LEADERSHIP VISIT REPORT

• Client / Site / Well #

• Conducted on

  Date

• Prepared by

• Product Line

• TES-MS-0031
  Enter doc control information (TBD)

COMPLETED LEADERSHIP VISIT REPORTS MUST BE ROUTED TO THE QHSSE DEPARTMENT

INSPECTION

• STIM / Wireline / Coil Tubing control cabin interior clean and tidy

  Yes

  No

  N/A

• Fire truck fueled, storage compartments / interior clean and tidy

  Yes

  No

  N/A

• Clear and safe access around the site

  Yes

  No

  N/A

• Data cable runs protected from trampling

  Yes

  No

  N/A

• Temporary trip hazards clearly marked

  Yes

  No

  N/A

• Appropriate signage installed throughout the site

  Yes

  No

  N/A

• Catwalks / stairs have dual handrails and firmly installed

  Yes

  No

  N/A

• Whip-checks and restraints installed throughout the location

  Yes

  No

  N/A

• Noise, vehicles, dust and facial hair issues are compliant

  Yes

  No

  N/A

• Spot check chemicals MSDS readily available and up to date

  Yes

  No

  N/A

• All containers labeled (regardless of size or application)

  Yes

  No

  N/A

• Correct amount of safecards (see site QHSSE representative) e.g. 1 per person / shift

  Yes

  No

  N/A

• SSE's visibly identified with mentors assigned

  Yes

  No

  N/A

• PPE worn is in good condition and if not in use, stored properly

  Yes

  No

  N/A

• Correct PPE observed (hearing, fall, face, eye, hand, respiratory etc.)

  Yes

  No

  N/A

• Un-attended, running vehicles chocked

  Yes

  No

  N/A

• Environmental liners in place and sides are in the upright position

  Yes

  No

  N/A

• Lifting equipment is inspected (see site QHSSE representative)

  Yes

  No

  N/A

• Is a lock out / tag out box available on location with a suitable amount of locks?

  Yes

  No

  N/A

• Controlled work instructions on site & readily available

  Yes

  No

  N/A

• Controlled work instructions are current

  Yes

  No

  N/A

• Chemical transport manifest on site and signed by driver

  Yes

  No

  N/A

• Delivery notes on site and signed by the driver and the receiver

  Yes

  No

  N/A

• If there has been an incident during the shift, it has been recorded and reported properly

  Yes

  No

  N/A

• If there has been NPT during the shift, it has been recorded and reported properly

  Yes

  No

  N/A

• Sample a measuring device or calibrated tool on site. Is it within its calibration date and is the date visible on the device/tool?

  Yes

  No

  N/A

• Is the Statement of Excellence and TES IS SAFE posted

  Yes

  No

  N/A

• Rig Up/Down - Is the Swivel Lifting Aid available and in use?

  Yes

  No

  N/A

SAFE ACTS COMMENDED

UNSAFE ACTS OBSERVED (Use below categories as a reference)

PEOPLE - REACTIONS: Changing positions, stopping work, rearranging job, hiding or dodging, changing tools, applying lockout, adjusting PPE

PEOPLE - POSITION: Striking against, caught in, on or between, inhaling/absorbing, electrical, falling, struck by

PEOPLE - PPE: Head, eyes, ears, face, respiratory, hands, arms, feet, legs

PARTS / TOOLS / EQUIPMENT: Right for the job, used correctly, in safe condition, harnesses, barricades, warnings, check/restraint, pre-job safety checklist

PROCEDURES / PERMITS: Standard is adequate, standard is established, standard is understood, spotter, permit to work, emergency provision, control of work

HOUSEKEEPING: standard established, standard understood, materials storage, stairs, platforms, tools, trailer

SUMMARY # OF UNSAFE ACTS (Input the # of unsafe acts observed in each category)

Personal Protective Equipment

• Enter the number of at risk issues observed

Ergonomics

• Enter the number of at risk issues observed

Tools / Parts / Equipment

• Enter the number of at risk issues observed

Procedures

• Enter the number of at risk issues observed

Housekeeping

• Enter the number of at risk issues observed

CUSTOMER FEEDBACK (Note: Do not leave space or make a new paragraph between sentences. It will not show when converting to the pdf report.)

ACTION ITEMS (Note any actions taken or follow up required to address area of concern)

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