LEG Pipeline Safety Audit

• Site/Crew

• Manager

• Supervisor

• HSE Tech/Prepared by

• Conducted on

  Date
• Location
  Address

JSA/JHA

• JSA Signed?

  Yes

  No

  N/A

• Performed

  Yes

  No

  N/A

• Appropriate for Task/Task Covered

  Yes

  No

  N/A

• Reviewed

  Yes

  No

  N/A

• Comments:

Environmental/Emergency Response

• Spill Response Kit

  Yes

  No

  N/A

• Certified Responders

  Yes

  No

  N/A

• First-Aid Kit

  Yes

  No

  N/A

• Comments:

Hazardous Communication

• Handling Procedures Followed

  Yes

  No

  N/A

• Language/Bilingual SDS Available

  Yes

  No

  N/A

• SDS Available

  Yes

  No

  N/A

• SDS Reviewed

  Yes

  No

  N/A

• Containers Labeled Properly

  Yes

  No

  N/A

• Comments:

Hygiene

• Restrooms

  Yes

  No

  N/A

• Potable Water Available

  Yes

  No

  N/A

• Adequate Drinking Water for Employee<br>Hydration

  Yes

  No

  N/A

• Washing Facilities

  Yes

  No

  N/A

• Comments:

PPE

• Hard Hat

  Yes

  No

  N/A

• Hand

  Yes

  No

  N/A

• Eye/Face

  Yes

  No

  N/A

• Hearing

  Yes

  No

  N/A

• Footwear

  Yes

  No

  N/A

• Hi-Vis Vest

  Yes

  No

  N/A

• Respirator

  Yes

  No

  N/A

• Respiratory Program in Place (MEQ, Fit<br>Test, Training, etc...)

  Yes

  No

  N/A

• FRC

  Yes

  No

  N/A

• Monitors Available, In Use, Calibrated (4-<br>Gas, H2S or Other)

  Yes

  No

  N/A

• Comments:

Material Handling

• Lifting sling in good condition and up to date

  Yes

  No

  N/A

• Tag Lines Used

  Yes

  No

  N/A

• Load Secure, Rigged Properly

  Yes

  No

  N/A

• Body Mechanics

  Yes

  No

  N/A

• Manual Lifting Devices (Come-a-Longs,<br>Chain falls, etc.)

  Yes

  No

  N/A

• Safety Latch

  Yes

  No

  N/A

• Slings

  Yes

  No

  N/A

• Hooks & Shackles

  Yes

  No

  N/A

• Wire Rope

  Yes

  No

  N/A

• Comments:

Vehicle/Equipment/Crane

• Designated Signal Person

  Yes

  No

  N/A

• Seatbelt Used

  Yes

  No

  N/A

• Backup Alarm

  Yes

  No

  N/A

• Hand Signal Chart

  Yes

  No

  N/A

• Daily/Weekly/Annual Inspection

  Yes

  No

  N/A

• Inspection Completed Properly

  Yes

  No

  N/A

• Authorized/Certified Operator

  Yes

  No

  N/A

• Comments:

Material Storage

• Material Stored Properly

  Yes

  No

  N/A

• Flammable/Combustible Storage

  Yes

  No

  N/A

• Pipe Chocked

  Yes

  No

  N/A

• Comments:

Fall Prevention/Protection

• Access/Egress

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

• Fall Protection Inspected

  Yes

  No

  N/A

• Scaffolds/Ladders - Proper Type

  Yes

  No

  N/A

• Scaffolds/Ladders - Inspected

  Yes

  No

  N/A

• Scaffolds/Ladders - Use

  Yes

  No

  N/A

• Handrails

  Yes

  No

  N/A

• Comments:

Hand Tools

• Condition

  Yes

  No

  N/A

• Guards/Handles

  Yes

  No

  N/A

• Proper for Job/Use

  Yes

  No

  N/A

• Comments:

