LEADERSHIP VISIT REPORT

Product Line/Division: QHSSE Document Number: QHSSE-03 Revision Level: 1 Release Date: 01-Feb-2012

• Leadership Visit Date

  Date

• Conducted by

• Location
  Address

• Product Line(s)

• Client

  Internal

  External

• Job Supervisor

• Document No.

Emergency Procedures

• Is there an Emergency Procedure in the facility/on the job site?

  Yes

  No

  N/A

• Are all TESL employees on-site familiar with the emergency procedures?

  Yes

  No

  N/A

• Give a brief description of the emergency procedures for evacuation and medical case?

  Yes

  No

  N/A

Behavioral Based Program

• Have you been trained in a Behavioral Based Program? (STOP, Safe Card, FOCUS, etc.)

  Yes

  No

  N/A

• Do TESL employees on-site meet the minimum KPI target per day/job?

  Yes

  No

  N/A

• Do you get feedback on your safety inputs?

  Yes

  No

  N/A

• Are the safety inputs available for review?

  Yes

  No

  N/A

JRA/JSA

• Is the JRA/JSA completed and reviewed for the current activity on site i.e. high risk, environmental issues?

  Yes

  No

  N/A

• Was a pre-job safety meeting held before the task was started?

  Yes

  No

  N/A

• Have all parties involved in task signed off on JRA/JSA?

  Yes

  No

  N/A

• Are all personnel wearing appropriate PPE for the task?

  Yes

  No

  N/A

• Is the PPE used onsite within required specifications?

  Yes

  No

  N/A

• Is the JRA/JSA completed and reviewed for the current activity on site i.e. high risk, environmental issues?

  Yes

  No

  N/A

Housekeeping

• Are proper housekeeping practices in use at the work area?

  Yes

  No

  N/A

• Does the equipment appear to be clean and in good working condition?

  Yes

  No

  N/A

• Are all walkways and emergency exits clear?

  Yes

  No

  N/A

• Is there any potential hazard identified in the work area (Flying objects, slip, trip, falls, drop, etc.?

  Yes

  No

  N/A

Chemical Compliance

• Is the MSDS available at the job location and is it easily accessible?

  Yes

  No

  N/A

• Are all the chemicals properly identified and labelled?

  Yes

  No

  N/A

• Are the MSDS stored in a designated area and in close proximity to the job site?

  Yes

  No

  N/A

• Are all personnel familiar with MSDS requirements for all chemicals?

  Yes

  No

  N/A

• Are all chemicals properly stored in the designated area onsite?

  Yes

  No

  N/A

• Is there a current chemical inventory available?

  Yes

  No

  N/A

• Is there an emergency spill response action plan?

  Yes

  No

  N/A

• Are there spill kits/clean-up materials readily available on the jobsite?

  Yes

  No

  N/A

Equipment

• Did all the required equipment arrive on schedule?

  Yes

  No

  N/A

• Is all equipment equipped with all safety devices? i.e. guards, relief valves, etc.

  Yes

  No

  N/A

• Is all safety critical equipment identified? e.g. PRV, Automatic Shut-Down, Overpressure Shutdown etc.

  Yes

  No

  N/A

• Is all equipment function tested for conformance?

  Yes

  No

  N/A

• Is there a record of the equipment and its certification status?

  Yes

  No

  N/A

• Was the placement and rig-up of equipment coordinated in a safe and efficient manner?

  Yes

  No

  N/A

• Is there a record of the pre and post Maintenance Check list for all equipment?

  Yes

  No

  N/A

Personnel

• Did the crew arrive on schedule?

  Yes

  No

  N/A

• Does everyone understand their roles and responsibilities?

  Yes

  No

  N/A

• Does everyone understand the job activities?

  Yes

  No

  N/A

• Is a pre-job checklist done prior to each job and a copy retained?

  Yes

  No

  N/A

• Are there sufficient competent personnel on site to carry out the job safely and efficiently?

  Yes

  No

  N/A

• Have all TESL employees onside been through the relevant site induction program?

  Yes

  No

  N/A

Incident Reporting and Investigation

• Are TESL personnel familiar with the TESL and/or Client Incident Reporting/Investigative Procedure, Failure Analysis Report, Corrective and Preventative Action Report (CAPA)?

  Yes

  No

  N/A

General/Client Feedback

• Have the customer's reporting requirements been met? (e.g. Morning reports, HSE reports, equipment reports, problem job reports)

  Yes

  No

  N/A

• Was all the necessary technical support documentation available at the well-site? e.g. Equipment manuals, well program, etc.

  Yes

  No

  N/A

• Was the crew briefed on the job objectives, well data, HSE issues and job plan prior to arrival at the well-site?

  Yes

  No

  N/A

• Was a review carried out with the customer to confirm job objectives, well data (depths, temps, pressures), HSE issues, anticipated job time and job plan?

  Yes

  No

  N/A

Purpose: To document areas for improvement and recommend corrective actions.

• Item # 1 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photo

  Media

• Item # 2 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photo

  Media

• Item # 3 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photo

  Media

• Item # 4 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photo

  Media

• Item # 5 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photo

  Media

• Item # 6 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photo

  Media

• Item # 7 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photo

  Media

• Item # 8 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photo

  Media

• Item # 9 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photos

  Media

• Item # 10 - Recommended Corrective Action

• Responsibility

• Due Date

  Date

• Closed Out Date

  Date

• Photo

  Media

Conducted by

• Add signature

  Sign

Verification and final closure (product line manager/designate)

• Reviewed by

  Sign

• Date

  Date

• Verified by

  Sign

• Date

  Date

Reviewed by (QHSSE representative)

• Reviewed by

  Sign

• Date

  Date

• Comments/Remarks