Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Employee #1 Information
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Enter employees name and position
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Is the employee wearing all required PPE? (Hardhat, Steel Toes, Safety Glasses, FRC's)
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Is the employee's general appearance acceptable? (Clean, PPE in good repair, etc)
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Is the employee demonstrating acceptable work ability and habits? (listens to crew pusher, follows PWI's, etc)
Employee #2 Information
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Enter employees name and position
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Is the employee wearing all required PPE? (Hardhat, Steel Toes, Safety Glasses, FRC's)
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Is the employee's general appearance acceptable? (Clean, PPE in good repair, etc)
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Is the employee demonstrating acceptable work ability and habits? (listens to crew pusher, follows PWI's, etc)
Employee #3 Information
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Enter employees name and position
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Is the employee wearing all required PPE? (Hardhat, Steel Toes, Safety Glasses, FRC's)
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Is the employee's general appearance acceptable? (Clean, PPE in good repair, etc)
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Is the employee demonstrating acceptable work ability and habits? (listens to crew pusher, follows PWI's, etc)
Employee #4 Information
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Enter employees name and position
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Is the employee wearing all required PPE? (Hardhat, Steel Toes, Safety Glasses, FRC's)
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Is the employee's general appearance acceptable? (Clean, PPE in good repair, etc)
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Is the employee demonstrating acceptable work ability and habits? (listens to crew pusher, follows PWI's, etc)
Employee #5 Information
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Enter employees name and position
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Is the employee wearing all required PPE? (Hardhat, Steel Toes, Safety Glasses, FRC's)
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Is the employee's general appearance acceptable? (Clean, PPE in good repair, etc)
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Is the employee demonstrating acceptable work ability and habits? (listens to crew pusher, follows PWI's, etc)
Employee #6 Information
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Enter employees name and position
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Is the employee wearing all required PPE? (Hardhat, Steel Toes, Safety Glasses, FRC's)
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Is the employee's general appearance acceptable? (Clean, PPE in good repair, etc)
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Is the employee demonstrating acceptable work ability and habits? (listens to crew pusher, follows PWI's, etc)
Record of Driving Evaluation
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Did the driver complete a pre trip inspection in accordance with DOT regulations?
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Did the driver properly hook onto the trailer?
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Did the driver utilize chocks on both truck and trailer whenever stopped?
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Did the driver keep smooth control of vehicle at all times?
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Did the driver utilize a spotter when backing trailer?
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Was the driver consistently alert and attentive?
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Did the driver maintain proper speed?
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Did the driver look back and utilize mirrors?
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Were all loads (Bobcat, Augers, Pipe, etc) secured in accordance with DOT Regulations?
Equipment and Tools Checklist - Please Note: Item must be serviceable in order to receive a 'Pass' score.
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Is the Crew Pusher in possession of a One Call Ticket and/or the One Call Number?
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Augers - This includes Buckets, Rock and Dirt Augers
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Bobcat Equipment - This includes Forks and Bucket
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Shovels
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Landing Bars
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Pry Bars
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Wrenches
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Tape Measures
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Stakes
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Welding Rod
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Welding Helmet
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Tool Pins and Bolts
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Crash Kit
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Registration
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Insurance
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First Aid Kit
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GPS
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Seat Covers
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Floor Mats
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Door Stickers
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DOT Number
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Unit Number
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JSA Book
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MSDS Book
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Front Bumper
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Tool Box
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Jumper Cables
General Evaluation Items
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Are all vehicles parked with consideration of first move forward policy?
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Is the parking break set on all vehicles?
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Are all vehicles free of leaks?
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Is there a spill kit available?<br>
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Where safety belts used?
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Where vehicles traveling within the posted speed limits?
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Are wheel chocks being used?
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Is there a clearly marked 100 foot buffer zone around the hole?
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Are all non-essential personnel observing the 100 foot safety zone?
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Are employees who are handling cellar rings wearing gloves to prevent cuts?
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Are all down riggers properly positioned on pads?
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Are all non-essential vehicles clear of the work area?
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Were spotters utilized when unloading equipment with the bobcat?
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While unloading equipment did non-essential personnel remain at least 25 feet from the unloading operation?
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After unloading equipment was complete was all other unused equipment secured to trailer?
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Are Drill Operator and Assistant aware of proper hand signals while rigging up?
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Were proper hand signals utilized while rigging up?
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While the drill mast is being raised is only the spotter within a 50 foot buffer zone?
JSA
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Was a JSA safety meeting held prior to Rig Up?
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Was a JSA safety meeting held prior to beginning work?
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Was a JSA safety meeting held prior to rigging down?
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Are all signature sheets accounted for?
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Are changes made and documented for job specific conditions?
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Any adverse challenges (weather, mud, extreme temperature, etc.) identified and communicated in the JSA process?
PPE
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Are minimum PPE (hard hat, safety glasses, steel toed boots and FRC's) being properly utilized?
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Is all PPE in a serviceable condition?
Behavioral Based Safety
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Are there any signs of the following: Rushing, Frustration, Fatigue, Complacency
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Are there any signs of the following: Mind Not On Task, Eyes Not On Task, Balance/Traction/Grip Issues, Line Of Fire
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Is the crews overall attitude positive? (If the answer is 'No' please describe why)
Crew Pusher/Supervisor
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Crew Pusher/Supervisor inspected the rig and 3rd party equipment for unsafe conditions?
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Crew Pusher/Supervisor ensured that all equipment is rigged up correctly?
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Crew Pusher/Supervisor ensured that all personnel are aware of all proper procedures and are utilizing them?
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Crew Pusher/Supervisor ensured that all personnel worked safely?
Hot Work and Setting Pipe
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Will hot work be performed? (Welder)
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Was a hot work permit completed?
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Are a minimum of two fire extinguishers available?
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Was the gas sniffer utilized?
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Did affected personnel utilize proper PPE while welding?
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Are the proper shackles being utilized? (With nut and cotter pin)
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Was a danger zone of at least 75 feet established while setting pipe?
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Did all personnel observe the danger zone?
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Was a tag line utilized while setting pipe?
Cellar Rings
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Are chocks being utilized to prevent cellar rings from rolling while unattended?
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Is the cellar ring being cut? (If yes please answer following questions)
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Are all personnel standing upwind from cutting operations?
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Is proper PPE being worn? (Safety Glasses, leather gloves)
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Is there a fire extinguisher available?
Cellar Entry
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Are personnel entering the cellar? (If yes please answer following questions)
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Was a ladder utilized?
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Was fall protection utilized?
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Is there a hole watch?
Augers
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Are there any augers being stored at the base of the operators cab?
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Are there any augers that are standing without support?
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Were personnel changing auger teeth? (If yes please answer the following questions)
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Was a face shield worn?
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Were safety glasses worn?
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Were gloves worn?
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Was a brass hammer utilized?
Noble Casing, Inc
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Are there any SSE/SPE employees present? If 'yes' please place number in comments.
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Are any Noble Casing, Inc employees smoking inside of the designated smoking area?
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Are any Noble Casing, Inc employees operating 3rd party equipment? If 'yes' please identify in comments.
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Are any Noble Casing, Inc employees utilizing a cell phone while working?
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By signing this I hereby certify that I conducted this Rat Hole Field Evaluation and that all information is true and correct
