Summit Pipeline Safety Audit - Updated Version

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Traffic Control

• Proper signs and placement per MUTCD

  Yes

  No

  N/A

• Posted speed limit

  Yes

  No

  N/A

• Designated flaggers

  Yes

  No

  N/A

• Do the flaggers have an escape route

  Yes

  No

  N/A

• Has there been consideration for large emergency response vehicles in regards to lane width

  Yes

  No

  N/A

• Are the construction vehicles located within the work zone displaying their strobe lights

  Yes

  No

  N/A

• Have the flaggers been instructed on the process for control regarding EMS vehicles entering the job site

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Job Site Evaluation

• Description of job task

• JSA performed

  Yes

  No

  N/A

• JSA signed

  Yes

  No

  N/A

• Pedestrian traffic accessibility

  Yes

  No

  N/A

• Have provisions been made for pedestrians with disabilities

  Yes

  No

  N/A

• Are pedestrian pathways free of tripping hazards

  Yes

  No

  N/A

• Has the work zone been properly barricaded from the public entering the work zone

  Yes

  No

  N/A

• Housekeeping and cleanliness of job site

  Yes

  No

  N/A

• Are there signs to identify the safe passage for pedestrians

  Yes

  No

  N/A

• Are all holes guarded within the pedestrian pathways

  Yes

  No

  N/A

• Are there any holes either in the roadway or sidewalk that require immediate attention

  Yes

  No

  N/A

• Weather

  Yes

  No

  N/A

• Temperature

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Vehicle and Equipment Evaluation

• Authorized and qualified operator

  Yes

  No

  N/A

• Daily/ weekly/ annual inspections

  Yes

  No

  N/A

• Designated signal person

  Yes

  No

  N/A

• Seat belt used

  Yes

  No

  N/A

• Travel/ back up alarm properly working

  Yes

  No

  N/A

• Does the equipment have a fire extinguisher

  Yes

  No

  N/A

• Are the required monthly and annual inspection tags present and filled out

  Yes

  No

  N/A

• Are there any significant leaks that require immediate attention

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Trailers

• Safety chains in use

  Yes

  No

  N/A

• Condition of safety chains

  Yes

  No

  N/A

• Is the emergency break away hooked up

  Yes

  No

  N/A

• Condition of break away

  Yes

  No

  N/A

• Is the safety pin properly being used

  Yes

  No

  N/A

• Are wheel chocks being used

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Hand Tools and Portable Equipment Evaluation

• Are guards and handles in place

  Yes

  No

  N/A

• Condition of hand tools

  Yes

  No

  N/A

• Proper job use

  Yes

  No

  N/A

• Is there a generator being used

  Yes

  No

  N/A

• Is there a fire extinguisher in close proximity to the running generator

  Yes

  No

  N/A

• Does the generator have a built in GFCI

  Yes

  No

  N/A

• If not is there a portable GFCI being used

  Yes

  No

  N/A

• Inspection of all cords

  Yes

  No

  N/A

• Have any cords been deemed in unsatisfactory condition for use

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Material Handling and Storage

• Lifting chains

  Yes

  No

  N/A

• Shackles and lifting hooks

  Yes

  No

  N/A

• Slings

  Yes

  No

  N/A

• Have any of the above been deemed unsafe for continued on the job use

  Yes

  No

  N/A

• Any loads requiring the use of tag lines

  Yes

  No

  N/A

• Has the load been rigged and secured properly

  Yes

  No

  N/A

• Flammable liquids labeled and stored properly

  Yes

  No

  N/A

• Has the lay down area been secured by means of barricades/ cones/ or caution tape

  Yes

  No

  N/A

• Has pipe storage been chocked

  Yes

  No

  N/A

• Has pipe storage been secured/ stabilized/ barricaded or coned off

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Environmental/Emergency Response

