H & N Holdings

• Location
  Address

• Site

• General Contractor

• Conducted on

  Date

• Prepared by: Bill Strong

Daily vehicle safety inspection

• First aid kits (current & stocked)

  Yes

  No

  N/A

• Emergency kit, triangles, flares , etc

  Safe

  At Risk

  N/A

• Rescue kit

  Safe

  At Risk

  N/A

• Fire extinguisher (current inspection tags)

  Safe

  At Risk

  N/A

• Tires

  Safe

  At Risk

  N/A

• Current registration and inspection

  Safe

  At Risk

  N/A

• Engine fluids

  Safe

  At Risk

  N/A

• Other?

  Safe

  At Risk

  N/A

Daily basic job site inspection forms

• Tailgate meeting forms signed by all crew

  Yes

  No

  N/A

• Daily rigging form signed and completed

  Safe

  At Risk

  N/A

• Daily Job Hazard Analysis signed and completed

  Safe

  At Risk

  N/A

Personal Protection

• Personal fall arrest system

  Safe

  At Risk

  N/A

• Positions lanyards

  Safe

  At Risk

  N/A

• Proper work boots & attire

  Safe

  At Risk

  N/A

• Rope or cable grab

  Yes

  No

  N/A

• Hard hats, safety glasses, and gloves in use?

  Yes

  No

  N/A

• Barricades up where applicable?

  Safe

  At Risk

  N/A

• Other?

  Safe

  At Risk

  N/A

Daily use rigging inspection

• Synthetic chokers

  Safe

  At Risk

  N/A

• Steel chokers

  Safe

  At Risk

  N/A

• Blocks

  Safe

  At Risk

  N/A

• Shackles, properly fitting pin

  Safe

  At Risk

  N/A

• Ropes

  Safe

  At Risk

  N/A

• Lifelines

  Safe

  At Risk

  N/A

• Decenders

  Safe

  At Risk

  N/A

• Other?

  Safe

  At Risk

  N/A

Daily use tools and equipment

• Power tools

  Yes

  No

  N/A

• Ladders

  Yes

  No

  N/A

• Cad welding equipment

  Safe

  At Risk

  N/A

• Cable pulling grips

  Safe

  At Risk

  N/A

• Come-alongside, wire or chain, tirfers

  Safe

  At Risk

  N/A

• Capstan hoist & out switch

  Safe

  At Risk

  N/A

• Extension cords

  Safe

  At Risk

  N/A

• Site signage package

  Safe

  At Risk

  N/A

• 2-way radios

  Safe

  At Risk

  N/A

• Other?

  Safe

  At Risk

  N/A

Instrumentation

• Transit/theodolite

  Yes

  No

  N/A

• Dynamometer

  Yes

  No

  N/A

• Guy transit (scope)

  Yes

  No

  N/A

• RF monitors

  Yes

  No

  N/A

• Anamometers

  Yes

  No

  N/A

• Other?

  Safe

  At Risk

  N/A

Hoists

• Manual & maintenance log

  Safe

  At Risk

  N/A

• Trial lift form if hoisting personnel

  Safe

  At Risk

  N/A

• Anti-two block

  Safe

  At Risk

  N/A

• Engine & hydraulic fluids

  Safe

  At Risk

  N/A

• Overall appearance and condition of winch line

  Safe

  At Risk

  N/A

• Wedge sockets, cable clamps, or cable eye

  Safe

  At Risk

  N/A

• Wedge properly in place in winch drums

  Safe

  At Risk

  N/A

• Other?

  Safe

  At Risk

  N/A

Man basket

• Man baskets

  Safe

  At Risk

  N/A

• Rigging for man basket

  Safe

  At Risk

  N/A

Gin poles

• Load chart with reference to specific pole

  Safe

  At Risk

  N/A

• Visual inspection for cracked welds or bent members

  Safe

  At Risk

  N/A

• Jump blocks

  Safe

  At Risk

  N/A

• Bolts

  Safe

  At Risk

  N/A

• Rooster head and sheave, and grease fitting

  Safe

  At Risk

  N/A

• Thrust bearing adequately clean and greased

  Safe

  At Risk

  N/A

• Basket and bridle chokers

  Safe

  At Risk

  N/A

• Other?

  Safe

  At Risk

  N/A

Miscellaneous

• Rams

  Safe

  At Risk

  N/A

• Pull plates (guy pulling)

  Safe

  At Risk

  N/A

• Push plates (ram pulling)

  Safe

  At Risk

  N/A

• Spool stands

  Safe

  At Risk

  N/A

• Temporary guys

  Yes

  No

  N/A

• Oxygen acetylene gauges and hoses, caps and bottles

  Yes

  No

  N/A

• RF suits

  Safe

  At Risk

  N/A

Mobile Equipment/ Lifts

• Aerial Lift Pre-use inspection complete?

  Yes

  No

  N/A

• Forklift Pre-use inspection complete?

  Safe

  At Risk

  N/A

• Other?

  Safe

  At Risk

  N/A

12. Behavioral Observations

• Safe behaviors observed - Actions taken to encourage safe behavior

  Safe

  At Risk

  N/A

• Unsafe behaviors observed - Actions taken to correct and prevent reoccurrence

  Safe

  At Risk

  N/A

• 100% Tie off observed

  Safe

  At Risk

  N/A

• Other?

  Safe

  At Risk

  N/A