Safety Hazard Report rev15, 4-3-17

• Document No.

• Division

  Select Western Fort Worth Eastern Mid Con Permian Western Canada

  • Western
  • Fort Worth
  • Eastern
  • Mid Con
  • Permian
  • Western Canada

• Location: (Roosevelt, Piceance, Orangeville, LaBarge, Farmington, Bakken, Trinidad)

• Employee Name:

• Report type: (LOTO, Safety Audit, Hot Work, JSA, Electrical JSA)

• Facility/ Site Name

• Conducted on

  Date

• Reason for permit:

• Type of report:

  Pre-Job Electrical Hazard

  Safety Audit

  Pre-Job Hazard/ Tail Gate Safety

  LOTO

  Hot Work

• Can this work be performed de-energized

  Yes

  No

  N/A

• Voltage Levels involved

  Select 12DC 24DC 120AC 240AC 480AC

  • 12DC
  • 24DC
  • 120AC
  • 240AC
  • 480AC

• Equipment Type:

• Primary Disconnect

  Voltage

  Amperage

• What is the voltage?

• What is the amperage?

• Hazard Category:

• Is all Category PPE Present?

  Yes

  No

  N/A

• Shock Boundary

• Arc Flash Boundary

• Unqualified Persons Boundary

• Single Line Diagrams

  Yes

  No

  N/A

• Voltage Testing Equipment Verified

  Yes

  No

  N/A

• At what Voltage was equipment verified?

• Is Voltage testing equipment rated for the maximum voltage on job site?

  Yes

  No

  N/A

• What is the maximum rating of test equipment, in volts?

• Critical Verification Voltage Test Points? List all that apply.

• Insulated Tools required?

  Yes

  No

  N/A

• How will this work be performed?

  Energized

  De-energized

• LOTO?

  Yes

  No

• Special LOTO Requirements?

• Signatures of Qualified Persons

Qualified Person

• Qualified Person

  Sign

• Company

• Minimum PPE Requirements:

  Select Hard Hat Personal H2S Monitor Passport / Training book Safety Glasses w/side shields Safety-Toed Footwear Hearing Protection Respirator Gloves Knee Pads Face Shield ARC Flash Fall Protection

  • Hard Hat
  • Personal H2S Monitor
  • Passport / Training book
  • Safety Glasses w/side shields
  • Safety-Toed Footwear
  • Hearing Protection
  • Respirator
  • Gloves
  • Knee Pads
  • Face Shield
  • ARC Flash
  • Fall Protection

• Hazard identification and safety briefing/discussion:

  Select Hazardous Position of People Falling from heights slips/trips/falls Extreme Heat/Cold Electrical Current Overexertion/ Heavy lifting Equipment LOTO been performed prior to work Hot Work Permit Required Overhead Work / Suspended Loads/ Chains/Slings Trapped Pressure Flammables/Combustibles/Explosives Pinch Points/ Moving/ Rotating Equipment Hazardous Substances Hazardous Atmospheres Walking/Working Surfaces Noise Levels Blinds or skillets installed Insects/snakes/Etc

  • Hazardous Position of People
  • Falling from heights
  • slips/trips/falls
  • Extreme Heat/Cold
  • Electrical Current
  • Overexertion/ Heavy lifting
  • Equipment LOTO been performed prior to work
  • Hot Work Permit Required
  • Overhead Work / Suspended Loads/ Chains/Slings
  • Trapped Pressure
  • Flammables/Combustibles/Explosives
  • Pinch Points/ Moving/ Rotating Equipment
  • Hazardous Substances
  • Hazardous Atmospheres
  • Walking/Working Surfaces
  • Noise Levels
  • Blinds or skillets installed
  • Insects/snakes/Etc

• List all Identified Hazards and action taken to mitigate risk:

Identified Hazard

• Identified Hazard:

• Remedy to mediate risk of hazard:

• XTO Safety Handbook references: (List all that apply, include page numbers, or N/A if not applicable)

• Signatures of all attendees:

Attendees

• Attendee Signature

  Sign

Post-Job Debriefing:

• Were any additional hazards encountered during the course of this work?

  yes

  no

• List additional hazards:

• Comments:

• XTO Representative:

  Sign

Safety Audit

• Personal Protective Equipment: (Check all that apply)

  Select Hard Hat Personal H2S Monitor Passport / Training book Safety Glasses w/side shields Safety-Toed Footwear Hearing Protection Respirator Gloves Knee Pads Face Shield ARC Flash Fall Protection

  • Hard Hat
  • Personal H2S Monitor
  • Passport / Training book
  • Safety Glasses w/side shields
  • Safety-Toed Footwear
  • Hearing Protection
  • Respirator
  • Gloves
  • Knee Pads
  • Face Shield
  • ARC Flash
  • Fall Protection

• Work Area - General: (Check all that apply)

  Select Proper housekeeping Adequate Lighting Hazardous conditions exist noise control is in place Dust control is utilized

  • Proper housekeeping
  • Adequate Lighting
  • Hazardous conditions exist
  • noise control is in place
  • Dust control is utilized

LOTO

• Is LOTO being used?

