M V He's

• Department / Area / Machine #

• Document No.

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Area free of rubbish?

  At Risk

  Safe

  Needs Work

  N/A

(PPE) Personal Protective Equipment

• PPE Pics

  Media

• Employees wearing safety glasses at all times?

  Yes

  No

  N/A

• Employees wearing gloves when exposed to cuts and bruises?

  At Risk

  Safe

  Needs Work

  N/A

• Safety Glasses in use were task requires them to be worn.

  At Risk

  Safe

  Needs Work

  N/A

• Face shield or splash goggles worn during chemical operations? (Splash Hazard into eyes)

  At Risk

  Safe

  Needs Work

  N/A

• Hearing Protection worn properly by employees when required?

  At Risk

  Safe

  Needs Work

  N/A

• Condition of PPE? (Clean & sanitary condition)

  At Risk

  Safe

  Needs Work

  N/A

• PPE properly stored when not being used?

  At Risk

  Safe

  Needs Work

  N/A

• Dust masks worn in building 5

Electrical

• Electrical Pics

  Media

• Electrical panels and devices labeled and secured?

  At Risk

  Safe

  Needs Work

  N/A

• Cover plates or switch plates in place?

  At Risk

  Safe

  Needs Work

  N/A

• Extension cables in good condition?

  At Risk

  Safe

  Needs Work

  N/A

• Extension cable NOT used on a permanent basis?

  At Risk

  Safe

  Needs Work

  N/A

• A quick (random) inspection was performed.

• Extension cables not used across aisle ways or walk ways.

  At Risk

  Safe

  Needs Work

  N/A

• Fuse boards door are closed when not in use?

  At Risk

  Safe

  Needs Work

  N/A

• Electrical panels, Breaker boxes, Disconnect boxes unobstructed? ( 3 ft clearance)

  At Risk

  Safe

  Needs Work

  N/A

Machinery & Machine Guarding

• Machine Pics

  Media

• Is the current guard(s) effective?

  At Risk

  Safe

  Needs Work

  N/A

• Is the Light curtain working properly?

  At Risk

  Safe

  Needs Work

  N/A

• Do adjustable arms for light curtains have padlocks in place?

  At Risk

  Safe

  Needs Work

  N/A

• Potential for employee to reach (Over, Under, Around, Through) the guard?

  At Risk

  Safe

  Needs Work

  N/A

• E-stop properly labeled (Emergency Shut-off)?

  At Risk

  Safe

  Needs Work

  N/A

• Caution / Warning signs in place?

  At Risk

  Safe

  Needs Work

  N/A

• Are all gates, grates, fencing, pin guards, etc in place to prevent employee from entering a hazardous area or nip point.

  At Risk

  Safe

  Needs Work

  N/A

• Are moving parts guarded (belts, shafts, rotating/reciprocating parts, pinch points, etc.)?

  At Risk

  Safe

  Needs Work

  N/A

• Do saws stop within 10 seconds when switched off

  Yes

  No

  N/A

Hand and Power Tools

• Tool Pics

  Media

• Power Tools free from damage (switches and guards)?

  At Risk

  Safe

  Needs Work

  N/A

• Cables free from damage or frays?

  At Risk

  Safe

  Needs Work

  N/A

• Cable plug is equipped with ground plug....electrical?

  At Risk

  Safe

  Needs Work

  N/A

• Hand tools free from damage ( handles, shaft, head, etc.)?

  At Risk

  Safe

  Needs Work

  N/A

• Safety guards in place? (Grinders, sanders, etc.)

  At Risk

  Safe

  Needs Work

  N/A

• Grinders have handles in place and free from damage?

  At Risk

  Safe

  Needs Work

  N/A

• A quick (random) inspection was performed.

( Crane/Hoist ) - MEWP/Lifting Components

• Properly stored when not in use?

  At Risk

  Safe

  Needs Work

  N/A

• Properly tagged or labeled?

  At Risk

  Safe

  Needs Work

  N/A

• Is tag / label legible?

  At Risk

  Safe

  Needs Work

  N/A

• A quick (random) inspection was performed.

