Information
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Conducted on
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Client / Site
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Location
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Job Name
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Job Number
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Prepared by
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Personnel
TRUCKS
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Switch "ON" to activate this section
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Truck #
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Equipment secured properly during transit?
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Service engine or other warning lights activated?
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Emergency Equipment Present?
- Spare Tire
- Jack
- Tire Tools
- Fire Extinguisher
- Road Markers
- First Aid Kit
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Lights, blinkers, wipers, tire issues?
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Other notable conditions
TRAILERS AND BOATS - TOWING
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Switch "ON" to activate this section
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Dive Trailer or Boat #
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Registration?
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Spare tire, jack, tire tool present?
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Trailer lights working?
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Break-away switch, safety chains, hitch, electrical connection, safety pin in good condition and used properly?
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Do the emergency brakes seem operational?
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Spare tire?
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Other notable conditions
BOAT SAFETY EQUIPMENT
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Switch "ON" to activate this section
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One PFD for each person onboard?
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PFD's readily accessible?
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Life-Ring with 90' of floating line immediately available?
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USCG approved fire extinguisher/s (2) type B I or (1) type B II Inspected and good condition?
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Visual distress signals in kit (3) day and (3) night?
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Sound producing device in kit?
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Lighting for night operation or reduced visibility?
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Trash and oil pollution placards in place?
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Other notable conditions
SITE SAFETY
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Switch "ON" to activate this section
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Do hazardous conditions from vehicle traffic exist?
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Was it briefed properly before starting work?
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Have adequate safety precautions been taken?
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Do environmental hazards exist?
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Was it briefed properly before starting work?
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Have adequate safety precautions been taken?
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Other site or topside safety hazards?
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Were they briefed properly before starting work?
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Have adequate safety precautions been taken?
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Other notable conditions
PERSONAL PROTECTIVE EQUIPMENT
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Switch "ON" to activate this section
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PPE worn properly by all personnel?
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Is PPE applicable to the task being performed?
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PPE in good condition?
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Eye and face protection worn as required?
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Hearing protection worn as required?
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Decibel level reading
- Not Taken
- <70 db
- 70 db
- 71 db
- 72 db
- 73 db
- 74 db
- 75 db
- 76 db
- 77 db
- 78 db
- 79 db
- 80 db
- 81 db
- 82 db
- 83 db
- 84 db
- 85 db
- 85 db
- 86 db
- 87 db
- 88 db
- 89 db
- 90 db
- >90 db
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Respiratory protection worn as required?
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Fall protection needed / worn?
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Fall protection condition?
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Workers dressed properly for the job / task?
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Other notable conditions
GENERAL SITE SAFETY / HOUSEKEEPING
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Switch "ON" to activate this section
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Walkways, stairs, steps clear of material and debris?
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Cords and hoses strung to prevent trip and fall hazard?
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Compressor has functioning catch pan or other method of containing spills?
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Liquid spills cleaned up immediately?
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Dive station and work areas clean and orderly?
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Trailers, spaces, and equipment kept clean and orderly?
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Trash, scrap, and debris picked up and disposed of?
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Other notable conditions
FIRE PROTECTION AND HAZARDS
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Switch "ON" to activate this section
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Fire Safety Included in Pre Job Briefing / JSA
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Fire extinguishers readily accessible?
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Fire extinguishers inspected?
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Smoking prohibited within 50 feet of where flammables are located?
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Is "No Smoking" signage in place?
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Flammables stored and handled in approved containers?
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Fuel Cans in good condition?
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Fuel Can Type
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Refueling of machinery while in operation is prohibited?
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Adequate Cool Down time allowed prior to refueling?
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Other notable conditions
ELECTRICAL SAFETY CONSIDERATIONS
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Switch "ON" to activate this section
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Extension cords in good condition?
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Cords protected from sharp edges / routed properly?
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Cords, connections, breakers, etc. Not overloaded?