• Certified Responders

  Yes

  No

  N/A

• First-Aid Kit

  Yes

  No

  N/A

• Spill Response Kit

  Yes

  No

  N/A

• Emergency Action Plan

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Hazardous Communication

• MSDS Available

  Yes

  No

  N/A

• MSDS Reviewed

  Yes

  No

  N/A

• Containers Labeled Properly

  Yes

  No

  N/A

• Handling Procedures Followed

  Yes

  No

  N/A

Hygiene

• Restrooms

  Yes

  No

  N/A

• Adequate Drinking Water for Employee Hydration

  Yes

  No

  N/A

PPE

• Hard Hat

  Yes

  No

  N/A

• Eye/Face

  Yes

  No

  N/A

• Hand

  Yes

  No

  N/A

• Hearing

  Yes

  No

  N/A

• Footwear

  Yes

  No

  N/A

• Hi-Vis Vest

  Yes

  No

  N/A

• Is there a cut off saw in use

  Yes

  No

  N/A

• Respirator

  Yes

  No

  N/A

• Respiratory Program in Place (MEQ, Fit Test, Training, etc...)

  Yes

  No

  N/A

• FRC

  Yes

  No

  N/A

• Monitors Available, In Use, Calibrated (4-Gas, H2S or Other)

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

• Number of employees not wearing safety glasses

  Yes

  No

  N/A

Fall Prevention/Protection

• Access/Egress

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

• Fall Protection Inspected

  Yes

  No

  N/A

• Scaffolds/Ladders - Proper Type

  Yes

  No

  N/A

• Scaffolds/Ladders - Inspected

  Yes

  No

  N/A

• Scaffolds/Ladders - Use

  Yes

  No

  N/A

• Handrails

  Yes

  No

  N/A

Hot Work

• Permit

  Yes

  No

  N/A

• Permit Conditions Followed

  Yes

  No

  N/A

• Fire Watch

  Yes

  No

  N/A

• Gas Cylinder Management

  Yes

  No

  N/A

• Leads/Hoses/Gauges

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

Fire Protection & Prevention

• Fire Suppression Equipment

  Yes

  No

  N/A

• Annual/Monthly Fire Extinguisher Inspection

  Yes

  No

  N/A

• Properly Rated/Size (BC versus ABC)

  Yes

  No

  N/A

• Combustible/Flammable Material Away from Hot Work

  Yes

  No

  N/A

Excavation

• Excavation Type:

  Stable Rock

  Type A

  Type B

  Type C

• Depth of excavation

  Yes

  No

  N/A

• Documented Inspection by Competent Person

  Yes

  No

  N/A

• Sloped Properly

  Yes

  No

  N/A

• Benched Properly

  Yes

  No

  N/A

• Trench Box/Shoring Proper

  Yes

  No

  N/A

• Trench Box Certifications

  Yes

  No

  N/A

• Access/Egress Points

  Yes

  No

  N/A

• Spoil Pile Minimum 2-Feet From Excavation

  Yes

  No

  N/A

• Signs, Signals & Barricades

  Yes

  No

  N/A

• One Call Made

  Yes

  No

  N/A

• Utilities Identified

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Overhead Power Lines

• Power Lines Marked with Goal Post and Signs

  Yes

  No

  N/A

• Designated Spotter

  Yes

  No

  N/A

• Proper Equipment for Spotter (Air Horn, Vest, etc…)

  Yes

  No

  N/A

Pressure Testing

• Equipment Integrity

  Yes

  No

  N/A

• Whip Checks/Connections Pinned

  Yes

  No

  N/A

• Signs, Signals & Barricades

  Yes

  No

  N/A

Confined Space

• Permitted

  Yes

  No

  N/A

• Personnel Trained

  Yes

  No

  N/A

• Emergency Rescue Plan

  Yes

  No

  N/A

• Rescue/Retrieval Equipment (Anklets, Harness, Life Line, etc...…)

  Yes

  No

  N/A

General comments