Safe Work Observation Process Report

/ Form 000.653.F0171
Safe Work Observation Process Report
Date: / Observers:
Time: / Supervisor:
Job/Task:
CATEGORY / SCORE / Comments or Observations
Possible / Actual
%
NA / 1 / 2 / 3 / 4 / 5
JSA/STA (as appropriate)
Completed
On job
Being followed
Permits
Position of People
Task layout
Work area
Storage
PPE
Eye/face/hands/fall/hearing/ foot/hat/respiratory/specific
Work Instructions
Followed and understood
Procedures adequate
Isolation/Tagging
Positive isolation
Procedures
Scissor plate/locks used
Pre-start checks
Driving
Seat belts
Conditions/vehicle clean
Road regulations
Correct license
Flashing amber light/flag pole/whip aerial
Pre-start check
Tools/Equipment
Condition and use
Appropriate for job
MSDSspresent
Slings
Correct harness
Housekeeping
Passageway clear
Fire hazards
Trip/slip
Rubbish-free/tidy
SCORES:
(1) =unsatisfactory - not present;
(2) =extensive improvement required;
(3) =average – still some improvement required;
(4) =only minor improvement necessary;
(5) =excellent –in place and fully operational and satisfactory. / Suggested time frame for implementing corrective action – jobs scoring:
100%Corrective action not required
90 – 100%Plan for implementation of corrective action within 1month
80 – 90%Plan for implementation of corrective action within 1week.
70 – 80%Plan for implementation of corrective action within 1day.
Less than 70%Plan for immediate implementation of corrective action.
Any critical task/activity scoring less than 90% shall be addressed immediately.
(Critical Tasks have the highest potential for loss if not correctly carried out).
Describe the job/taskobserved:
Describe clearly any practices, conditions, or procedures that require changing:
Are there any parts of the job/task that are “critical” and need to be changed? Yes No
If Yes, describe above
Is there a documented procedure for the job? Yes No
If No, describe above
Is the procedure correct? Yes No
If No, describe above
Are all potential hazards identified? Yes No
If No, describe above
Follow-up actions required; person responsible and date for implementation:
Supervisor’s Signature:
Any task or activity that has the potential for serious injury must be stopped immediately
and corrective action implemented.

Alternative

Date: / Assessor:
Time: / Supervisor:
Job/Task:
Location
Observation Criteria / NA / Yes / No / Comments or Observations
Hazard Identification
Hazard identification conducted
Risk assessed and rated
Risk controls identified
Housekeeping Practices
Work area free of trip hazards
Aware of housekeeping responsibilities
Able to explain importance of clean work area
PPE
Correct PPE identified and used
Able to explain maintenance requirements
Procedures
Procedure/JSA/STA available and being followed
Agrees with contents of procedure
Understands importance of procedures
Tools and Equipment
In good order and checked
Knows safety features and how to use
Adequate for task being performed
Communication
Aware of HSE requirements
Can recall safety topic from pre-start meeting
Aware of recent incidents on site
Body Position
Able to explain correct lifting techniques
Correct body position during task performance
Mechanical aides available and used

Reminder: All “No” marks must be commented on.

Handed to HSE Representative on ______

Note This form is referenced in Practice000.653.1306.