Employee Involvement

Given at Task Location

KBR / ITI
TOTAL SAFETY TASK INSTRUCTION

Rev. 01/11
Every Task
Every Day

Exact Location where work is done: ______________________________________________ PPE Assessed by: __________________________________
Date: ______________ Time From: ____________________ To: ___________________ Supervisor/Designee:____________________________

Step 1 - Job Description

Permit # _______________

Emergency Action Plan

Evacuation Routes Identified &
Checked.
Alarm Codes Reviewed
Wind Direction Reviewed
Muster Point / Assembly Area / Safe
Shelter ____________________________
Telephone Numbers
SECURITY (EMERGENCY)
6-4444
_______________________________

Tools/Equipment To Be Used

Sequence of Basic Job Steps/Tasks

Sequence of Basic Job Steps/Tasks

Step 2 - Planning
1

10

11 Materials disposed of properly

12 Work Area Clean-up completed

Personal Protective Equipment

Specialized Operations

List All Equipment Needed for Job Task

Hand Tools
Step Ladder
Extension Ladder
Forklift (Licensed Operator)
JLG/Manlift (Licensed Operator)
Cordless Drill Motor
Electric Drill Motor
Reciprocating Saw
Porta-Band Saw
Circular Saw
Extension Cord
Mule
Hand Grinder
Pencil Grinder
Other

Management of Change
Yes (Client Notification Required)
No

Hazard Communication
MSDS Available
Discuss Health Hazards

Employee/Additional Comments

Supplied Air Respirators/SCBA

Chemical Protective Clothing
Electrical Lock-Out
Asbestos Abatement
Excavations and Shoring
Crane-Suspended Work Platform
Working on Energized Electrical
Circuit
Line Breaking
Demo Process Piping

(Instruction A)
(Instruction B)
(Instruction C)
(Instruction F)
(Instruction G)
(Instruction H)
(Instruction I & M)
(Instruction O)

Personnel Protection Devices

Barricades (Tape / Signs)
Equipment / Grounding / GFCI
Fire Blanket / Extinguisher / Hose
Fire Watch _____________________________
Entry Attendant__________________________
Fresh Air / Ventilation Equipment
Ladders / Scaffolding
Fall Protection Device / System
Safety Shields / Netting
Safety Shower & Eye Wash
Vapor Proof / Low Voltage Lighting

Equipment / PPE Inspection

Manlift Inspected
Forklift Inspected
Test Equipment current
Bucket Truck Inspected
Glove (high voltage) Tested and Current
Rubber Mats Tested and Current
Flash Suit Clean
Scaffolding / Inspected

Air Monitor ____________________________

Body Protection _________________________
Bunker ______________________________
Chemical Resistant ____________________
Disposable (Tyvek, Etc.) ________________
Flash Suit ____________________________
FRC ________________________________
Rain Slicker Suit ______________________
Other ________________________________
Eye & Face Protection ____________________
ANSI Safety Glasses____________________
Face Shield ___________________________
Goggles-Chemical _____________________
Goggles-Impact _______________________
Goggles-Burning ______________________
Foot Protection _________________________
Chemical Resistant _____________________
Safety-Toed___________________________
Hand Protection Chemical Resistant__________
Cotton/Canvas Cloth ___________________
Electrical Insulated _____________________
Latex ________________________________
Leather_______________________________
Leather Insulated ______________________
Head Protection _______________________
Hearing Protection______________________
Respiratory Protection ____________________
Air Purifying-Half Face ________________
Air Purifying-Full Face _________________
Air Purifying-PAPR ___________________
Air Supplied _________________________
Air-Supplied w/Egress _________________
SCBA ______________________________
Other__________________________________

Job Walkthrough/Housekeeping
Walkway Clean / Work Area Clean
Tools, Materials & Equipment
Stored Properly
Trash & Scrap Metal Placed in Correct
Containers
Hazardous Waste Disposal
Other_____________________________

Step 3 - See Reverse Side

Step 4 - Verification

YES NO
1. Have Hazards/Risks for this job been assessed to ensure appropriate safety precautions and proper controls?
YES NO
2. Did pre-job briefing & training provide adequate information to perform the job task?
YES NO
3. Did Supv/Designee provide adequate preparation by conducting a walk-through & completing TSTI at the task location?
YES NO
4. Are you familiar with the job performance standards required for this job task?
YES NO
5. Do you have an adequate level of experience to perform this task?
YES NO
6. All persons are trained and qualified on the tools and equipment they plan on using to perform the task?
YES NO
7. Have all tools and equipment used for this job task been properly inspected?
YES NO
8. Did communication with other affected personnel about activities which may represent a hazard/risk take place?
YES NO
9. Have proper precautions been taken for others in the immediate work area that may be affected?
YES NO
10. Is the work area free of housekeeping deficiencies, slippery walking surfaces and unsafe conditions?
YES NO N/A 11. Are all employees familiar with, or has MSDS been reviewed for, any hazardous substance that may be present?
YES NO N/A 12. Has the line/equipment been drained, depressurized, and decontaminated?
YES NO N/A 13. Has the area been barricaded or stand-by posted?
YES NO N/A 14. Has LOTO equipment been walked out and verified?
YES NO N/A 15. Has each affected employee attached personal lock/tag to the lock out?
YES NO N/A 16. Have Stop-work conditions been discussed and reviewed?
DO NOT BEGIN WORK if any questions are answered NO Notify your supervisor for consultation. Your Supervisor can provide on-the-job training, change the
crew mix, correct the condition or halt the job.

Step 5 - See Reverse Side

Step 3 - Risk Assessment

Rev. 11/10

Describe
Controls
PPE

Skill Training

Classroom

Adequate
Supervision

Written
Procedure

Safe System

Guard

Enclose

Replace

Work Activity Hazards

Remove

Management Controls (see definitions

sheet)

Management Controls / Work Activity Hazards "WORKSHEET"

Fall from height

Falling objects
Slip, trip, fall
Crushing
PHYSICAL

Cuts / abrasion
Pinching
Impact
Entanglement
Fire / explosion
Engulfment (1)
Pressurized systems
Hot / cold surfaces
Flying debris
Hazardous (2)
Dust / Fibers (3)
CHEMICAL

Fumes (4)
Mist / Aerosols(5)
Gases (6)
Vapors (7)
Smokes (8)
Biological (9)

ELECTRICAL

ENVRNMNT

Spill / Release (10)

Heat / cold stress
Excess noise / vibration
Poor local lighting
Drowning
Direct contact
Indirect contact
Short circuit
High voltage
Source of ignition
WORK TASK

Repetitive action
Stressful posture
Manual handling
Mental stress

CONTRIBUTORY

Visual fatigue
Inclement weather
Poor communications
Adjacent work activity
Poor ambient lighting
Rush job

Supervisor/Designee _________________________________ If not completed by supervisor, supervisor must initial here:

PLEASE CHECK ALL LIFE SAVING RULES THAT WILL APPLY TO JOB TASK:
Permitting

Suspended Load

Gas Test

No Smoking

Energy Isolation

Drug/Alcohol

Confined Space

System Override
Auth

Cell Phones/Speeding

Buckle Up

Fall Protection

Journey Management