Globe San Angelo

• Completed by?

• Conducted on

  Date

• Lease / well

• Location
  Address

• Document No.

• San Angelo rig #

• Personnel

Initial impression

• Overall housekeeping?

  Yes

  No

  N/A

• Vehicles backed in on location, to ensure safe and quick departure in a emergency?

  Yes

  No

  N/A

• Vehicles ,pumping equipment outside guy pattern?

  Yes

  No

  N/A

• Emergency Derrick escape in place?

  Yes

  No

  N/A

• Did personnel meet you with JSEA, and location rules?

  Yes

  No

  N/A

• Lock out , tag out in place?

  Yes

  No

  N/A

• Pipe racks equipped with retainer pins?

  Yes

  No

  N/A

• No smoking inside guy pattern, open fires outside guy pattern, fire hazards controlled , no standing oil on location?

  Yes

  No

  N/A

• List all discrepancies noted for this section.

• Hazard signs in place at entrance.

  Yes

  No

  N/A

• Guy lines flagged with high visibility maker tape.

  Yes

  No

  N/A

• Dogs in locked position, clearly identified with high visibility neon flagging?

  Yes

  No

  N/A

Doghouse

• Safety chains attached , with hook and spring latch?

  Yes

  No

  N/A

• Safety pin available to prevent accidental separation from vehicle?

  Yes

  No

  N/A

• Propane bottles off, when not in use?

  Yes

  No

  N/A

• Propane bottles secured to apparatus?

  Yes

  No

  N/A

• Tires in good condition?

  Yes

  No

  N/A

• Sheet metal intact / no sharp or rough edges ?

  Yes

  No

  N/A

• Interior of trailer clean / free from trips hazards?

  Yes

  No

  N/A

• Are there any open flames inside the dog house?

  Yes

  No

  N/A

• First aid kit ready ,stocked ,and in date?

  Yes

  No

  N/A

• Eye wash available , in date?

  Yes

  No

  N/A

• All appropriate paper work displayed , available ? Example JSEA ,MSDS.

  Yes

  No

  N/A

• List all discrepancies noted for this section.

Company vehicle

• Exterior clean?

  Yes

  No

  N/A

• All sheet metal intact, no lose, rough, or sharp edges ?

  Yes

  No

  N/A

• All lights clean,intact and functioning properly?

  Yes

  No

  N/A

• Tires in good condition?

  Yes

  No

  N/A

• Windshield wipers in good condition?

  Yes

  No

  N/A

• Windshield free from cracks, repaired rock chips?

  Yes

  No

  N/A

• Interior clean and free of falling, rolling debris?

  Yes

  No

  N/A

• Fire extinguisher mounted as such that it dose not become a hazard?

  Yes

  No

  N/A

• Extinguisher charged, in date , monthly punched, annual updated,service date and hydro tested if applicable?

  Yes

  No

  N/A

• Registration

  Media

• Inspection

  Media

• License plate

  Media

• List all discrepancies noted for this section.

Service rig

• Interior of cab clean, free of falling , rolling debris?

  Yes

  No

  N/A

• Wheel chicks in place?

  Yes

  No

  N/A

• Rig hours

  Media

• Windshield free from cracks, repaired rock chips?

  Yes

  No

  N/A

• Windshield wipers in good condition?

  Yes

  No

  N/A

• Hydraulic jacks on stable, solid footing?

  Yes

  No

  N/A

• Hydraulic jacks secure with mechanical lock nut?

  Yes

  No

  N/A

• All tanks labeled / hydraulic fluid ,water,diesel, etc?

  Yes

  No

  N/A

• All guards in place and in good condition?

  Yes

  No

  N/A

• Tires in good condition?

  Yes

  No

  N/A

• Hub mileage

  Media

• Under side free of leaks?

  Yes

  No

  N/A

• Unit grounded, so as to prevent static electricity build up?

  Yes

  No

  N/A

• Brake linkage free of bends, cracks, free operation, linkage pins safeties ?

  Yes

  No

  N/A

• Emergency kill switch working properly?

  Yes

  No

  N/A

• Road gear lockout?

  Yes

  No

  N/A

• List all discrepancies noted for this section.

Guy line wires and cables.

• Minimum of four wind guys?

  Yes

  No

  N/A

• All lines secured with at least four clamps?

  Yes

  No

  N/A

• Guy lines secured to permanently installed anchors ?

  Yes

  No

  N/A

• All clamps torqued to specification?

  Yes

  No

  N/A

• Tubing board guys strung and crossed for racking?

  Yes

  No

  N/A

• Excess lines rolled up, so as not to cause additional trip hazard, or be run over?

  Yes

  No

  N/A

• Lines at least 9/16" in diameter?

  Yes

  No

  N/A

• Emergency Derrick escape set up and anchored?

  Yes

  No

  N/A

• All ends taped or secured to prevent scrapes or cuts?

  Yes

  No

  N/A

• All lines in good condition/no kinks,wears,wicks ring,smashed,or fraying?

  Yes

  No

  N/A

• Main line/spool in good condition,no wear,wickering ,kinks,or fraying?

