| Date | 2026-06-14 | Heure | |
| Intervenant | Company/team | ||
| Equipment/area | Mark / TAG / reference | ||
| Localisation | Initial state | ||
| Authorization / instructions | Secure area | ||
| Energy/risks controlled | Controlled coactivity | ||
| Means / PPE |
| Point | Attendu | State | Severity | Commentaire |
|---|---|---|---|---|
| Clearly identified equipment, area or installation | Marker, location, perimeter and purpose of the report confirmed | ✅ Compliant | ||
| Request, work order or instruction available | Intervention authorized and understood before action | Not specified | ||
| Specific risks of the profession identified | Energy, product, height, pressure, coactivity, tools or environment taken into account | ❌ Non-compliant | ||
| Secure work area | Access, marking, cleanliness, circulation and third parties controlled | Not specified | ||
| PPE and suitable means available | Protective equipment and technical means compatible with the intervention | Not specified | ||
| Initial state observed and described | Symptom, defect, state or initial condition provided | Not specified | ||
| Product, sample, effluent or process parameter identified | Reference, nature, danger and area confirmed | Not specified | ||
| SDS, chemical instructions or procedure available | Toxicity, burn, ATEX, reaction or pollution risks taken into account | Not specified | ||
| Containers, valves, lines or sampling points checked | Compatible and identified equipment | Not specified | ||
| Measurement or sampling carried out according to method | Reliable and traceable sample, result or value | Not specified | ||
| Risk of spill, leak or exposure controlled | Retention, absorbent, rinse or shower available if necessary | Not specified | ||
| Waste or residue treated correctly | Compliant sorting, container and disposal | Not specified | ||
| Result or drift reported if anomaly | Operational, laboratory or HSE information transmitted | Not specified | ||
| Clean and safe storage area | No product, leak, bottle or abandoned equipment | Not specified |
| Mesure | Valeur | Unit | Attendu | Result |
|---|---|---|---|---|
| Intervention duration | min | |||
| Number of points checked | nombre | |||
| Number of anomalies noted | nombre | |||
| Number of tests carried out | nombre | |||
| Return to service time | min |
Actions carried out:
Final result: