Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

1 Driving Safety Score Comments

Are vehicles in good condition and is the emergency

1
equipment available?

Are loads secure and within manufacturer design

2
specifications or rated capacity of the vehicle?

Does number of passengers exceed the manufacturer’s

3
design specification?

4 Are seat belts installed and worn by all occupants?

5 Are speed limits observed?

6 Are mobile phones used during driving?

Are drivers trained to operate the class of vehicle and have

7
the appropriate certificate with them?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011
 Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

2 Management of Change Score Comments

1 Do personnel recognise and report change in conditions?

In case of overriding or disabling safety critical equipment,

2 is a risk assessment completed and appropriate
authorization applied for prior to such action?

Are changes from mandatory requirement (such as those

3 defined in a policy, standard or procedure) approved in
writing by the Company authorized competent person?

In case of changes, is the Toolbox risk identification card

4
(TRIC) updated and communicated?

Does the supervisor understand management of change

5
(MoC) requirements and the conditions that trigger a MoC?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011
 Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

3 Lifting Operation Score Comments

Are non-routine lifts subjected to a specific risk

1 assessment, lift plan and toolbox talk prior to commencing
the lift? Is the PTW in place?

Are lifting activities undertaken by people who are trained

2 and qualified, and working under the supervision of a PIC
with a valid certificate (according to Local Regulations)?

Are Banksmen (flagmen) present during the entire lifting

3
operation?

Are lifting devices colour coded and inspected and certified

4
by a competent person?

Are loads within dynamic and or static capacities of lifting

5
equipment?

Are personnel prevented from working under suspended

6
loads?

Is the crane operator in the cab at the controls of the crane

7 without undertaking any other activity during the entire lift
operation?

Have the risk assessment, lift plan, TBT and applicable

8 permits been completed prior to commencing personnel
lifts (man rated baskets)?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011
 Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

4 Fire Safety Score Comments

Is suitable fire fighting equipment available and in good
1
conditions and inspected?

Are personnel trained in the proper use of fire fighting

2
equipment?

Are flammable or combustible substances (fuels, gases and

3 oxidizing chemicals, etc) stored in dedicated areas
conforming to Local Regulations?

Are gas cylinders properly secured and capped when not in

4
use?

5 Are flash back arrestors installed in cylinders and torches?

Is there any smoking observed outside the designated

6
smoking areas?

7 Has a fire risk assessment been carried out?

Are fire detection and alarms fitted and tested in offices

8
and accommodation?

Is there an Emergency Evacuation Plan for the place of

9 work or accommodation and has the staff been instructed
on the actions to be taken in the event of fire?

Are Fire exits identifiable, kept unlocked and escape routes

10
kept free of obstructions at all times?

11 Are housekeeping standards maintained?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011
 Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

5 Working at Height Score Comments

Are all scaffolds erected/dismantled by a competent person,
1 has a risk assessment been undertaken and a PTW
completed?

Are all scaffolds inspected, re-inspected and tagged?

2 [note: scaffolding must be inspected weekly and tags must
be current].

Are operators trained in the proper use of the of Mobile

3
Elevated Work Platform (MEWP)?

Where applicable; has the contractor provided personal fall

4
protection and identified the appropriate anchor points?

Have workers wearing personal fall arrest devices been

5
trained on its use?

6 Are toolbox talks conducted prior to working at height?

Are emergency recovery procedures in place and have

7
those procedures been practiced?

8 Are work surfaces and ground holes adequately protected?

Are ladders properly angled and secured, exceeding 1-

9
metre past the landing?

10 Are work platforms free from excess materials and waste?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011
 Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

6 Energized Systems Score Comments

Has an Isolation Confirmation Certificate (ICC) been

1 completed before proceeding with mechanical or electrical
isolation?

Is the system de-energized by qualified and competent

2
personnel?

Are all personnel working on energized systems qualified

3
and certified?

