Information

  • Audit Title

  • Document No.

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Location:

  • Select date

Pretask/Tailgate/JSA

  • Performed

  • Appropriate for Task/Task Covered

  • Reviewed

  • Signed

  • Other:

Environmental/Emergency Response

  • Spill Response Kit

  • Emergency Action Plan

  • Certified Responders

  • First-Aid Kit

  • Other:

Hazardous Communication

  • MSDS Available

  • MSDS Reviewed

  • Containers Labeled Properly

  • Handling Procedures Followed

  • Language/Bilingual MSDS Available

  • Other:

Hygiene

  • Restrooms

  • Potable Water Available

  • Adequate Drinking Water for Employee Hydration

  • Washing Facilities

  • Other:

PPE

  • Hard Hat

  • Eye/Face

  • Hand

  • Hearing

  • Footwear

  • Hi-Vis Vest

  • Respirator

  • Respiratory Program in Place (MEQ, Fit Test, Training, etc...)

  • FRC

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

  • Other:

Material Handling

  • Body Mechanics

  • Manual Lifting Devices (Come-a-Longs, Chain falls, etc…)

  • Safety Latch

  • Slings

  • Hooks & Shackles

  • Wire Rope

  • Lifting Chains

  • Load Secure, Rigged Properly

  • Tag Lines Used

  • Other:

Vehicle/Equipment/Crane

  • Authorized/Qualified Operator

  • Designated Signal Person

  • Seatbelt Used

  • Backup Alarm

  • Hand Signal Chart

  • Daily/Weekly/Annual Inspection

  • Inspection Completed Properly

  • Other:

Material Storage

  • Material Stored Properly

  • Flammable/Combustible Storage

  • Pipe Chocked

  • Other:

Fall Prevention/Protection

  • Access/Egress

  • Fall Protection

  • Fall Protection Inspected

  • Scaffolds/Ladders - Proper Type

  • Scaffolds/Ladders - Inspected

  • Scaffolds/Ladders - Use

  • Handrails

  • Emergency Rescue Plan

  • Other:

Hand Tools

  • Condition

  • Guards/Handles

  • Proper for Job/Use

  • Other:

Electrical

  • GFCI/Assured Grounding Program

  • Cords/Tools – Inspected

  • Other:

Hot Work

  • Permit ( Hot Work Permit Issued By Authorized SWN Personnel )

  • Permit Conditions Followed

  • Fire Watch

  • Gas Cylinder Management

  • Leads/Hoses/Gauges

  • Combustible/Flammable Material Away from Hot Work

  • Other:

Fire Protection & Prevention

  • Fire Suppression Equipment

  • Annual/Monthly Fire Extinguisher Inspection

  • Properly Rated/Size (BC versus ABC)

  • Combustible/Flammable Material Away from Hot Work

  • Fire Extinguisher ( Fully Charged, Inspection Band, Inspection Up-To-Date, & Not Damaged)

  • Other:

Excavation

  • Excavation Type:

  • Documented Inspection by Competent Person

  • Sloped Properly

  • Benched Properly

  • Trench Box/Shoring Proper

  • Trench Box Certifications

  • Access/Egress Points

  • Spoil Pile Minimum 2-Feet From Excavation

  • Signs, Signals & Barricades

  • One Call Made

  • Utilities Identified

  • Other:

Signs/Barricades

  • Condition

  • Proper Type

  • Marking Hazards

  • Other:

Housekeeping

  • Dunnage

  • Trash

  • Trash Receptacles

  • Crew Trucks/Trailers

  • Other:

Walking Surfaces

  • Holes Guarded

  • Pathways

  • Trip Hazards

  • Other:

Traffic Control

  • Designated Flagger

  • Signs Posted per SWN

  • Escort Required/Used

  • Other:

Overhead Power Lines

  • Power Lines Marked with Goal Post and Signs

  • Designated Spotter

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

  • Other:

Radiation Sources

  • Type:

  • Signs, Signals & Barricades

  • Film Badges for X-Ray Crew

  • Other:

Pressure Testing

  • Equipment Integrity

  • Whip Checks/Connections Pinned

  • Signs, Signals & Barricades

  • Other:

Abrasive Blasting

  • Trap and Carbon Filter Installed

  • CO Alarm in use

  • Dead-Man Switch Operable

  • Proper PPE

  • Other:

Lock-Out/Tag-Out

  • Potential Energy Sources Identified

  • Isolated

  • Type of Isolation:

  • Verified

  • Affected Personnel Informed

  • Other:

Confined Space

  • Permitted (by authorized SWN Personnel)

  • Personnel Trained

  • Emergency Rescue Plan

  • Rescue/Retrieval Equipment (Anklets, Harness, Life Line, etc...…)

  • Other:

Ladders

  • Damaged Ladder(s)

  • Postioning of Ladder Correctly (4:1 Ratio)

  • Ladder Properly Secured

  • Ladder Unsuitable for Job? (e.g. - Metal Ladder used in Eletrical Work)

  • 3 Points of Contact While Ascending or Descending

  • Other:

Sign-Off

  • Inspectors Signature

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