Chesapeake

• Conducted on

  Date

• Prepared by

• Location
  Address

• HTTR PM Safety Checklist conducted for

  Yes

  No

  N/A

• Audit Title

• HTTR PM

  Yes

  No

  N/A

• Conducted on

  Date

• 12/6/18, 1:30 PM

  Yes

  No

  N/A

• Document No

• Prepared by

• Name

• Location

• Site location

• Personnel

• Company

• Score

Audit - 30/30 - 100%

• Question

  Yes

  No

  N/A

Response

Details

Site Details

• Site / Project Name

• Location/ HTTR PM

• Use this audit to assess the following aspects of this site as Safe, At Risk or Not Applicable. Unsafe should be attached where appropriate, particularly to At Risk items

Work Areas

Score (6/6) 100%

• General Housekeeping (neat, tidy, dust free)

  Yes

  No

  N/A

• Walkways (free of debris and obstructions)

  Yes

  No

  N/A

• Work Surfaces (clear of clutter and dust)

  Yes

  No

  N/A

• Sides or Holes (safety guards or covered)

  Yes

  No

  N/A

• Impalement Hazards (none present, or adequately marked)

  Yes

  No

  N/A

• Material Storage/Lay Down (neat and tidy)

  Yes

  No

  N/A

Personal Protective Equipment (PPE)

• Hard Hats (available, worn by crew and in safe condition)

  Yes

  No

  N/A

• Safety Glasses with Side Shields (available, worn by crew and in safe condition)

  Yes

  No

  N/A

• Face Shield / Goggles (available, worn by crew and in safe condition)

  Yes

  No

  N/A

• Respiratory Protection (available, worn by crew and in safe condition)

  Yes

  No

  N/A

• Hearing Protection (available, worn by crew and in safe condition)

  Yes

  No

  N/A

• Appropriate Clothing (in safe condition)

  Yes

  No

  N/A

Score (8/8) 100%

• HTTR PM

  Yes

  No

  N/A

• Score (30/30) 100%

  Yes

  No

  N/A

• Question

  Yes

  No

  N/A

Response

Details

• Gloves (available, worn by crew and in safe condition)

  Yes

  No

  N/A

• Foot Protection (fit for task, worn by crew and in safe condition)

  Yes

  No

  N/A

Fall Protection Equipment

• Suitable Anchorage Points

  Yes

  No

  N/A

Ladders

• Proper Ladder for Task

  Yes

  No

  N/A

Tools and Equipment

• General condition of tools

  Yes

  No

  N/A

• Right tools are being used for tasks

  Yes

  No

  N/A

• Crew members are trained to be competent in the tools appropriate for their work tasks

  Yes

  No

  N/A

• Personnel

• HTTR PM

  Yes

  No

  N/A

• Score (30/30) 100%

  Yes

  No

  N/A

• Score (3/3) 100%

• Score (3/3) 100%

• Score (4/4) 100%

• Score (3/3) 100%

• Question

  Yes

  No

  N/A

Response

Details

• Behavior is orderly and professional

  Yes

  No

  N/A

• Proper lifting technique demonstrated

  Yes

  No

  N/A

People Safety

• Score (3/3) 100%

Team Member 1

• Name

• Team member signature

  Sign

• (to verify this interview knowledge)

  Yes

  No

  N/A

• HTTR PM

  Yes

  No

  N/A

• Score (30/30) 100%

  Yes

  No

  N/A

• HEATER-TREATER - 15/15 - 100%

  Yes

  No

  N/A

• Question

  Yes

  No

  N/A

Response

Details

• Has the Chesapeake Representative drained and depressurized the Heater-

  Yes

  No

  N/A

• Treater?

  Yes

  No

  N/A

• Has an inspection been performed on the

  Yes

  No

  N/A

• HTTR BMS (Burner Management System) which includes pilot line, gas inlet line,

  Yes

  No

  N/A

• flame arrestor, orifice, burner stack,

  Yes

  No

  N/A

• regulator, thermostat control, piping, and if

  Yes

  No

  N/A

• any issues found, have they been

  Yes

  No

  N/A

• addressed and cleaned/repaired/replaced if

  Yes

  No

  N/A

• needed?

  Yes

  No

  N/A

• Have the HTTR manway hatches been to specification when installing back on

  Yes

  No

  N/A

• HTTR with new gaskets?

  Yes

  No

  N/A

• Has the HTTR fire tube been removed for inspectioncleaning/replacing as per

  Yes

  No

  N/A

• HTTR PM

  Yes

  No

  N/A

• Score (15/15) 100%

  Yes

  No

  N/A

• Question

  Yes

  No

  N/A

Response

Details

• Has a visual inspection been made on

  Yes

  No

  N/A

• HTTR PM

  Yes

  No

  N/A

• Score (15/15) 100%

  Yes

  No

  N/A

• General Comments

• Question

  Yes

  No

  N/A

Response

Details

• Brief description of job scope

• Add any additional relevant photos

  Media

Sign Off

• Name and Signature of

  Sign

• Pusher Name

• Name and Signature of

  Sign

• Chesapeake

• Representative

• HTTR PM

  Yes

  No

  N/A

• Score (0/0) 100%