Electrical

• GFCI/Assured Grounding Program

  Yes

  No

  N/A

• Cords/Tools v Inspected

  Yes

  No

  N/A

• Comments:

Hot Work

• Permit Conditions Followed

  Yes

  No

  N/A

• Fire Watch

  Yes

  No

  N/A

• Gas Cylinder Management

  Yes

  No

  N/A

• Leads/Hoses/Gauges

  Yes

  No

  N/A

• Permit

  Yes

  No

  N/A

• Comments:

Fire Protection & Prevention

• Annual/Monthly Fire Extinguisher Inspection

  Yes

  No

  N/A

• Properly Rated/Size (BC versus ABC)

  Yes

  No

  N/A

• Combustible/Flammable Material Away<br>from Hot Work

  Yes

  No

  N/A

• Fire Suppression Equipment

  Yes

  No

  N/A

• Comments:

Excavation

• Excavation Type:

• Line finder used before trenching

  Yes

  No

  N/A

• Benched Properly

  Yes

  No

  N/A

• Trench Box Certifications

  Yes

  No

  N/A

• Access/Egress Points

  Yes

  No

  N/A

• Spoil Pile Minimum 2-Feet From Excavation

  Yes

  No

  N/A

• Signs, Signals & Barricades

  Yes

  No

  N/A

• One Call Made

  Yes

  No

  N/A

• Number

• Documented Inspection by Competent<br>Person

  Yes

  No

  N/A

• Trench Box/Shoring Proper

  Yes

  No

  N/A

• Sloped Properly

  Yes

  No

  N/A

• Utilities Identified

Signs/Barricades

• Marking Hazards

  Yes

  No

  N/A

• Condition

  Yes

  No

  N/A

• Proper Type

  Yes

  No

  N/A

• Comments:

Housekeeping

• No trash

  Yes

  No

  N/A

• Trash Receptacles

  Yes

  No

  N/A

• Crew Trucks/Trailers

  Yes

  No

  N/A

• Dunnage (organization of loose material)

  Yes

  No

  N/A

• Comments:

Walking Surfaces

• Pathways

  Yes

  No

  N/A

• No trip Hazards

  Yes

  No

  N/A

• Holes Guarded

  Yes

  No

  N/A

• Comments:

Traffic Control

• Designated Flagger

  Yes

  No

  N/A

• Signs Posted per MUTCD

  Yes

  No

  N/A

• Escort Required/Used

  Yes

  No

  N/A

• Comments:

Overhead Power Lines

• Proper Equipment for Spotter (Air Horn,<br>Vest, etc.)

  Yes

  No

  N/A

• Power Lines Marked with Goal Post and<br>Signs

  Yes

  No

  N/A

• Designated Spotter

  Yes

  No

  N/A

• Comments:

Radiation Sources

• Type:

• Signs, Signals & Barricades

  Yes

  No

  N/A

• Film Badges for X-Ray Crew

  Yes

  No

  N/A

• Comments:

Pressure Testing

• Signs, Signals & Barricades

  Yes

  No

  N/A

• Equipment Integrity

  Yes

  No

  N/A

• Whip Checks/Connections Pinned

  Yes

  No

  N/A

• Comments:

Abrasive Blasting

• Dead-Man Switch Operable

  Yes

  No

  N/A

• Proper PPE

  Yes

  No

  N/A

• Trap and Carbon Filter Installed

  Yes

  No

  N/A

• CO Alarm in use

  Yes

  No

  N/A

• Comments:

Lock-Out/Tag-Out

• Potential Energy Sources Identified

  Yes

  No

  N/A

• Isolated

  Yes

  No

  N/A

• Type of Isolation:

• Verified

  Yes

  No

  N/A

• Affected Personnel Informed

  Yes

  No

  N/A

• Comments:

Confined Space

• Permitted

  Yes

  No

  N/A

• Add media

  Media

• Final Comments:

Sign off

• On site representative

  Sign

• Signature

  Sign