Converting 8 Pitfalls, Rev. 10-2015

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

Section 1.0 PPE

• 1.1 - PPE available and used before entering the work area

  Safe

  At Risk

  N/A

• 1.2 - Performance Measurement (Nominal - 3)

Section 2.0 Vehicles / Equipment

• 2.1 - Walk around inspection performed on carts, vehicles, and mobile equipment

  Safe

  At Risk

  N/A

• 2.2 - Horn and headlights are operational

  Safe

  At Risk

  N/A

• Note: Take pictures of any mobile equipment hazards

  Media

• 2.3 Performance Measurement (Nominal - 3)

Section 3.0 - Overhead Work

• 3.1 - Communicated with impacted process leaders

  Safe

  At Risk

  N/A

• 3.2 Safety cones, barricades, warning tape, and spotter used to communicate hazard zones

  Safe

  At Risk

  N/A

Section 4.0 - Fire Prevention

• 4.1 - ABC Fire extinguisher within 25 - 50 ft of work.

  Safe

  At Risk

  N/A

• 4.2 How Work Permit obtained prior to beginning work

  Safe

  At Risk

  N/A

• Note: Take pictures of any potential Fire Hazard

  Media

• 4.3 Performance Measurement (Nominal - 7)

Section 5.0 - Fall Protection

• 5.1 - Task performed greater that 15 feet from an edge, hole, or opening

  Safe

  At Risk

  N/A

• 5.2 - Harness, anchor, lanyard (retractable), and lifeline used to prevent 6 ft free fall

  Safe

  At Risk

  N/A

• Note: Take pictures of any Fall hazard

  Media

• 5.3 Performance Measurement (Nominal - 24)

Section 6.0 - Communication

• 6.1 - Communicated work and location prior to beginning task

  Safe

  At Risk

  N/A

• 6.2 Communicated unsafe task(s) or behavior(s) to responsible parties

  Safe

  At Risk

  N/A

• 6.3 - Broken and defective equipment reported to maintenance.

  Yes

  No

  N/A

• 6.4 Performance Measurement (Nominal - 7)

• Add media

  Media

Section 7.0 - Housekeeping

• 7.1 - Trash and debris removed from work site daily

  Safe

  At Risk

  N/A

• 7.2 Trash and debris not blocking aisles, access, or doorways

  Safe

  At Risk

  N/A

• Note: Take pictures of housekeeping hazrads

  Media

• 7.3 Performance Measurement (Nominal - 7)

Section 8.0 - Stairs and Ladders

• 8.1 - Stairs and ladders are clear of obstructions

  Safe

  At Risk

  N/A

• 8.2 - Ladder is 3 ft above landing and secured at top and bottom

  Safe

  At Risk

  N/A

• 8.3 - Greases and slippery chemicals are removed from stairs, ladders, and work surfaces

  Safe

  At Risk

  N/A

• Note: Take pictures of ladder or stair hazards

  Media

• 8.4 Performance Measurement (Nominal - 8)