KBR / ITI TOTAL SAFETY TASK INSTRUCTION Employee Involvement Given at Task Location Every Task Every Day Exact Location where work is done: ______________________________________________ PPE Assessed by : __________________________________ Date: ______________ Time From: ____________________ To : ___________________ Supervisor/Designee :____________________________ Step 1 - Job Description Permit # _______________  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 Tools/Equipment To Be Used 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  Walkway Clean / Work Area Clean  Tools, Materials & Equipment Stored Properly  Trash & Scrap Metal Placed in Correct Containers  Hazardous Waste Disposal  Other_____________________________ 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? Employee/Additional Comments  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 Step 2 - Planning Hazard Communication  MSDS Available  Discuss Health Hazards Step 4 - Verification 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.  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__________________________________ Step 3 - See Reverse Side Step 5 - See Reverse Side Job Walkthrough/Housekeeping Personal Protective Equipment Specialized Operations Personnel Protection Devices (Instruction A) (Instruction B) (Instruction C) (Instruction F) (Instruction G) (Instruction H) (Instruction I & M) (Instruction O) Rev. 01/11  Evacuation Routes Identified & Checked.  Alarm Codes Reviewed  Wind Direction Reviewed  Muster Point / Assembly Area / Safe Shelter ____________________________  Telephone Numbers  SECURITY (EMERGENCY) _______________________________ Emergency Action Plan Sequence of Basic Job Steps/Tasks Materials disposed of properly Work Area Clean-up completed Management of Change  Yes (Client Notification Required)  No  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 Equipment / PPE Inspection