Has a risk assessment been completed by a qualified

competent person prior to commencing work and has it
4
been communicated to all personnel assigned to the task
(e.g. TBT)?

Are all appropriate certificates, tags, locks and permits in

5
place?

Are personnel aware of the reporting requirement for

6
defective equipment?

Is temporary equipment free from patent defects? (e.g.

7 diesel or gasoline generators, air compressors, temporary
electrical panels, etc)

Is portable appliance tested conducted in accordance with a

8
designated schedule? (inspected)

Are there current protective devices installed and in good

9
working order?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011
 Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

7 Excavation Safety Score Comments

Have the locations of underground services been identified

1
and checked by a competent person prior to excavation?

Have the appropriate excavation risk assessment, plan and

2 certificate been completed and signed by authorized
personnel?

Are all relevant personnel aware of hazards associated with

3
the excavation?

Have personnel working near the excavation been notified

of the hazards and control measures and are they observed?
4 [Pertaining to people not directly involved in the
excavation but working in close proximity of the
excavation]
Are the excavations effectively shored, sloped, or benched
5 or otherwise protected and barricaded, including the
posting of applicable warning signs

Has the excavation been inspected by a competent person

6
and is the “Green Tag” present, dated and signed?

7 Is the excavation supervised by a competent person?

Has a PTW been obtained to authorise entry for

8
excavations exceeding 1.5 metres?

9 Is safe access and egress provided?

Are measures in place to prevent build up of water within

10
the excavation?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011
 Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

8 Permit To Work (PTW) Score Comments

Is the PTW in place for: confined space entry, energized
systems work, ionizing radiation, and radiography, entry
1
into excavation, diving activities and hot work in
potentially explosive or flammable environments?

Has the work description been clearly and sufficiently

2
detailed on the Work Permit?

3 Are hazards identified and risk assessed?

Are control measures to eliminate or mitigate hazards

4
correctly identified?

Is the work location correctly identified on the PTW and is

5
there no conflict between other or nearby work activities?

6 Have all necessary authorisations been obtained?

No attempt will be made to circumvent or bypass the

7
requirements of the permit to work?

Have all requirements and conditions in the PTW been

8
explained to all personnel prior to commencing any work?

Has a confined space hazard assessment been conducted,

9 gas test performed by a competent person, PTW completed
and are all personnel confined space trained?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011
 Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

9 Health Management Score Comments

Is a Health Risk Assessment (HRA) carried out for all

1 significant workplace agents that are hazardous to health
(to which personnel may be exposed)?

Are workers whom are working with any hazardous agent

2
trained/informed on its safe use?

Are MSDSs for hazardous substances available at the site

3
in the Company language?

Is the Alcohol and Drugs policy available, displayed and

4
enforced?

Do personnel know where to obtain First-aid treatment and

5
are first aid kits available?

Do supervisors and personnel know ER / Medical

6
contacts/information in the event of an emergency?

Are Food Safety and Sanitary Hygiene inspections carried

7
out on site by competent person?

8 Are site welfare facilities sufficient and suitable?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011
 Health & Safety Golden Rules Evaluation

Location Contractor Name Contract Nº

Area

10 Personal Protective Equipment (PPE) Score Comments

1 Are hard hats worn as required?

2 Is hearing protection worn as required?

3 Is eye protection worn as required?

4 Is suitable hand protection worn as required?

5 Is suitable foot protection worn as required?

6 Are face shield or goggles worn as required?

7 Are suitable coveralls worn as required?

Does contractor provide employees with suitable (of

8
approved quality standards) and sufficient PPE fee of charge?

Are employees properly trained in the use and the purpose of

9
PPE?

Eni Participant
Name (printed) Signature Date

Contractor Participant
Name (printed) Signature Date

Scoring
0= Serious Deviations 1= Major Deviations 2= Improvement Required 3= Meets Requirements 4= Exceeds Requirements
Rev. 00 – May 2011