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Electrical connections kept dry?
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Generators kept dry / protected from weather?
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GFI's tested?
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Overhead or nearby wiring hazards exist?
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Other notable conditions
PORTABLE LADDERS
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Switch "ON" to activate this section
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Proper ladder selected for task?
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Ladder rated sufficiently for intended use?
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Ladder inspected prior to use?
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Ladder/s being used properly?
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Other notable conditions
CONFINED SPACE
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Switch "ON" to activate this section
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Is this a permit required space? (IDLH)
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Is there a current and signed permit?
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Dangers Present
- Hazardous Atmosphere
- High Oxygen >23.5%
- Low Oxygen <19.5%
- Flammable Gasses
- Flammable Liquids
- Flammable Items
- Toxic Gasses or Items
- Radiological Hazards
- Engulfment Hazard
- Falling Hazard
- Drowning Hazard
- Mechanical Equipment Hazard
- Line of Fire Hazard
- Pinch Point Hazard
- Entanglement / Fouling Hazard
- Sea-Life or Other Wildlife Hazard
- Thermal Hazard (cold)
- Thermal Hazard (heat)
- Steam Hazard
- Insect Hazard
- Strong Flow or Current
- Delta P Hazard
- Other Hazard
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Has the Atmosphere been Monitored
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Monitor Information
- UESI Monitor
- Borrowed Monitor
- Monitor Calibration Current
- Monitor Calibration Not Current
- Bump Test Performed
- Bump Testing Not Performed
- Sample taken close to the water
- Sample taken middle of air column
- Sample taken near the entrance / Opening
- Sample taken at the top of air column
- Sample taken from other Location
- Monitor is Man Carried / Worn monitor
- Monitor pumping sample through tubing
- Monitor pump has filter at end of sample tubing
- No filter at end of sample tubing
- Continuous Monitoring
- Spot Monitoring performed
- Before Entry into space
- During Work / Occupants Present
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Entry Point
- Built-In Ladder
- Scaffold Built Ladder
- Extension Ladder
- Other Ladder
- Ladder Not Required
- Walk-In
- Crawl-In
- Squeeze-In
- Ladder Secured
- Ladder Not Secured
- Fall-Arrest System used properly
- Fall-Arrest System not used properly
- Fall Arrest Not Used / Needed
- Fall-Arrest Not Required
- Fall-Arrest Inspection Current
- Fall-Arrest / Extraction Device Inspection Current
- Fall-Arrest / Extraction Device Inspection Not Current
- Crew Unable to operate extraction device
- Extraction Device Not Working
- Extraction Device Damaged / Worn
- Needs Service
- In Good Condition
- Crew Knowledgable / Skilled in use
- Not Used Properly
- Fall Harness good condition
- Fall Harness Poor Condition
- Tending Line Needed
- Tending Line Worn
- Tending Line Not Worn
- Adequate Signage and Barriers in Place
- Signage and Barriers Not Adequate
- Need Lanyards
- Lanyards Used Properly
- Scaffold Barrier
- Protective Fencing
- Signage
- Red Danger Tape
- Yellow Caution Tape
- Tags in Place on Tape
- Horses
- Traffic Cones
- Other Barriers
- Tripod Used to mount Extraction Device
- Tripod Mount In good condition
- Tripod Mount Needs Service
- Unsafe Anchor Point
- Safe Anchor Point capable of supporting 5000#
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Hazard Abatement
- Identified Hazards covered during JSA / Job Brief
- Identified Hazards Not Briefed
- Continuous Venting
- Inerting
- Other Engineering Control in Place
- Work Stoppage for unforseen hazard abatement
FALL ARREST EQUIPMENT
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Switch "ON" to activate this section
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Harnesses in good condition?
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Harnesses labeled, annual inspection marked?
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Fall arrest equipment inspection current?
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Crew skilled at extraction device operation?
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Lanyards in good condition?