  Yes

  No

  N/A

• Sand line in good condition,no wear, wickering, kinks, or fraying?

  Yes

  No

  N/A

• Sand line permanently flagged by manufacturer?

  Yes

  No

  N/A

• Dead line anchor and retainer, with 2 1/2 wraps, and securely mounted?

  Yes

  No

  N/A

• Date that tubing line was tested or replaced?

• List all discrepancies noted for this section?

Catwalk, operator station, and work platform.

• Hand rails with mid rail, and toe boards at least 4' high?

  Yes

  No

  N/A

• Are the hand rails secured with safety pins to prevent accidental release?

  Yes

  No

  N/A

• Cat walk floor in good condition, no holes or raised sections that could cause falling or tripping?

  Yes

  No

  N/A

• Stairs with hand rails, and clear path for safe entrance/ exit?

  Yes

  No

  N/A

• Operator controls labeled?

  Yes

  No

  N/A

• Manufacturer and spec plate attached and easily read?

  Yes

  No

  N/A

• Scale working properly and clear view of the operator?

  Yes

  No

  N/A

• Work platform equipped with hand rails, mid rails, and tie boards at least 4' in height, if applicable?

  Yes

  No

  N/A

• Stairs with hand rails on both sides leading to the platform, if appicable?

  Yes

  No

  N/A

• Platform in good condition, with no holes or raised sections that could cause falling/tripping hazard?

  Yes

  No

  N/A

• All working services equipped with non skid coating?

  Yes

  No

  N/A

• Working surfaces clean and free of oil, grease, or tripping hazards?

  Yes

  No

  N/A

• List all discrepancies noted for this section.

Derrick

• Derrick properly secured with locks in place and pins secured with safeties to prevent backing out?

  Yes

  No

  N/A

• Derrick set at proper angle to prevent traveling blocks from coming in contact?

  Yes

  No

  N/A

• Derrick mast in good condition with no cracked, bent, or damaged beams or cross sections?

  Yes

  No

  N/A

• Climbing ladder in good condition, no bent, broke, or missing rungs?

  Yes

  No

  N/A

• Dogs verified as inspected by clearly defined neon flagging wrapped around both sides ?

  Yes

  No

  N/A

• Safety harness clean, in good condition, no wear spots, fraying, cuts, fits properly , in date?

  Yes

  No

  N/A

• Derrick ladder climbing device working properly?

  Yes

  No

  N/A

• Derrick fall device working properly?

  Yes

  No

  N/A

• Tubing board and racking platform in good condition?

  Yes

  No

  N/A

• List all discrepancies noted for this section.

Tools and equipment.

• Power tongs in good condition, all bolts or pins need to be drilled and safety clipped.

  Yes

  No

  N/A

• Safety gate.

  Yes

  No

  N/A

• Backup

  Yes

  No

  N/A

• Stiff arm, snub line, clamps in place and line condition.

  Yes

  No

  N/A

• Head guards in place?

  Yes

  No

  N/A

• Hose and fittings in good condition , no leaks?

  Yes

  No

  N/A

• Pipe handling slips in good condition?

  Yes

  No

  N/A

• Slip dies sharp with proper pins?

  Yes

  No

  N/A

• Bowl and slips in good condition, not worn?

  Yes

  No

  N/A

• Traveling assembly in good condition?

  Yes

  No

  N/A

• Blocks

  Yes

  No

  N/A

• Sheave guards in place?

  Yes

  No

  N/A

• Bales free of cracks and or bends?

  Yes

  No

  N/A

• Elevators handles, spring, lathes, and bolts working properly and installed?

  Yes

  No

  N/A

• Rod hooks, latching and spring mechanism working properly?

  Yes

  No

  N/A

• Transfer elevators safety latches, wire lines in good condition? Transfer elevators swivel bolt and , or Clovis must be drilled and safety clipped.

  Yes

  No

  N/A

• Are all hand tools clean, in good condition? Threads on swedges protected with couplings, handles for hammers not cracked, or broke, pipe wrench jaws in good condition and not worn, so as not to cause slipping when in use.

  Yes

  No

  N/A

• List all discrepancies noted for this section.

We'll control equipment.

• BOP installed, tested, and functional?

  Yes

  No

  N/A

• Fully opening safety valves?

  Yes

  No

  N/A

• Wheel for opening and closing valve in place?

  Yes

  No

  N/A

• Comments.

Safety equipment and training.

• Rig#

  Yes

  No

  N/A

• Fire extinguisher on location, set out at designated points on opposite corners, and outside guy pattern?

  Yes

  No

  N/A

• Location-rig / brand: / model: Serial#: / year: 6 year service due: Hydrostatic test due:

• Issue:

  Yes

  No

  N/A

• Was extinguisher issue resolved, or replaced?

  Yes

  No

  N/A

• Explain details.

• Location- rig/ brand/ model: Serial # / year Annual: 6 year service due: Hydrostatic test due:

• Issue:

  Yes

  No

  N/A

• Was extinguisher issue resolved, or replaced?

  Yes

  No

  N/A

• Explain details.

