Title Page

  • Conducted on

  • Prepared by

  • Employee ID

  • Ramp

  • Elevation

  • Shift

Entrance and Travelways

  • Is ground support in place?

  • why is there no support in place?

  • Has the heading been scaled?

  • Is the ventilation system working?

  • Do you have a MX4/MX6 to continue?

  • Can you ask for a supervisor for one?

  • Are signs/barriers/barricades/guards in place?

  • Why not?

  • Is there any housekeeping issues?

  • Is there dust issues?

  • Do you have a respirator?

  • Do you have proper road conditions to work safely?

  • Where is your nearest escapeway/refuge chamber?

Work area

  • Do you have proper PPE for the Work area?

  • Why not?

  • What is the condition of your ventilation system?

  • Is your heading ventilation fan on?

  • Do you have an MX4/MX6 to continue in heading?

  • Can you ask your supervisor for one?

  • Is there big holes in your vent duct or poor installation of the vent duct?

  • Can you describe the location and add pictures?

  • Is the air directed to the active face if there is multiple faces?

  • Can you choke off the other heading to direct the air to the active heading?

  • What do you recommend to improve?

  • What is the condition of the heading utilities?

  • What exactly is wrong?

  • Is scaling bar present?

  • Can you ask your supervisor for one?

  • Is it the right height for this heading?

  • How are the ground conditions in this heading?

  • Can you correct the ground hazard?

  • What do you recommend to correct the hazard?

  • What did you do to correct the hazard?

  • What can be done to make the ground conditions better?

  • How is the housekeeping in this area?

  • Can you correct it?

  • Why not?

  • What did you do to correct it?

  • What can be done to better the area?

  • Is there proper signage in this heading?

  • Is there an immediate hazard?

  • Can you put up a barrier/barricade?

  • What kind of barrier/barricade did you put up?

  • Have you informed your supervisor?

  • Can you contact someone that can?

  • Can you put up a barrier/barricade?

  • Can you notify your supervisor to add one?

  • What kind of barrier/barricade did you put up?

  • Are ropes/slings/whip checks being used in heading?

  • Have they been inspected for rips/tears?

  • Do they have rips or tears?

  • Can you destroy the rope/sling or replace the whip check and dispose the item?

  • Do they have the proper weight rating?

  • Can you get the proper rope/sling for the job?

  • Is there a fire extinguisher in the area?

  • Do you have one in/on your equipment?

  • Can you explain why you do not have one?

  • Have you inspected your fire extinguisher?

  • Was the pressure in the green? Pin in place? Nozzle clear? Clear of damage?

  • The fire extinguisher needs to be replaced, can you get a new one?

  • Can you contact your supervisor for a new one?

  • Do you have fire suppression on your equipment?

  • Have you inspected it? Do you know the location of it?

  • Is there any misfires in the heading?

  • Are you trained to deal with misfires?

  • Can you contact a supervisor?

  • Describe location of misfire.

  • Is there any leads or undetonated explosive material coming out of the holes?

  • Can you contact a supervisor and add proper barrier?

  • Are you comfortable to continue?

  • Can you contact a supervisor?

  • Can you contact your supervisor?

  • Is there anything which needs to LOTOTO? (locked out, tagged out, tried out)

  • What are you locking out?

  • Have you locked it out?

  • Have you tagged it out? include picture of tag

  • Have you tired it out?

  • Is there anything that needs a permit?

  • What kind of permit?

  • Is yours up to date?

  • Any other comments?

Unusual work

  • Are you working in an unusual work condition?

  • Has a FLRA been completed?

  • Can you fill out a FLRA before the task is started?

  • Are you working with unusual hazards?

  • Has a FLRA been completed?

  • Can you fill out a FLRA before the task is started?

Safety Interactions

  • Are you working to standards?

  • Why not?

  • Are you competent to preform this work?

  • Why not?

  • Have you had a safety interaction?

  • What was discussed?

  • Can you have a safety interaction?

  • What was discussed?

  • Why will you continue to work safe?

Employee Comments/Notes

  • Any comments/notes?

Supervisor Signature

  • Signature to confirmed the document has been checked

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