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Lanyards labeled, annual inspection marked?
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Proper length lanyard being used fall zone clear?
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Attachment point rigged properly and capable of supporting at least 5000 lbs?
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Rigging in good condition?
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All rigging components rated for the load?
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Other notable conditions
DIVING READINESS
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Diving Brief Elements:
- Diver Fitness
- Standby Diver Fitness
- Medications
- Dives in last 12 hours
- Job and Task
- Associated Hazards
- Emergency Plans
- Emergency Numbers
- Job Assignments
- See Something Say Something
- Everyone's Input matters
- Personal Diving Equipment Condition
- Other - Not listed
- Asked for Input / Concerns / Clarification
- Did not assess diver or crew
- Did not assign jobs / tasks
- Hazards not addressed
- Job / Task Hazards not covered
- Repet dives not accouunted for
- Emergency Plan not discussed
- Personal Diving Equipment not addressed
- Rushed / Vague
- Safety Not Stressed
- Individual Input not needed / wanted
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UESI Safe Practices Manual on-site?
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Condition of Safe Practices Manual
- Good Condition
- Poor Condition
- Current Revision
- Not the current version
- Up to date / Newest changes installed
- Not up to date / needs changes installed
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Diver Fitness
- Diver and Standby condition questioned during brief
- Prior to making assignements
- Fitness to dive not established
- Diver's Health in question
- Diver's physical fitness questionable
- Diver sounds congested
- Diver looks tired or ill
- Diver looks injured
- Diver recovering from previous injury
- Diver Taking Medication
- Medication Use not established or questioned
- Previous Dives (RNT) not established
- Diver Physical not current
- Diver has current Physical on file
- Diver in good condition
- Diver and Standby in good condition, not taking any medication, and no dives in the last 12 hours
- RNT Accounted for in dive plan
- Not taking medication
- No meds or conditions contraindicated for diving
- Condition discussed in private
- Other condition or concern not listed
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Diver Harness
- Compliant
- Non-Compliant
- Umbilical Attachment
- Ability To Lift the diver from the water in an emergency
- Questionable condition or ability to lif the diver's weight in an emergency
- Would not be able to lif diver from the water in an emergency
- Breaking strength no less than 2000 lbs.
- Positive buckling device, not able to release with single action
- Umbilical attachment at least as strong as umbilical strength member
- Adjustable Permanently attached leg straps
- Lifting Recovering Ring capable of lifting the diver from the water with a hoisting device
- Designed to maintain the diver in a heads-up position during recovery
- Allows for disconnect of the umbilical and weights without removal of the bail-out harness
- Visually inspected prior to use
- Appears to be regularly maintained
- Does not appear to be regularly maintained
- Certified by the manufacturer
- Manufacturer tag not present
- Tag states manufacturer name
- Tag has Unique Identifier
- Tag states Breaking Strength
- Harness must be tagged as being certiified tested to withstand a tensile of at least 2000 pounds for five minutes without sustaining damage that would render it inoperable or unsafe to use.
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Diving Helmets
- Compliant
- Non-Compliant
- Company Helmet
- Personally Owned Helmet
- Kirby Morgan
- Gorski
- Desco
- Other Manufacturer
- Personal Maintenance Log maintained
- Unable to show maintenance log
- Annual inspection current
- In poor condition - Appears un-maintained
- Fair Condition - Needs Maintenance soon
- Good Condition - Properly Maintained
- Comms Not Working Properly
- Valves hard to operate / need service
- Regulator out of adjustment
- Missing or Damaged Components
- Leaking Components
- Locking Pins Need Attention
- Neckdam damaged / poor condition
- Locking device / Toilet Seat Damage
- Damageed Faceplate
- Oral Nasal Missing
- Other Damage, wear, or maintenance issue
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Bailout System
- Compliant
- Non-Compliant
- At least 30scf
- Current Hydro stamp
- Current Visual Inspection Sticker
- Hydro Not Current
- VIP sticker missing
- Regulator Leaking
- Hoses Bulging or Leaking
- Quick Disconnect in poor condition
- Snap Shackle in poor condition
- Tank Bands in poor condition
- Harness Non-Compliant
- Other Questionable condition or maintenance issue
- Not worn properly
- Too Small
- Too Large
- Damaged Buckles or attachments
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Emergency Aid / Phone List on-site and available to everyone?
