Wellsite HSE Assessment
ASE Safety Management System
Date
-
Month
-
Day
Year
Date
Assessor
First Name
Last Name
Email
example@example.com
Well Name/s
Type of Assessment
Scheduled Safety Assessment
Walk Through
Progress
Draft Assessment
Closed Assessment
Section 1 Lease Road & Entrance
1. Road surface damage excessive or could cause damage to vehicles
2. Litter present along lease road or entrance to location
3. Signage not adequate at entrance to location
4. Emergency Action Plan in place as per 29 CFR 1910.38
Section 1. Number of Deficiencies Noted
Section 1. Notes/Deficiencies
Section 1. Photo
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Section 2. General HSE
1. Poor housekeeping around the perimeter of the location
2. Poor housekeeping around wellhead
3. Presence of or condition of rental/ third-party equipment on location
4. Spills present on location
5. Fencing not adequate or in poor condition
6. Cattle guard in poor condition
7. Gate in poor condition if applicable
8. Open pit(s) on location
9. Pit(s) not adequately backfilled and/or reclaimed
10. Barrier not present around open pit
11. Cellar not filled in or barricaded
12. Mousehole not covered
13. Wind indicator in disrepair or not present
14. Leaks on location.
15. Liquid/chemicals not labeled
16. Wildlife hazard present on location
17. Grounding not adequate
18. Well identification sign not present
19. Facility Piping not adequate
20. Electrical components not adequate
21. Containment not adequate
22. Fire fighting equipment not adequate
23. Hazard/Caution signs not present or in poor condition
24. Safety equipment not adequate
25. Vegetation overgrowth
26. Other
Section 2. Number of Deficiencies Noted
Section 2. Notes/Deficiencies
Section 2. Photo
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Upload File if Applicable
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Additional Notes
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