Take 5 Safety Checklist

• Date & time conducted

  Date

• Name of person conducting the Take 5

• Signature of person conducting the Take 5

  Sign

• Site

• Drilling Rig #

• Shift

  Day Shift

  Night Shift

Step 1 - Safety Overview

• Stop, step back and assess

• Task

• Do you understand the task?

  Yes

  No

  N/A

• List what is not understood, in addition to this you must contact your direct supervisor.

• Is there a relevant procedures (ie. SWP, SOP, JSEA) that can be reviewed prior to commencing task or upon any doubt or confusion?

  Yes

  No

  N/A

• List what you believe to be required or why the SWP, SOP or JSEA's Maxfield Drilling currently has is not sufficient.

• Would the task be considered high risk and subjected to a SWMS?

  No

  Yes

  N/A

• Is a SWMS available that is suitable and relevant to the task?

  Yes

  No

  N/A

• Is any type of permit required for the task? (eg. hot works, excavation, confined spaces, working at height, permit to work)

  No

  Yes

  N/A

• Have you obtained the permit?

  Yes

  No

  N/A

• Do you have the correct PPE for the task?

  Yes

  No

  N/A

• List reasons why you do not have the correct PPE and list what PPE is required

• Do you have the correct tooling and equipment for the task?

  Yes

  No

  N/A

• List reasons why you do not have the correct tooling and equipment and list what tooling and equipment is required

• Are you competent and authorised (know how to and allowed to) to undertake the task?

  Yes

  No

  N/A

Step 2 - Risk Management

• Step 1: Identify the hazards
  Step 2: Assess the associated risks
  Step 3: Select and implement risk control measures
  Step 4: Review the effectiveness of controls
  Step 5: Confirm it is safe to proceed with the task

• If a hazard is identified, its best you photograph it and attach to this report by selecting the "media" button below the individual questions

• Manual handling hazards (eg. lifting, awkward positioning, over-exertion)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Gravity hazards (eg. slips, trips and falls or suspended loads)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Mechanical hazards (eg. exposure to rotating parts, moving equipment)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Electrical hazards (eg. exposure to live energy sources)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Chemical hazards (eg. exposure to hazardous chemicals or materials)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Pressure hazards (eg. exposure to high pressure air/hydraulic lines)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Noise hazards (eg. exposure to loud noises)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Biological hazards (eg. exposure to cross infection of diseases or illness)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Radiation hazards (eg. exposure to excessive light including ultraviolet light or x-ray)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Psychological hazards (eg. exposure to stress, violence or fatigue)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

• Temperature hazards (eg. exposure to extreme hot or cold temperatures)

  No

  Yes

  N/A

• List hazard specifics

• List proposed control measures

• Do you believe the control measures adequately mitigate the hazard?

  Yes

  No

  N/A

• Is it safe to proceed with the task?

  Yes

  No

  N/A

Completion of Take 5

• Do you require anything further to safely and effectively undertake the task?

  No

  Yes

  N/A

• List what you require

• Do you believe it is safe to continue with the task

  Yes

  No

  N/A

• Complete the take 5 and immediately contact your direct supervisor.