BASF ACWORTH EMPLOYEE SAFETY OBSERVATION FORM

• Observer

• Conducted on

  Date

• Have you used this form before

  Yes

  No

  N/A

• GROUND RULES FOR AN OBSERVER
  
  Seek permission to do the observation.
  Be non-threatening. Be friendly.
  Use effective dialogue. Welcome and record comments. Feedback is very important.
  Explain the process. 75-95% of all incidents are driven by behavior(s).
  At the end of observation, review and discuss the findings with the person(s) you were observing.
  Make positive and encouraging comments when you find someone working safely and following procedure(s). Stay away from negative comments.
  Mention/discuss at-risks with potential for serious injury. Ask them how to fix the issue and identify the barriers?
  And always thank the person at the end.
  

• CONDITIONS
  
  Slip/Trip/Fall Hazards – Walkways and working surfaces should be clear of slip/trip hazards (e.g., hoses, electrical cords, etc.).
  Chemical Storage & Labeling – Containers should be appropriate for the materials stored in them, closed, placed in designated storage areas, and be labeled appropriately with their contents.
  General Housekeeping – Examples to look for include, but are not limited to: tool and equipment storage, ladder storage, clear exit path(s), access to emergency equipment (e.g., fire extinguishers, eye/face washes, etc..
  

• CRITICAL BEHAVIOR DEFINITIONS
  
  Eye/face protection worn, including goggles and face shield for liquid/splash hazards – Goggles and face shields shall be worn for working with or around hazardous liquids (e.g., acids, solvents, cleaning agents, etc.). Specific examples include: Emptying or filling drums or U-turns; Loading or unloading tanks trucks; Rinsing of containers; Handling of acids or caustics; Line breaking or unclogging of lines where there is risk of chemical release; etc..
  Gloves worn and the proper type utilized – Leather, nitrile-coated, and/or “cotton-dot” gloves should be used for cutting/pulling straps from packages; Putting empty jugs in bins; Making cartons; Sweeping floors; Handling pallets; Handling drums; and other general contact hazards. Chemical-specific gloves should be worn when working with acids/caustics including unloading railcars
  Hard hat worn when overhead hazards are present – Hardhats shall be worn in all plant/maintenance areas (excluding offices, break rooms, and lunch areas).
  Foot Protection – Safety toe shoes (e.g., “steel toes”) shall be worn in all plant/maintenance areas. Rubber safety toe shoes should be worn when working in wet environments where liquid breakthrough of acids, caustics, etc., could occur.
  Proper Respiratory protection worn – Appropriate respirator and cartridges shall be worn when required. Respirator must be sanitary, stored properly when not in use and inspected prior to donning. Examples of tasks/locations where respirators are required: Aseptrol operations, dust generating activities.
  Hearing Protection – Proper hearing protection (earplugs and/or earmuffs) worn properly. Hearing protection should be worn when working in designated high noise level areas/tasks.
  Fall Protection – Fall Protection shall be worn when working at heights above six (6) feet where there is no fall prevention in place (walls, hand rails, etc.).
  Special Personal Protective Protection – Special PPE shall be worn for designated activities including, but not limited to: acid rail car unloading, welding, using cutting torch, KOH handling, Treater washing, see PPE matrix for area.
  Alert, Eyes on Task, Eyes on Path – Employee should have a clear view of task and not be distracted. Employee(s) should “keep eyes on path” while walking…eyes focused in direction of travel while walking (or driving).
  Not walking past or over trash, debris, or other slip/trip hazards – Employees ideally should not walk past or over trash or debris (which should be picked up and thrown away) or hoses, wet spots, etc.. Such hazards should be moved and/or cleaned up.
  Communications – Employee(s) should be in communication with their co-workers when working in close proximity (e.g., forklift drivers and pedestrians should make eye contact prior to a forklift starting or changing direction).
  Precautions taken when lifting or lowering - Persons should be standing with feet shoulder width, bending at knees and hips, lifting with back arched and locked, not trying to lift more that 55 lbs by ones self, and only lifting/lowering a load that is manageable.
  Body Placement / Line of Fire – Employee is out of the “line of fire,” e.g., throwing breaker switch while positioned AWAY from panel, “breaking” bolts on OTHER side of flange; remaining out of contact range during line clearing or other “struck by” or “contact with” hazards.
  Repetitive Motion - Avoidance of repetitive or extreme motion and/or twisting at waist while handling load, and avoidance of other body positions that might result in sprain, strain, or other injury.
  Forklift / Mobile Equipment - 5 mph on plant roads; safe speeds on forklift while rounding corners, when near other vehicles, or in vicinity of pedestrians.
  Seatbelt worn - worn at all times when in motion on forklift, automobile, or truck (no matter the distance of travel).
  Slows & sounds horn - Operator(s) should reduce speed when nearing and driving through cross aisles and should be frequently using horn to warn other drivers and pedestrians who may be in the area.
  Wheels chocked – Forklift/vehicle wheels should be chocked when equipment is unattended and parked on grade.
  Parking brake engaged – Forklift/vehicle’s parking brake should be engaged when equipment is unattended.
  Tools & Equipment – Tools should be “right for the job,” in good condition and used properly (Hand/Electric/Air/Hydraulic) – Includes hand and power tools. Operators must not use the wrong tool to perform a task or a defective tool.
  Procedures / Permits – The proper permits (Safe Work, Hot Work, Confined Space Entry, Line Breaking, Lockout/Tagout) are completed prior to maintenance/contractor work. The issuer and receiver of a safe work permit (& other permits) must complete all applicable line items on the permit (including a “field inspection”) before maintenance/contractor work can begin. Prior to clearing blockages or working on equipment/machinery, personnel must ensure that the machinery/equipment is isolated from all potentially hazardous energy (including mechanical, electrical, hydraulic, pneumatic, chemical, and thermal). This is done by closing/shutting down and locking out and/or tagging out the applicable energy isolating device (e.g., manually operated electrical circuit breakers, a disconnect switch, a slide gate, a process valve, a slip blind/blank, a block, or any similar device used to block or isolate energy).
  