Emergency / First Aid

• Clear access to fire extinguishers?

  At Risk

  Safe

  Needs Work

  N/A

• Clear assess to fire hose?

  At Risk

  Safe

  Needs Work

  N/A

• Are fire extinguishers properly mounted?

  At Risk

  Safe

  Needs Work

  N/A

• Are fire extinguisher signs in place or pole painted "RED"?

  At Risk

  Safe

  Needs Work

  N/A

• Fire extinguisher inspections current?

  At Risk

  Safe

  Needs Work

  N/A

• Access to Emergency fire exits?

  At Risk

  Safe

  Needs Work

  N/A

• Access to First Aid items / kit?

  At Risk

  Safe

  Needs Work

  N/A

• Emergency Pics

  Media

Eye Wash

• Eye Wash Pics

  Media

• Accessible or clear path?

  At Risk

  Safe

  Needs Work

  N/A

• Are adequate signs marking the location?

  At Risk

  Safe

  Needs Work

  N/A

• Clean (Free from dust, dirt or other debris)?

  At Risk

  Safe

  Needs Work

  N/A

• Expiration date ok or last inspection ok?

  At Risk

  Safe

  Needs Work

  N/A

• Caps or covers in place when not in use?

  At Risk

  Safe

  Needs Work

  N/A

• A quick (random) inspection was performed.

• Last documented inspection date.

Fall Protection

• Elevated work levels (Over 4 feet high) have guardrails or railing at the proper height of 42" with mid-rail at approx 21"?

  At Risk

  Safe

  Needs Work

  N/A

• Are fall arrest (Harness, Lanyard, Clips, Hooks) inspected?

  At Risk

  Safe

  Needs Work

  N/A

Chemicals

• All chemical containers labeled?

  At Risk

  Safe

  Needs Work

  N/A

• Chemical spill kits available near by?

  At Risk

  Safe

  Needs Work

  N/A

• Chemicals used and/or stored in an approved containers?

  At Risk

  Safe

  Needs Work

  N/A

• Aerosol cans have lids/caps in place when not in use?

  At Risk

  Safe

  Needs Work

  N/A

• Flammable materials stored properly in flammable proof cabinet? (Ie:Acetone, Paint, etc.)

  At Risk

  Safe

  Needs Work

  N/A

• Waste or spent chemicals properly disposed of?

  At Risk

  Safe

  Needs Work

  N/A

• Adequate number of fire extinguishers in place?

  At Risk

  Safe

  Needs Work

  N/A

• Space heaters properly located away from flammables?

  At Risk

  Safe

  Needs Work

  N/A

• Are there items that have the potential to catch fire or possibility to cause a fire.

  At Risk

  Safe

  Needs Work

  N/A

Welding

• Are welding screens safely in place around welding work areas?

  At Risk

  Safe

  Needs Work

  N/A

• Are welding screens clean or free from excessive dust?

  At Risk

  Safe

  Needs Work

  N/A

• Are welding gas bottles secured to rack, cart or fixture to prevent it from falling?

  At Risk

  Safe

  Needs Work

  N/A

• Hoses and/or cords free from defects?

  At Risk

  Safe

  Needs Work

  N/A

• A quick (random) inspection was performed.

Ladders (Fixed or Portable)

• Stored or secured correctly while not in use?

  At Risk

  Safe

  Needs Work

  N/A

• Ladders free from defects or damage?

  At Risk

  Safe

  Needs Work

  N/A

• Properly labeled or identified?

  At Risk

  Safe

  Needs Work

  N/A

Site lighting

• Are all lights working outside

  Yes

  No

  N/A

• Are all lights working in all building

  Yes

  No

  N/A

Dust plant

• Working correctly

  Yes

  No

  N/A

• Dust cover in place

  Yes

  No

  N/A

• Area clean all motors free from dust

  Yes

  No

  N/A

Slip,Trip Hazards / Walking & Working Surfaces

• Slip, Trip Hazard Pics

  Media

• Spills or leaks?

