Behavior-based Safety Checklist

• Site

• Location
  Address

• Observed by

• Conducted on

  Date

• Safety Observation Steps:
  1. Introduce yourself, put the worker at ease, and explain the process. Ask permission to do an observation.
  2. Ask the person to explain the job that is being performed and define the hazards and precautions associated with the task/s they are performing.
  3. Ask open-ended questions to learn more about at-risk barriers. (Ex: What’s the worst accident that can happen? How could you
  be hurt doing this task?)

• 4. Observe the job and add comments by tapping NOTE/photos by tapping IMAGE. Provide positive feedback by praising safe behaviors first. Draw out the corrective action that may be required (create this action by tapping ACTION).
  5. Obtain a commitment that the individual will carry out this action and thank the person for participating.

CRITICAL SAFE BEHAVIOR

BODY USAGE & POSITION

• The worker is positioning his body to avoid injury by any moving hazards (caught between, falling objects)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

• Lifting (proper lifting techniques - using legs, back straight, weight close to the body, feet flat on the ground, knees bent)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

• Pinch Point (aware of and avoid pinch points - pinch points blocked, maintaining body parts out of pinch points)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

• Awkward Position (proper body mechanics - over-extended, using leg not back when pulling)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

TOOLS & EQUIPMENT

• Tool Use/Selection (using the right tool for the job and using it properly - correct style wrench, pry bar)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

• PM Condition - tools, even if correct for the job, must be in good condition (air hoses, hose connections, pipe wrench, etc)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

EYES ON PATH/HANDS

• Eyes On Path (watching where you're going and go where you're watching - looking for/being aware of hazards).

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

• Eyes On Hands (aware of hand placement - watching where hands are placed during work or near hazard, not being distracted)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

• Travel Path (non-hazardous route of travel, a path of the least potential incident)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

• Work Speed (rate of speed to minimize potential incidents based on environment, surroundings or changing conditions)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Facility or Equipment Condition Personal Factors or Distractions Environment-related

  • Training Issue, Unfamiliar
  • Facility or Equipment Condition
  • Personal Factors or Distractions
  • Environment-related

COMPLETION

• Additional Observations

• Observer Name & Signature

  Sign