Statoil Bakken Business Unit / Facilities and Civil Construction Safety Report

• Conducted On:

  Date

• Location:

• Statoil Site Representative:

• Statoil Safety Representative:

• Contractors Working on Location:

• Equipment on Location:

• Status of Operations:

Signage:

• Safety Billboard in Place?

  Yes

  No

  N/A

• PPE & FRC's signage in Place at Entrance?

  Yes

  No

  N/A

• Lease Signs in Place?

  Yes

  No

  N/A

• No Smoking Signage at the Entrance of Location?

  Yes

  No

  N/A

• Confined Space Labels in Correct Location on Tanks?

  Yes

  No

  N/A

• Tanks Labeled with Placards in Place?

  Yes

  No

  N/A

• Separator Building Labeled?

  Yes

  No

  N/A

• Heater Treater Building Labeled?

  Yes

  No

  N/A

• Generator Fuel Tank Labeled?

  Yes

  No

  N/A

• Electrical Room Labeled?

  Yes

  No

  N/A

• Electrical Breakers Properly Indicated?

  Yes

  No

  N/A

• Electrical Board Panels with Warning Labels in Place?

  Yes

  No

  N/A

• Pumping Unit Safety Warning Labels in Place?

  Yes

  No

  N/A

• All Containers Labeled with their Contents?

  Yes

  No

  N/A

• Automatic Start Signage in Place?

  Yes

  No

  N/A

• Stay Off Berm Signage in Place?

  Yes

  No

  N/A

Applicable Permits

• JSA / SJA Completed with Contractor Sign-in Sheet?

  Yes

  No

  N/A

• Ground Disturbance Permit Completed?

  Yes

  No

  N/A

• Hot Work Permit Completed?

  Yes

  No

  N/A

• Confined Space Permit Completed and Posted?

  Yes

  No

  N/A

• Critical Lift Permit Completed?

  Yes

  No

  N/A

General Site Inspection:

• Interior / Exterior Berm or Containment Walls in Place?

  Yes

  No

  N/A

• Pinch Valve Closed and Secured with Lock & Chain?

  Yes

  No

  N/A

• Dead Man Marked / Visible and within its Life Expectancy?

  Yes

  No

  N/A

• Pumping Unit Safety Guards in Place, Ladders with Fall Protection Cage?

  Yes

  No

  N/A

• Ignitor Wire Functioning?

  Yes

  No

  N/A

• All Caps and Plugs in Place?

  Yes

  No

  N/A

• Plumbing Appeared to Teflon Tape on all Threads?

  Yes

  No

  N/A

• Heater Treater Ladder with Fall Protection Cage in Place?

  Yes

  No

  N/A

• Tanks, Walkways, Stairs Properly Grounded?

  Yes

  No

  N/A

• Grounds Available for Transport while Loading and Unloading?

  Yes

  No

  N/A

• Stairs and Catwalk Secured on Tanks with Two Threads Showing on Bolts?

  Yes

  No

  N/A

• Adequate Hand-Rails Provided on Stairs and Catwalk?

  Yes

  No

  N/A

• Windsock Up and Visible and in Good Shape?

  Yes

  No

  N/A

• Are Chemicals Stored Properly with MSDS Available?

  Yes

  No

  N/A

• Electrical Covers in Place?

  Yes

  No

  N/A

• Location Clean with Pathways Clear (No Obstructions)?

  Yes

  No

  N/A

Contractor Inspection

• All Crew Members Wearing Proper PPE & FRC's?

  Yes

  No

  N/A

• H2S Monitors Being Utilized?

  Yes

  No

  N/A

• Fall Protection Being Utilized?

  Yes

  No

  N/A

• Utilizing Safety Glasses/Grinding Shields while Grinding?

  Yes

  No

  N/A

• First Aid Kit Available on Location?

  Yes

  No

  N/A

• Fire Extinguishers Available with Monthly / Annual Inspection Completed?

  Yes

  No

  N/A

• Crew Utilizing Proper Tools for Job Functions?

  Yes

  No

  N/A

• Crew Using Proper Lifting Techniques?

  Yes

  No

  N/A

• Tools with Safety Guards in Place?

  Yes

  No

  N/A

• Good Housekeeping with Work Area Clean and Organized?

  Yes

  No

  N/A

• Crew Utilizing Proper Lockout / Tag Out?

  Yes

  No

  N/A

• Roll Over Protection in Place with No Obvious Defects?

  Yes

  No

  N/A

• Fire Watch Being Utilized?

  Yes

  No

  N/A

• Spotter Be Utilized while Equipment is in Operations?

  Yes

  No

  N/A

• Backup Alarms on Equipment Working Properly?

  Yes

  No

  N/A

• Does Contractor Equipment on Location Have Seat Belts (Being Utilized by Operator)?

  Yes

  No

  N/A

• Are Pipe Thread Cuttings be Collected?

  Yes

  No

  N/A

• Are Chock Blocks Being Utilized?

  Yes

  No

  N/A

• Are Compressed Cylinder Tanks Secured Upright with Valve Caps in Place?

  Yes

  No

  N/A

• Proper Rigging Techniques are Being Utilized while Lifting Loads?

  Yes

  No

  N/A

• Inspected Tag Lines are Being Utilized when Lifting Loads?

  Yes

  No

  N/A

• Rigging Equipment Appears to be in Good Working Condition?

  Yes

  No

  N/A

Contractors Excavating and Trenching

• Caution Tape / Barriers Fencing Off Around Open Pits and Trenches?

  Yes

  No

  N/A

• All Bell Holes are Properly Sloped and/or Benched?

  Yes

  No

  N/A

• Ladders, Steps, or Ramps Located in Bell Hole so No More than 25ft of Lateral Travel is Required?

  Yes

  No

  N/A

• Excavated Soil, Other Material, Or Equipment are Stored at Least 2ft from the Edge of the Excavation?

  Yes

  No

  N/A

Additional Findings or Concerns:

• Issue #1:

• Add media

  Media

• Issue #2:

• Add media

  Media

• Issue #3:

• Add media

  Media

• Issue #4:

• Add media

  Media

• Issue #5:

• Add media

  Media

• Issue #6:

• Add media

  Media

• Issue #7:

• Add media

  Media

• Issue #8:

• Add media

  Media

• Issue #9:

• Add media

  Media

• Issue #10:

• Add media

  Media

• Statoil Safety Representative:

• Add signature

  Sign

• Consultant / Company Man:

• Add signature

  Sign

• Contractor Supervisor / Foreman:

• Add signature

  Sign