  At Risk

  Safe

  Needs Work

  N/A

• Misc. items obstructing aisle ways?

  At Risk

  Safe

  Needs Work

  N/A

• Any holes in floor have been reported to Supervisor or Maintenance to be fixed?

  At Risk

  Safe

  Needs Work

  N/A

• Cables or hoses across aisle ways or walk ways?

  At Risk

  Safe

  Needs Work

  N/A

Environmental

Pollution Prevention

• Good Housekeeping, Preventive Maintenance, Spill Prevention, Training.

• Are BMP's (Best Management Practices) observed to prevent pollution?

  At Risk

  Safe

  Needs Work

  N/A

Recycling

• Are good recycling practices taking place?

  At Risk

  Safe

  Needs Work

  N/A

Water Conservation

• Any leaks or drips noticed?

  At Risk

  Safe

  Needs Work

  N/A

Energy Conservation

• Are lights turned off when applicable? (ie: natural light is plentiful or motion sensors are used)

  At Risk

  Safe

  Needs Work

  N/A

• Excess machinery, electrical devices are unplugged breakers turned off when not being utilized?

  At Risk

  Safe

  Needs Work

  N/A

Waste water

• Any observations of unauthorized items being disposed of down the drain?

  At Risk

  Safe

  Needs Work

  N/A

Storm Water

• Storm water drain access is clear and free from debris?

  At Risk

  Safe

  Needs Work

  N/A

Secondary Containment

• Is secondary containment being used?

  At Risk

  Safe

  Needs Work

  N/A

• Free from cracks, holes, etc?

  At Risk

  Safe

  Needs Work

  N/A

• Describe the type of secondary containment.

Safe/Unsafe acts observed?

• Unsafe Acts?

  Reckless or unsafe forklift driving

  Unsafe crane operations

  No unsafe acts noticed during this inspections

• Safe/ good working practice

  Yes

  No

  N/A

For this area/dept, How many accidents have occurred since the last assessment?

• Clinic Visit Injuries

• First Aid Only

• Report Only (No clinic visit needed)

• Property Damage

• Near Misses

Are there Risk controls that have failed or need to be enhanced in order to prevent future injuries?

• PPE (Besides Safety Glasses & Steel Toes)

  Select Full Suit Gloves Boots Hood Faceshield Welding Gear Respirator, PAPR, SAR Hearing Protection

  • Full Suit
  • Gloves
  • Boots
  • Hood
  • Faceshield
  • Welding Gear
  • Respirator, PAPR, SAR
  • Hearing Protection

• Engineering Controls

  Select Guard Rails Preventive Maintenance Gated Access Machine Guards Cranes Forklift / Powered Industrial Truck E-Stop, pumps, sensors, monitors Secondary Containment

  • Guard Rails
  • Preventive Maintenance
  • Gated Access
  • Machine Guards
  • Cranes
  • Forklift / Powered Industrial Truck
  • E-Stop, pumps, sensors, monitors
  • Secondary Containment

• Administrative Controls / Work Practice Controls

  Select Work Instructions SOP's Training Safety Meeting Two Way Radios Inspections/Audits R2A2 (Roles, Responsibilities, Accountability, Authority Housekeeping Decontamination

  • Work Instructions
  • SOP's
  • Training
  • Safety Meeting
  • Two Way Radios
  • Inspections/Audits
  • R2A2 (Roles, Responsibilities, Accountability, Authority
  • Housekeeping
  • Decontamination

• Communication Controls

  Select 2 Person Checklist Maps Signs / Posters Meetings Training / Awareness Investigations Other Visual communications Verbal Communication from Supervisor/Lead

  • 2 Person Checklist
  • Maps
  • Signs / Posters
  • Meetings
  • Training / Awareness
  • Investigations
  • Other Visual communications
  • Verbal Communication from Supervisor/Lead

• Additional comments on control failures.

Review

• Overall review?

  Great Job! keep up the good work.

  Not bad, but still needs improvement

  Poor, needs immediate attention

• Supervisor or Lead signature

  Sign

• EHS Manager signature

  Sign