Hennigan Energy Service Group

• Site conducted

Site Location and Personal

• Site Location
  Address

• Date

  Date

• Work Order and PO Number

• Supervisor Conducting Safety Talk ?

  Sign

• Personal Attending the Safety Talk ?

• Work Site Safety Hazards

  Select

• Job Site Description of work being preformed

• Has the SDS Reviewed and discussed with all team members.

  Yes

  No

  N/A

Confined Space Equipment

• Is this a Permit Required Confined Space ?

  Yes

  No

  N/A

• Has a proper barricade been placed around the confined space to prevent other contractors from entering the area of our confined space ?

  Yes

  No

  N/A

• Has Lock out Tag Out (LOTO) been completed and all members of the confined space locked out with personal locks?

  Yes

  No

  N/A

• Dose the plant have a Confined Space Permit for us to fallow.

  Yes

  No

  N/A

• Has Permit been filled out and signed by entrant and attendant?

  Yes

  No

  N/A

• Have all hazards inside the confined space been identified and properly eliminated.

  Yes

  No

  N/A

• Equipment Required for Confined Space

  Select

• MSA air monitoring Serial Number

• Calibration Date

• Fresh Air Calibration been completed

  Pass

  Fail

  N/A

• Is the confined space a vertical or horizonal entry?

  Select

• What type of space is the confined space ?

  Select

• Has the confined space been ventilated ?

  Yes

  No

  N/A

Repertory protections

• Is Respiratory Protection Required

  Yes

  No

  N/A

• Full Face MSA

• Half Face MSA

• GME Filter

• GMC Filter

• GMD Filter

• GmA Filter

• P-100 Filter

• N-95 Particulate Filter

• SCBA

• Supplied Air W/5-Minute Egress bottle

• Are Employee Respiratory Fit Tested and up to date ?

  Yes

  No

  N/A

PPE Required

• Is Fall protection Required

  Yes

  No

  N/A

• PPE Required for this project.

  Select

• Are Cut Resistance Gloves Required

  Yes

  No

  N/A

• Are personal air monitors required ?

  Yes

  No

  N/A

• Are Escape Respirators Required ?

  Yes

  No

  N/A

• Any Special PPE Required

Water Blast Equipment and Safety

• Has all equipment pre trips been completed before startup?

  Yes

  No

  N/A

• What type of work is being preformed ?

  Select

• Has all hoses and equipment been inspected and flushed before use.

  Yes

  No

  N/A

• Dose the water supply have adequate pressure and volume to supply the pump that will be in use?

  Yes

  No

  N/A

• Do you have barricades tape and tags barriers in place?

  Yes

  No

  N/A

• Have all whip checks been installed on the hoses

  Yes

  No

  N/A

• What equipment will be used in this project.

  Select

• What PPE is Required for this project?

  Select

• Have all hoses been secure and tied back to prevent falling or trip hazards?

  Yes

  No

  N/A

Vacuum Work

• What type of equipment is needed for this project?

  Select

• What type of space is the vacuum work being completed in?

  Select

• What Type of Hose is needed for this project?

  Select

• Bonding and Grounding

  Yes

  No

  N/A

• Has all hoses been tied back to prevent hazards?

  Yes

  No

  N/A

• Has Pre-Trip been completed before startup?

  Yes

  No

  N/A

• Has proper barricade Tape and Tags been placed for trip and fall hazards?

  Yes

  No

  N/A

Sign Off Of Personal for Safety Talk

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• I have attended the tool box safety talk with my supervisor and have read and acknowledge that I fully understand the Hazards and have been informed of the appropriate PPE and steps that need to be taken to prevent personal and team injuries due to the hazards on this project. I also understand that I have the right to voice my concerns of any and all hazards.

  Sign

• Safety Hazards Onsite

  Safe

  At Risk

  N/A

• Scaffolding Work

  Yes

  No

  N/A

• Is Scaffolding Tagged

  Yes

  No

  N/A

• What Color Tag is posted on the scaffolding

  Select

• Inspection Date on Tag

  Date

• Required Fall Protection

  Select

Ladder Safety Requirements

• Extension Ladder

  Yes

  No

  N/A

• Length of the ladder

  Select

• Are Fall Protection Required

  Yes

  No

  N/A

• What Fall protection is required

  Select

• Will the work task be preformed on the ladder

  Yes

  No

  N/A

• Was the Ladder inspected before use ?

  Yes

  No

  N/A

• Picture of the inspection tag and who preformed the inspection

  Media

• Step Ladder Height

  Select

• Is overhead electric present ?

  Yes

  No

  N/A

• Has Barricades been set up around the ladder work area?

  Yes

  No

  N/A