  Yes

  No

  N/A

• Is LOTO being used properly?

  Yes

  No

  N/A

Hazardous Materials

Electrical Safety

• Electrical Safety: (Check all that apply)

  Select GFI in Use Machine Guards in place Electrical Cords in good condition Adequate Electrical connections Exposed Electrical Wires

  • GFI in Use
  • Machine Guards in place
  • Electrical Cords in good condition
  • Adequate Electrical connections
  • Exposed Electrical Wires

• Was selected component(s) de-energized prior to work being performed?

  Yes

  No

  N/A

Lifting

• Lifting: (Check all that apply)

  Select Proper technique Cart in use Other mechanical devices

  • Proper technique
  • Cart in use
  • Other mechanical devices

Working Above 4' / Ladder

• Working at height: (Check all that apply)

  Select Ladder in Use Appropriate for job Used correctly

  • Ladder in Use
  • Appropriate for job
  • Used correctly

• Was work to be performed at a height >6ft?

  Yes

  No

  N/A

• Is fall protection being used?

  Yes

  No

  N/A

Hot Work

• Purpose for Permit:

  Select Exposed electrical terminal in a classified area Non-intrinsically safe equipment in a classified area Open flame within 35' of Classified Area Spark Producing device within 10' of a classified area

  • Exposed electrical terminal in a classified area
  • Non-intrinsically safe equipment in a classified area
  • Open flame within 35' of Classified Area
  • Spark Producing device within 10' of a classified area

• Hot Work conditions: (Check all that apply)

  Select Burning, Torch, Welding operations Fire extinguishers in place Fire protection in place Proper PPE worn Fire watch Electrical tools

  • Burning, Torch, Welding operations
  • Fire extinguishers in place
  • Fire protection in place
  • Proper PPE worn
  • Fire watch
  • Electrical tools

• List any corrective actions taken:

• Comments:

• XTO Representative

  Sign

LOTO

• List all equipment to be locked and tagged:

Equipment Item

• What type of energy source are you eliminating?: Select one

  Pressure

  Electrical

  Mechanical

• Effected Equipment Category

  Measurement

  Production

• Select system

  Plate Check/Change

  Repair/ Replace

  Other

• Please enter description:

• Select System

  Control Valves

  Other

• Please enter description:

• Effected Equipment Category

  Control System

  Service

• Select System

  ESD

  Production

  Other

• Please enter description:

• Please enter description:

• Select system:

  Primary Mover

  Other

• Please enter description:

• Physical Lock Location:

• Isolated Position

  Upstream/Downstream Valves closed and pressure relieved

  Disconnect Open and verified Zero voltage

• Tagged?

  Yes

  No

  N/A

• Locked?

  Yes

  No

  N/A

• Lock Number?

• Lock/Tag Installed Date and Time

  Date

• Lock/Tag Removed Date and Time:

  Date

Safe to perform verification: (all effected parties must sign before work can begin)

• By signing below I certify that I have examined and tested all energy control devices, and that the equipment / systems are isolated, decontaminated, and safe to perform the work indicated.

verification signature

• Signature

  Sign

Post Work - Safe to return to service: (All effected parties on site must sign prior to work beginning)

• By signing below I certify that I have examined the equipment / system and it is mechanically / electrically complete and safe to return to service.

verification signature

• Signature

  Sign

Hot Work

• Enter readings to document acceptable levels: (Initial check prior to work, and subsequent test if conditions have changed or you have left the area)

Atmosphere Test

• Time of test

  Date

• Oxygen:

• Combustible Gas: (LEL)

• Hydrogen Sulfide:

• Carbon Monoxide:

• Other:

• Special Precautions: (Check all that apply)

  Select Pre-job meeting has been conducted to communicated responsibilities and hazards Equipment has been properly locked and tagged Equipment has been properly cleaned and purged Area is clear of combustibles. Proper PPE is being utilized.

  • Pre-job meeting has been conducted to communicated responsibilities and hazards
  • Equipment has been properly locked and tagged
  • Equipment has been properly cleaned and purged
  • Area is clear of combustibles.
  • Proper PPE is being utilized.

• Hot Work: (Check all that apply)

  Select The work was moved outside to avoid a permit Welder is qualified per XTO specifications Fire extinguisher is in good working order and properly placed

  • The work was moved outside to avoid a permit
  • Welder is qualified per XTO specifications
  • Fire extinguisher is in good working order and properly placed

• Enter information for site personnel:

Operating Personnel Approval

• Company/Contractor or employee

• Assigned Task of Employee

• Signature

  Sign

• Are Hazardous materials being used?

  Yes

  No

  N/A

• List Hazardous Materials: