  At Risk

  N/A

• Other:

  Safe

  At Risk

  N/A

Hand Tools

• Condition

  Safe

  At Risk

  N/A

• Guards/Handles

  Safe

  At Risk

  N/A

• Proper for Job/Use

  Safe

  At Risk

  N/A

Electrical

• GFCI/Assured Grounding Program

  Safe

  At Risk

  N/A

• Cords/Tools – Inspected

  Safe

  At Risk

  N/A

Hot Work

• Permit

  Safe

  At Risk

  N/A

• Permit Conditions Followed

  Safe

  At Risk

  N/A

• Fire Watch

  Safe

  At Risk

  N/A

• Gas Cylinder Management

  Safe

  At Risk

  N/A

• Leads/Hoses/Gauges

  Safe

  At Risk

  N/A

• Other:

  Safe

  At Risk

  N/A

Fire Protection & Prevention

• Extinguisher inspection tag present and current

  Safe

  At Risk

  N/A

• Properly Rated/Size (BC versus ABC)

  Safe

  At Risk

  N/A

• Combustible/Flammable Material Away from Hot Work

  Safe

  At Risk

  N/A

• Fire Extinguishers at least 25ft away but no further than 75ft away from Fuel Cells

  Safe

  At Risk

  N/A

Excavation

• One Call completed

  Yes

  No

  N/A

• Utilities/identified/marked /flagged

  Yes

  No

  N/A

• Hand digging used when approaching/crossing buried facilities

  Safe

  At Risk

  N/A

• Competent Person/Bell Hole Report greater than 5ft. depth

  Yes

  No

  N/A

• Benched /Sloped Properly

  Safe

  At Risk

  N/A

• Trench Box/Shoring Proper

  Safe

  At Risk

  N/A

• Trench Box Certifications

  Safe

  At Risk

  N/A

• Ladder inspection and secured correct

  Safe

  At Risk

  N/A

• Access/Egress Points

  Safe

  At Risk

  N/A

• Spoil Pile Minimum 2-Feet From Excavation

  Safe

  At Risk

  N/A

• Signs, Signals & Barricades

  Safe

  At Risk

  N/A

Signs/Barricades

• Condition

  Safe

  At Risk

  N/A

• Proper Type

  Safe

  At Risk

  N/A

• Marking Hazards

  Safe

  At Risk

  N/A

Housekeeping

• Worksite free of clutter

  Safe

  At Risk

  N/A

• Equipment, machines/tools do not block pathway

  Safe

  At Risk

  N/A

• Tripping and slipping hazards

  Safe

  At Risk

  N/A

• Tools properly stored/staged

  Safe

  At Risk

  N/A

• Crew Trucks/Trailers clean and free of clutter

  Safe

  At Risk

  N/A

Ergonomics/ Jobsite

• Proper lifting techniques used

  Safe

  At Risk

  N/A

• Employees positioned away from hazards, moving parts and equipment

  Safe

  At Risk

  N/A

• Pinch points

  Safe

  At Risk

  N/A

• Proper body positioning

  Yes

  No

  N/A

Walking Surfaces

• Pathways

  Safe

  At Risk

  N/A

• Trip Hazards

  Safe

  At Risk

  N/A

• Holes Guarded

  Safe

  At Risk

  N/A

Overhead Power Lines

• Power Lines Marked with Goal Post and Signs

  Safe

  At Risk

  N/A

• Designated Spotter

  Safe

  At Risk

  N/A

• Proper Equipment for Spotter (Air Horn, Vest, etc…)

  Safe

  At Risk

  N/A

Radiation Sources

• Signs, Signals & Barricades

  Safe

  At Risk

  N/A

• Film Badges for X-Ray Crew

  Safe

  At Risk

  N/A

Pressure Testing

• Bolt-Up Torques verified

  Safe

  At Risk

  N/A

• Whip Checks/Connections Pinned

  Safe

  At Risk

  N/A

• Signs, Signals & Barricades

  Safe

  At Risk

  N/A

Equipment/ Tools

• Availability and condition of tools

  Safe

  At Risk

  N/A

• Adequate lighting/visibility

  Safe

  At Risk

  N/A

• Grounding of tools/pipe/containers

  Safe

  At Risk

  N/A

• Air tools/hose connections/pins in place

  Safe

  At Risk

  N/A

• Inspection Notes

• Inspection Photos

  Media

• Safety Inspector

  Sign

• Date & Time

  Date