Statoil Bakken Business Unit / Pipeline Construction Safety Report

• Conducted On:

  Date

• Location:

• Statoil Site Representative:

• Statoil Safety Representative:

• Contractors Working on Location:

• Equipment on Location:

• Status of Operations:

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

General 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

• First Aid Kit Available on Location

  Yes

  No

  N/A

• Fire Extinguishers On Location with Current Inspection

  Yes

  No

  N/A

• Crew Utilizing Proper Tools for Job

  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

• Are Pipe Thread Cuttings be Collected

  Yes

  No

  N/A

Material Handling Equipment:

• Spotter Be Utilized while Equipment is in Operations

  Yes

  No

  N/A

• Backup Alarms on Equipment Working Properly

  Yes

  No

  N/A

• Roll Over Protection in Place with No Obvious Defects

  Yes

  No

  N/A

• Equipment on Location in Good Working Condition (No Fluid Leaks)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Rigging Equipment (Side Boom Pulleys, Pins, and Wire Rope) Appears to be in Good Working Condition

  Yes

  No

  N/A

• Inspected Tag Lines are Being Utilized when Lifting Loads

  Yes

  No

  N/A

• Proper Rigging Techniques are Being Utilized while Lifting Loads

  Yes

  No

  N/A

Welding:

• Fire Watch Being Utilized

  Yes

  No

  N/A

• Utilizing Safety Glasses/Grinding Shields while Grinding

  Yes

  No

  N/A

• Are Compressed Cylinder Tanks (Oxygen/Acetylene) Labeled, Secured Upright, and Valve Caps in Place

  Yes

  No

  N/A

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

• Is Operator Exposing Charged Line in Safe Manner (Potholing, Positive ID, Probing Etc..)

  Yes

  No

  N/A

• Are Warning Signs Being Utilized and Safe Distance Being Maintained for Hydro-Testing Area

  Yes

  No

  N/A

• Are Warning Signs Being Utilized and Safe Distance Being Maintained for X-Ray Area

  Yes

  No

  N/A

• Proper Respirators Being Utilized

  Yes

  No

  N/A

Environmental:

• All Material Contained (No Spills on Location)

  Yes

  No

  N/A

Additional Findings or Concerns:

• Issue #1:

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• Issue #2:

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• Issue #3:

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• Issue #4:

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• Issue #5:

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• Issue #6:

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• Issue #7:

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• Issue #8:

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• Issue #9:

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• Issue #10:

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• Statoil Safety Representative:

• Add signature

  Sign

• Contractor Supervisor / Foreman:

• Add signature

  Sign

• Person In Charge (PIC):

• Add signature

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