Workover Rig HSE Assessment
Safety Management System
Date
/
Month
/
Day
Year
Date
Rig
Type of Assessment
Scheduled Safety Assessment
Walk Through
Status
In Progress
Closed
Current Activity
Supervisor on Duty
Person Performing Assessment
First Name
Last Name
Assessor Email
example@example.com
Section 1: Observations/Training
1. All location personnel have not had Arrow S Energy Operating Orientation
2. Proper clothing, gloves, hard hats, safety glasses, steel toe shoes not used.
3. Fall protection not used at 4' or higher.
4. No Smoking areas are not designated or posted.
5. Unsafe acts or conditions observed.
6. First aid training is not provided minimum of 1 trained person on site.
7. (H2s locations) H2s warning signs are not erected, All personnel are not trained.
8. Tailgate pre-task/JSA safety meeting not held with all personnel.
9. Hazards/tasks not communicated with all contractors on site.
10. Wind indicator not adequate.
11. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 1
Note the count for the total number of deficiencies for this section (this includes multiples of like violations)
Notes:
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Section 2: Location/Rig Up
1. Distance from overhead power lines is not a minimum of 10 feet.
2. No Hazard signs displayed or not adequate (no smoking, hard hat area, authorized personnel only, no vehicles in guy line pattern, wear caustic protection).
3. Guy wires not flagged 8' from ground.
4. Fall line of derrick is not clear.
5. Vehicles within guy pattern.
6. Overall housekeeping (carrier and derrick is bot free of excessive oil buildup, standing oil, slip/trip hazards).
7. Pipe racks, catwalk - are not level and stable (personnel should not walk on racked pipe).
8. Spark arrestors missing on exhaust.
9. All engines - mud pumps and other engines are not at least 50 ft. away from wellhead or other sources of gas.
10. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 2
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Notes:
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Section 3: Crown to Ground Guy Lines
1. Number of wind guys are less then a minimum of four)
2. Condition of guylines are not (free of kinks, excessive corrosion, knots, bends, breaks, and splices)
3. Diameter of guylines are not (minimum of 9/16")
4. There is not minimum of three wire clamps at each attachment point/ four clamps when turned back on a sheave
5. Ground anchors are not (permanently installed as per manufacturer pattern)
6. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 3
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Notes:
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Section 4: Tubing Board & Internal Load Guys
1. Are not strung and crossed for racking
2. There are not a three clamps minimum on wire rope
3. Are not adjusted for tension according to manufactures specification
5. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 4
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Notes:
Photos Section 4
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Section 5: Mast/Derrick
1. Manufacturers operation/specification plate is not in place and legible.
2. Evidence of damage/corrosion (visually inspect for damage to legs, braces, girts,and excessive corrosion)
3. Ladder has missing or bent rungs, corrosion, excessive grease or oil
4. Tubing Board condition has bends, breaks or missing sections)
5. Rod Basket bottom damaged/corroded, hangs in the way of travel assembly, hinge points not greased or excessively worn support lines.
6. Crown railing shows signs of corrosion and/or physical damage
7. Manual latch dog extension/retraction mechanism (confirm operation,check lubricant, wear or damage).
8. Latch dogs visually not inspected prior to loading derrick (to be done each rig up)
9. Scoping ram stabilizers not in place, functional, lubricated, free from wear or damage
10. Crown-sheave guards not in place or in satisfactory condition.
11. Finger board safety cable not in place, functional, wire condition unsatisfactory
12. Cracks, metal failure or wear at hinge points (visual)
13. No safety retainers on hinge pins (locking pins not in place when derrick erected)
14. Derrick locking pins in not place with safety pins
15. Derrick hydraulic system shows signs of leaks
16. Full body harness, lanyards and lifelines not provided at all elevated work areas and not inspected for condition and use.
17. Anti-fall/climbing assist device is not provided
18. Emergency derrick escape /anchor is not properly installed and functional
19. Lighting system not in proper location, secured, wiring not insulated and/ or secured
20. Air is not purged from hydraulic raising cylinder
21. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 5
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Notes:
