Behavior-based Safety Checklist CCG 10/23

• 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?)

• [This is an example of how you can use iAuditor to include best practice reference images in your templates to assist with observations]

  

• 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

PPE

• Head Protection - (hard hat worn appropriately where the hazard exists)

  Yes

  No

  N/A

• Reason

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• Eye & Face Protection (proper eye and face protection for the task - glasses, face shield, goggles)

  Yes

  No

  N/A

• Reason

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• Hearing Protection (proper hearing protection where the hazard exists - ear plugs, ear muffs)

  Yes

  No

  N/A

• Reason

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• Hand Protection (proper gloves)

  Yes

  No

  N/A

• Reason

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• Body Protection (proper protective clothing, long pants, shirt with at least 4" collar, or FR’s

  Yes

  No

  N/A

• Reason

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• Visibility - Class II (minimum) hi-visibility safety vest

  Yes

  No

  N/A

• Reason

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• Foot Protection (proper foot protection - steel-toed shoes or boots)

  Yes

  No

  N/A

• Reason

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

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 Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• 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 Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• 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 Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• 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 Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

TOOLS & EQUIPMENT

• Position Parked (the vehicle is left in the position which creates the least possibility of an incident and safety of the public)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• Outrigger pads used

  Yes

  No

  N/A

• Reason

  Select

• Red danger tape used to block swing path

  Yes

  No

  N/A

• Reason

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

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 Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• 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 Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• Ascending/Descending (proper climbing techniques on trucks and trailers - facing the ladder, not skipping rungs or steps, hold onto handles)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

• Travel Path (non-hazardous route of travel, a path of the least potential incident - walking/driving around spills, barricades, rough terrain)

  Safe

  At Risk

  N/A

• At-Risk Barrier

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

Site Operations

• Is ticket signed by customer?

  Yes

  No

  N/A

• Reason

  Select

• Are outriggers fully extended

  Yes

  No

  N/A

• Reason

  Select

• Was a pre-lift safety meeting held

  Yes

  No

  N/A

• Reason

  Select Training Issue, Unfamiliar Management Pressure/System Apathy, Insignificant Facility or Equipment Condition Disagreement on At-Risk Practices Personal Factors or Distractions Accepted Culture, Peer Pressure Environment-related Not available No response given

  • Training Issue, Unfamiliar
  • Management Pressure/System
  • Apathy, Insignificant
  • Facility or Equipment Condition
  • Disagreement on At-Risk Practices
  • Personal Factors or Distractions
  • Accepted Culture, Peer Pressure
  • Environment-related
  • Not available
  • No response given

COMPLETION

• Additional Observations

• Observer Name & Signature

  Sign