HEALTH & SAFETY PROGRAM MANUAL Attachment 02-3

Potential Hazard Form Date: 2/3/05

NAME: MIKE HEATH ID #: 0207 DATE (mm/dd/yyyy): 01/17/2006 TEAM #:    

Team Leader or Safety Champion Name: TREVOR JOB
Facility Name or Customer Location: SOLDOTNA, ALASKA

Name of individual observed (if applicable):      

Company Name: VETCOGRAY

Substandard Actions (Check all that apply)

Operating Equip. Without Authority Failure to Lockout / Tag-out Improper Placement
Failure to Warn Improper Lifting Improper Position for Task
Failure to Secure Violation of Safety Rules Improper Assignment of Personnel
Operating Improperly Working too Rapidly Repetition
Disabling/Removing Safety Devices Inattention or Distraction Improper Loading / Placement
Use of Defective Equipment Failure to Use Proper PPE
Other Explain:      
Substandard Conditions (Check all that apply)
Inadequate or Missing Guards/Barriers Excessive Heat Prior Damage
Inadequate or Improper PPE Excessive Cold Inadequate Maintenance
Defective Tools, Equipment, Or Materials Radiation Hazards Electrocution Hazard
Congestion or Restricted Action Inadequate Ventilation Severe Weather
Inadequate Warning System Illumination Inadequate Clearance
Warning System Failure Excessive Repetition Improper Tool/Equip. for Task
Fire or Explosion Hazard Excessive Noise Inadequate Staffing
Poor Housekeeping Inadequate Aisles/Exits Poor Work Station Design
Hazardous Environmental Condition No JSEA or Work Permit No MSDS on File
Other Explain: NUMEROUS PRESSURE TESTING DEVICES LAYING AROUND SHOP

Location of Potential Hazard:

THROUGH-OUT SHOP
     
     

Description of Potential Hazard:

IN OUR SHOP THERE WERE MANY PIPE FITTING DEVICES MADE UP TO DEADHEAD PRESSURE
AGAINST TO TET PNEUMATIC AND HYDRAULIC HAND PUMPS. THEY HAVE A CHECK VALVE ON
ONE END AND A PLUG ON THE OTHER, SO PRESSURE CAN BE TRAPPED BETWEEN THE CHECK
VALVE AND THE PLUG. IF THE PRESSURE HAS NOT BEEN RELIEVED, SOMEONE COULD BE HURT
BY BREAKING DOWN THE DEVICE
Immediate Action Taken (if Stop Work Intervention issued, complete next section):
     
     
     

Was a Stop Work Intervention issued as per H&S 61? Yes No If yes, provide additional information below:
Date and Time Stop Work Issued:             am pm Date and Time Work Resumed:             am pm

Who issued the Stop Work Intervention?      

Who was notified?      

Team leader or Safety Champion must review this potential hazard for validity and if valid, assign and forward it to the
person that will be responsible for implementing the permanent corrective action. A copy must also be sent to your HSE
representative.
Team Leader Signature: TREVOR JOB Date Reviewed (mm/dd/yyyy): 01/17/2006
Responsible Person: MIKE HEATH Date Assigned (mm/dd/yyyy): 01/17/2006

Permanent Corrective Action Taken: Date Corrected (mm/dd/yyyy): 01/17/2006

ALL FITINGS WERE BLED OFF AND THEN BROKEN APART
     
     
     
After permanent corrective action has been completed, forward copies to the HSE representative and the Team
Leader/Safety Champion where the potential hazard report originated.