Photos Section 5
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Section 6: Rig Cab
1. Seat belt not used, and/or not functional
2. Loose or flammable materials stored in cab
3. Glass/ mirrors damaged view obstructed.
4. Fire Extinguisher not inspected and/or properly mounted
5. Reflectors damaged or missing
6. Windshield wipers not in good condition or functional
7. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 6
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Notes:
Photos Section 6
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Section 7: Carrier
1. Inadequate supplemental footing provided
2. Handrails/guards missing or damaged on elevated walkways/steps
3. Walkways with slip trip hazards (grease, oil, tools or fittings)
4. Head, tail and signal lights broken, dirty and non-functioning
5. Wheels not properly chocked
6. Condition of tires/wheels in poor condition (wear, tread, apparent rubbing and breaks)
7. Fuel, hydraulic and other tanks not labeled correctly
8. Fuel or other fluid leaks (check for seepage or accumulation)
9. Hydraulic leveling jacks not secured by automatic mechanical locknuts(locknuts jammed)
10. Brakes not set/secure
11. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 7
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Notes:
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Section 8: Drawbacks/Winch
1. Guards at drawworks not in place and/or in poor physical condition
2. Tubing/drill line in poor repair
3. Sandline has Whickering, fraying, broken strands, stretching
4. Insufficient wraps left on drum without locks in down position (per manufacturers recommendation)
5. Dead-line anchor and retainer (Wraps on incorrectly, number of wraps(2-2 1/2), clamps not secure, retainer not in place)
6. Hydromatic break in poor condition, antifreeze, has leakage.
7. Break linkage has bends, or cracks (no free operation, Linkage pins not secured)
8. Tubing/sandline brakes (drums not smooth, bands cracks, pad thickness)
9. Movement from winch to road gear not prevented with road gear lock-out
10. Handling winch and tail chain (grade 8 and tagged in poor condition)
11. Catline has kinks, knob, splices fraying and/or excessive wear)
12. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 8
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Notes:
Photos Section 8
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Section 9: Assembly Condition
1. Traveling Blocks in poor condition.
2. Traveling Blocks not properly guarded.
3. Bales and/or links in poor condition.
4. Elevators in poor condition.
5. Hoisting hook equipped missing or inadequate safety latch.
6. Transfer elevators (inspect suspension line, safety latches, pivot)
7. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 9
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Notes:
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Section 10: Operators Station/Work Floor
1. Operator control panel is not properly labeled/identified.
2. Kill Switch at control panel not operational.
3. Rig floor in poor condition, not level,secured on both sides, holes not covered
4. Chains and cables not labeled and tagged.
5. Sliding section missing stops or pins (sliding section cannot close completely)
6. Winch Cables, Load Hooks, Swivel, Chain Choker Hooks and approved Shackles in poor condition.
7. Steps/handrails damaged or missing.
8. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 10
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Notes:
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Section 11: Tools and Equipment/Power tongs condition
1. No backup in place and functional
2. Stiff arm, snub/safety line (clamps missing or in poor condition)
3. Covers/head guards missing or in poor condition
5. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 11
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Notes:
Photos Section 11
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Section 12: Blow out Preventer (BOP)
1. BOP improperly installed/secured. (bolts missing)
2. BOP not properly tested and functional.
3. Training procedures for BOP use not established or in use
4. Safety valve and handle for tubing (valve not available with proper connection and handle)
5. Accumulator valves not in open or closed position
6. Whip checks not adequate
7. No items of non-compliance discovered for this section
Other
Number of Deficiencies in Section 12
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Notes:
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Section 13: Hand Tools
1. Condition of handles, jaws, faces, heads poor
2. Cleanliness (excessive grease, oil, dirt or rust)
3. Unused tools improperly stored/racked
4. Tools modified or home made
5. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 13
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Notes:
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Section 14: Mud/Circulation System
1. Standpipe not secured at each end
2. Circulation hose not secured to gooseneck and swivel with safety hobbles(attached to hose via hose clamp, wire line or chain is acceptable)
3. High pressure fittings in high pressure system
4. Pressure relief valves (cap covering shear pin, pin of properdiameter and strength)
5. Discharge lines from relief valve improperly anchored (blooey line anchoredpop-off missing place)
6. No guards in place /swabs (pinch points)
7. Mud pit walkways/steps not level, clear, free of damage, handrails if applicable
8. Iron/high pressure lines are not tagged certified.
9. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 14
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Notes:
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Section 15: Material Handling Equipment
1. Forklift operators not trained and certified
2. Forklift not equipped with seat belt and/or not used when in operation.
3. Forklift not inspected prior to use.
4. Manlift operators not trained and certified.
5. Manlift operators not using fall protection as required.
6. Manlift not inspected prior to use.
7. Lifting equipment not in proper order
8. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 15
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Notes:
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Section 16: Safety Equipment
1. No First Aid/Blood borne pathogen kit
2. Fire extinguishers not (up to date and a minimum of three 20 lb.)
3. Lock out-tag out equipment
4. Emergency numbers not posted
5. SDS and emergency response plan not available on site
6. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 16
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Notes:
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Section 17: Vehicles
1. Glass and mirrors are not clean, unbroken and/or roperly attached
2. Lights, turn signals, brakes, horn, tires, reflectors are in poor condition.
3. Seatbelts not accessible, clean, without evidence of use.
4. Hitch and ball have excessive wear, safety chains or cables missing or nonfunctional.
5. No items of non-compliance discovered for this section.
Other
Number of Deficiencies in Section 17
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Notes:
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