Title Page

  • Near Miss

  • # at risk?

  • # safe?

  • BBS observation

  • # safe?

  • # at risk?

  • Date & time

  • Name of Observer

  • Joint Observation?

  • 2nd observer name.

  • Home terminal?

  • Customer name? (e.g. Oxy)

  • Customer location? (e.g. rig #) I

  • Description of job being performed?

  • Description of observation?

  • Description of feedback immediately provided?

  • Supervisor feedback?

Analysis of At Risk Behaviors observed.

Check all that apply

  • Type of observation

Answer yes or no to the subgroup which the BBS pertains, and select if at risk or safe.

  • Job Planning

  • 101 Safe Work Permit, tailgate, JSA complete

  • 102 Short Service Employees identified and informed

  • 103 Avoiding obstacles

  • 104 Spotter use hand signals

  • 105 Obeying posted signs/limits/warnings

  • Vehicle Operation

  • 201 Basic Safety(lights, seatbelt, signals)

  • 202 Speed appropriate to situation

  • 203 Use of spotters

  • 204 Securing load

  • 205 Stabilizing trailer yo remain

  • Forklift Operation

  • 301 Speed of approach

  • 302 Angle of approach

  • 303 Speeding of lifting load/lowering load

  • Body Mechanics

  • 401 Lifting/ pulling/ pushing/ carrying

  • 402 Line of fire

  • 403 Eyes on work/ path

  • 404 Pinch points/ hand placement

  • 405 Pinch points/ body

  • 406 Repetitive motion

  • 407 Climbing

  • 408 Work surface stable and clean

  • 409 Positioned to avoid twisting

  • 410 Avoiding being sprayed, hit, struck

  • PPE

  • 501 PPE: Hard hat, H2S monitor, eye protection, steel-toed boots, FRC’s, Gloves

  • Tools

  • 601 Proper tool available & in use

  • 602 Tool used properly for job

  • 603 Wheel Chocks used

  • Conditions not under MWT control

  • 701 Guatds or Protective Devices

  • 702 Material/ Tool Storage

  • 703 Access to fire/ safety equipment

  • 704 Houskeeping

  • 705 Waste properly disposed

  • 706 Work environment (noise, heat, etc.)

  • 707 Tight work space/ crowded

  • 708 Emissions/ Discharge

  • 709 Spill control equipment

CBI CODE

  • CBI CODE

Root Cause

  • Root Cause

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.