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Emergency telephone available?
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First aid kit fully stocked with current inventory?
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Emergency oxygen cylinders charged and within expiration date?
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Emergency oxygen regulator in good condition?
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AMBU bag with mask and oxygen tubing in good condition?
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Depth / Time profile being tracked?
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RNT of repet dives tracked and logged?
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Deco Tables, Repet Tables, and No D Tables present?
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Timekeeping device present and dedicated to the dive?
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Divers' depth tracked by pneumo gauge?
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All Hoses are labeled with current test cert?
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Pneumo gauge/s calibrated within last 6 months?
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Diver condition checked after each dive?
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Carbon Monoxide monitor calibration current?
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High Pressure Alarm in place and being used properly?
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HP cylinders mounted securely?
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HP Bank / E-Air system tested? Pressure and regulator setting checked frequently?
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HP E-Air cylinder hydro test date within 5 years?
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E-Air bank pressure?
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Diver's Air Compressor #
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Current air certification?
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Intake Up-wind of exhaust? (6' / 12' rule)
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LP Volume tank serviced within 1 year, hydro within 5 years?
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2-stage filter bank filters changed within 3 months, with string, then carbon filtration present?
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Manifold pressure checked before every dive, and frequently during the dive?
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Manifold pressure setting?
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Alpha and Recreational Diving Flags flown visibly during diving operations?
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Diving ladder extends at least 3 feet below the water and at least 3 feet above the surface?
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Umbilicals pressure tested and marked every 10 feet?
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A plan exists to assist an injured diver out of the water with adequate equipment available?
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All dive team members are attentive to the dive?
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Diver tended continuously throughout dive?
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Diver's bailout pressure checked before every dive?
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Divers dressed properly with sufficient exposure protection?
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Standby rig capable of same or greater depth/length than the primary?
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Standby rig connected to hat, air and comms tested, bailout ready, pressure recorded?
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Standby diver ready for deployment?
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Other notable conditions
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TERMINATION OF DIVE
- Diver lost voice communication
- Diver fails to respond to Comms or Signals
- Diver goes on bailout or E-air
- Diver wants to get out
- Hazardous conditions exist
- Supervisor directed
- Technical issues with equipment or work plan
- Dive profile limit
- Task completed
- Emergency drill conducted
DIVING EMERGENCY DRILL
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Switch "ON" to activate this section
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Drill Elements
- Poor response
- Good response
- Excellent response
- Leadership Drill
- Equipment Drill
- Fire Drill
- Medical Drill
- Lost Communication
- Diver Mechanical Injury
- Unresponsive Diver / Unconscious
- Fouled Diver
- Lost Diver
- Diver Has Headache
- Diver Can't Clear
- Diver Performance / Productivity Issues
- Missed Deco Stop
- Delay / Fouled on Bottom
- Delay / Fouled >50'
- Delay / Fouled <50'
- Ascending too fast
- Approaching Boat or other Craft
- Bad Weather
- Load / Crane Overhead
- Personnel Behaviour Issue - Topside
- Personnel Behaviour Issue - Diver
- Previous Diver (Working Topside) Suddenly Has DCS
- Topside Support Worker Injury
- Compressor Failure
- Support Equipment Issue
- Diver (In Water) Equipment Issue
- Other Issue
- Client Notified
- Client Present
- Client Not Present
- Client Not Notified or N/A
SAFETY / READINESS STATUS
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Readiness Rating
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