• Location- rig / brand / model: Serial # / year: Annual : 6 year service due: Hydrostatic test due:

• Issue:

  Yes

  No

  N/A

• Location - dog house / brand / model: Serial # / year: Annual : 6 year service due: Hydrostatic test due:

• Issue:

  Yes

  No

  N/A

• Was extinguisher issue resolved, or replaced?

  Yes

  No

  N/A

• Explain details.

• Location- truck / brand / model: Serial # / year: Annual: 6 year service due: Hydrostatic test due:

• Issue.

  Yes

  No

  N/A

• Was extinguisher issue resolved, or replaced?

  Yes

  No

  N/A

• Explain details.

• Extinguishers checked and verified compliant on.

  Date

• SCBAs on location, set out at designated points on opposite corners, and outside guy pattern?

  Yes

  No

  N/A

• Serial # Year: Hydrostatic test due:

• Issue:

  Yes

  No

  N/A

• Was SCBA issue resolved, or replaced?

  Yes

  No

  N/A

• Explain details, and current psi of SCBA

• Serial # Year: Hydrostatic test due:

• Issue:

  Yes

  No

  N/A

• Was SCBA issue resolved, or replaced?

  Yes

  No

  N/A

• Explain details, and current psi of SCBA

• SCBAs checked and verified compliant on.

  Date

• H2s monitor worn properly?

  Yes

  No

  N/A

• Employee: operator

• Change pertains to:

  Yes

  No

  N/A

• Explain the above issue and record bump test information.

• Employee: Derrick hand

• Change pertains to:

  Yes

  No

  N/A

• Explain the above issue and record bump test information.

• Employee: floor hand

• Change pertains to:

  Yes

  No

  N/A

• Explain the above issue and record bump test information.

• Employee: floor hand

• Change pertains to:

  Yes

  No

  N/A

• Explain the above issue and record bump test information.

• Other crew information :

• Rig monitor in place, good condition, calibrated, with sensor in proximity of the well and protected from fluids? Record brand and serial number in space below.

  Yes

  No

  N/A

• Rig monitor: brand and serial #

• All PPE worn on location, safety glasses, hard hat, gloves, steel toe boots, and FRC, minimum?

  Yes

  No

  N/A

• Emergency Derrick escape equipment / hand cart with brake, line anchor,equipment in place?

  Yes

  No

  N/A

• Additional comments regarding repairs made or needed?

Pumping equipment.

• Pumping equipment clean and in good condition?

  Yes

  No

  N/A

• Pump lines staked down?

  Yes

  No

  N/A

• Pumping equipment free of leaks?

  Yes

  No

  N/A

• Pumping equipment out of guy pattern?

  Yes

  No

  N/A

• Pumping equipment out of fall lane? Safest spot for parking is in front of the carrier, outside of the guy pattern if it is not possible to park off location.

  Yes

  No

  N/A

• All fluids on location clearly labeled?

  Yes

  No

  N/A

• All PPE used while pumping abrasive material.. Cement, salt, gel, brine water, acid, etc.

  Yes

  No

  N/A

• MSDS / SDS available on location for all fluids brought on location by contractors?

  Yes

  No

  N/A

• Comment:

Safety policies.

• Is there a JSEA completed for the task being performed? If not explain reasoning below.

  Yes

  No

  N/A

• Are all personnel following accepted safety policy and procedures? If not explain below.

  Yes

  No

  N/A

• Are personnel using the equipment provided to mitigate hazards on location? If not explain below.

  Yes

  No

  N/A

• Are personnel watching out for each other, and speaking up when an unsafe act is observed? Explain answer below.

  Yes

  No

  N/A

• Do you as a inspector see a safer way of doing a particular job for this rig, in means to prevent accident or injury? Explain below.

  yes

  minimal

  no unsafe practices

• Are you as the inspector, enforcing safety policy and procedures, and using stop work authority to identify, and limit or eliminate potentional hazards for all employees on location? Explain below.

  Yes

  No

  N/A

• Have all safety related hazards / concerns been addressed prior to you , as the inspector, been solved before leaving location? Explain resolved and or unresolved issues below.

  Yes

  No

  N/A

• Comments:

Rig personnel comments for safe practices.

• Rig operator concerns, or needed equipment.

Summary of needed improvement.

• Improvements needed.

• Equipment issues.

• Repairs made.

Itemized pricing detail.

Fire extinguishers

• Extinguisher supplies

  personal h2s monitor

  ear plugs

  cotton gloves

  impact gloves

  safety glasses

SCBA

• SCBA supplies / service

  personal h2s monitor

  ear plugs

  cotton gloves

  impact gloves

  safety glasses

Rig h2s monitor

• Rig h2s monitor parts/ service:

  personal h2s monitor

  ear plugs

  cotton gloves

  impact gloves

  safety glasses

• PPE

  personal h2s monitor

  ear plugs

  cotton gloves

  impact gloves

  safety glasses

• Total mileage charge @ $1.00 per mile.

Add $150 dollars for the inspection and calculate the total charges from above enter total inspection charges below.

• Total charges:

Signatures.

• Rig operator signature.

  Sign

• Inspector signature.

  Sign

• Additional pictures if necessary.

  Media