• Start Observation

  Date

• Employee(s) Name Observed

• Task(s) Observed

• Department

PPE

• Head Protection

  Safe

  At Risk

  N/A

• Foot Protection

  Safe

  At Risk

  N/A

• Hearing Protection

  Safe

  At Risk

  N/A

• Fall Protection

  Safe

  At Risk

  N/A

• Special Personal Protective Protection (e.g., Rain Suit, Chemical Suit, Tyvek, etc..)

  Safe

  At Risk

  N/A

• Respiratory Protection

  Safe

  At Risk

  N/A

• Eye/Face Protection (including goggles and face shield for liquid/splash hazards)

  Safe

  At Risk

  N/A

• Hand Protection (Gloves worn and the proper type utilized)

  Safe

  At Risk

  N/A

BODY USE / ERGONOMICS

• Speed safe for task/area

  Safe

  At Risk

  N/A

• Body Placement – Out of the “Line of Fire” (includes hand, foot, etc. positioning)

  Safe

  At Risk

  N/A

• Repetitive Motion (No excessive twisting or awkward position hazards)

  Safe

  At Risk

  N/A

FORKLIFT / MOBILE EQUIPMENT SAFETY

• Slows/stops and sounds horn at cross aisles and vision-obstructed locations

  Safe

  At Risk

  N/A

• Wheels Chocked

  Safe

  At Risk

  N/A

• Parking Brake Set

  Safe

  At Risk

  N/A

• Speed safe for task/area

  Safe

  At Risk

  N/A

• Seatbelt worn

  Safe

  At Risk

  N/A

TOOLS & EQUIPMENT

• Selection & Condition – right tool for the job, in good condition, and used properly

  Safe

  At Risk

  N/A

PROCEDURES / PERMITS

• Proper Permits (Safe Work, Hot Work, Lockout/Tagout, Confined Space, Line Breaking)

  Safe

  At Risk

  N/A

CONDITIONS / HOUSEKEEPING

• Slip / Trip Hazards

  Safe

  At Risk

  N/A

• Chemical Storage (including container labeling)

  Safe

  At Risk

  N/A

• General Housekeeping (if at-risk, describe below)

  Safe

  At Risk

  N/A

• Completed

  Date

• Observers Signature

  Sign