Work Site Safety Checklist

Minimum 1 form for each job. Fill out daily or each shift for multiple shifts.
Lifecycle Services Site conditions must be reviewed daily

Customer Site Contact SR / Order No:

Location Telephone No Date:
CIty,State/Province List of persons on Job: Business Unit
Country Your Name
Emergency Phone #/Radio

EMERSON LIFECYCLE SERVICES EMPLOYEES SHALL NOT PERFORM THE FOLLOWING OPERATIONS*:
Line or Pressure Path Breaks Confined Space Entry Work on a Live Electrical System
Work above 6 feet or 1.8 meters Lock out Tag out as an Authorized Person
All high work which is not performed on approved scaffolds, ladders, properly guarded work platforms, manlifts, or on flat or low slope roofs at distances greater than
1.8 meters from an unguarded edge, shall require a special review with an Emerson Process Management Safety Professional before work proceeds
* Emerson employees are trained to be aware of these hazards but are not certified to perform the operations stated without advanced training. For more
information contact your Safety Team
The customer site representative must sign off on this document and verify all hazards have been correctly identified.

Did you inspect your company/rental vehicle today? Y N NA

A Customer Site Procedures Required/ Explained

Y NA Y NA
Emergency Procedures Reviewed Inclement Weather Evacuation
Location & use of Medical facilities Location of Emergency Equipment known
Alarm Types/ Alarm Systems Reviewed Know How to Report Emergency/Accident
Emergency Showers/ Eyewash SDS Location Known
Walking/Working Surfaces Evaluation Nearby equipment/activity reviewed
Special Hazards

Site escort required Y N

Was Site Safety orientation provided? Y N
Was a customer Job Risk Assessment Provided? Y N If Yes, attach a copy if available

B Does the scope of work involve a risk of contact with a toxic, corrosive or otherwise harmful substance? Y N

If YES:
i) Review the SDS (Safety Data Sheet) for the harmful substance to identify its specific hazards.

ii) Complete the Risk Assessment on Page 2 of this form to note the measures required to prevent harm from the hazards identified in the SDS.

Has the SDS been reviewed and have measures been taken to prevent harm from the hazards identified ? Y N/A

Identify the primary hazards listed from the SDS (for example, health hazard, flammable, corrosive, toxic, etc.)
Fluid Temp

Note: Presurized Systems

Always check for 'LINE OF FIRE' hazard on pressurized equipment. DO NOT WORK IN THE LINE OF FIRE.

C Personal Protective Equipment Requirements

Is your PPE inspected and in good condition? Y N Comments:
Y NA Y NA
Safety Shoes or Boots Hearing Protection
Hard Hat Safety Glasses
Goggles/ Face Shield Gloves (Type)
FR Clothing (minimum Hazard Class 2) High Visibility Clothing
Respirator/ Escape Respirator Arc Flash Protection
Headlamp (Class 1 Div 1) First Aid Kit
Lockout Tagout (LOTO) Kit Other PPE

Safe At Risk NA
D Work at Height ft or m Note:
Scaffolding / Ladders Maintain 3-point contact on ladders
Personell Lift Inspect fall protection equipment before use
Risk of Falling Objects from above EMERSON REQUIRES FALL PROTECTION ABOVE 1.8meters
Fall Protection Equipment in Use If using fall protection, double lanyard is required.
E Customer/Emerson Permits Required Yes NA Note:
Lockout / Tag Out (LOTO*) *Customer should apply primary LOTO with EPM
Hotwork technicians applying secondary LOTO. Customer to
Work at Height document LOTO requirements for each job/device. To
Line Breaking prevent unexpected energization, technicians must apply
personal locks to customer LOTO.
Air Monitoring
Other

F Equipment/ System Work Site Inspection

Safe At Risk NA Safe At Risk NA
System/ Equip De-Energized System/ Equipment locked Out
Decontamination by Customer Tool Inspection
Atmosphere safe? (i.e. confined space, etc.) Are there barricades or signs needed?
* H2S Present? Level below 10ppm? Explain:
* Flammable Vapors within 10% of LEL Explain:
* O2 content < 19.5% or > 20.8% Make a 360 safety check of the areas surrounding your work site:
* CO Present? Y N
Hoses, pipes and fitting Are access and exit routes clear?
in good condition? Are there hazards from nearby plant or machinery?
Max Pressure Rating of System: Are there hazards from other nearby work?

Stop Work Authority All Emerson Employees have Stop Work Authority
If any items are "AT RISK", a 3Ws hazard assessment must be completed and any corrective action applied before work proceeds.
Was it necessary to escalate any deficiencies to Emerson Process Management? Y N
If Yes, provide details and information to your manager on a Near Miss Report.

Employees have the responsibility to stop work when an unsafe condition or act could result in an undesirable event. If the site and job specific
risks were not adequately identified, first attempt to resolve the deficiencies with the site contact.
If the job hazards were still not adequately identified and prevented:
ⅰ）Do Not Proceed With the Work until it is safe to do so. Immediately stop work if unsafe work conditions are found.
ⅱ）Inform Your Service Manager as soon as possible to assist in resolving the issue.

Approval Prior to Commencing Work:

Emerson Service Representative Date Customer Contact Date

Detailed description of Job:

3-Ws Hazard
Assessment

What can go wrong? Describe the hazards that may be present at the job location.

What condition or action by others or me can cause it to go wrong? Describe dangerous conditions/actions that you or others may bring to the job.

What can I do to prevent it from going wrong?

Manager - After reviewing this form and following up on any deficiencies, file this completed formand any associated permits/documentation with
Project/Service documentation and per your specific Business Unit process.