Behavior Based Safety Observation Checklist

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Was daily safety check completed?

Housekeeping

• Aisles/Walkways kept clear?

  Safe

  At Risk

  N/A

• Work area kept organized?

  Safe

  At Risk

  N/A

• Housekeeping: spills, cords or other trips, trash/clutter, lighting, or Flammables

Personal Protective Equipment

• All appropriate equipment or gear worn correctly?

  Safe

  At Risk

  N/A

• PPE kept in good condition?

  Safe

  At Risk

  N/A

• Personal protective equipment: hand, body, eyes/face, head, foot, respiratory, fall protection, hearing protection, or FR clothing/gear

Working Position

• Body position

  Safe

  At Risk

  N/A

• Location in working environment

  Safe

  At Risk

  N/A

• Working Position: poor posture, over stretched, above shoulder, below knees, twisting, caught in between, struck by, working at heights greater than 4', floor or wall opening, unprotected work edge, or false ceiling or floor.

Tools and Equipment

• Appropriate tools or equipment being used?

  Safe

  At Risk

  N/A

• Tools or equipment being used correctly?

  Safe

  At Risk

  N/A

• Tools or equipment in good condition?

  Safe

  At Risk

  N/A

• Tools and equipment: ladders, power or hand tools

Safe behaviors observed-actions taken to encourage safe behavior

• what are some positives of the observation?

Unsafe behaviors observed-action taken to correct and prevent recurrence

• What are some improvements to be made?

Line of fire. Is the worker in the line of fire?

• Grinding or drilling operations creating flying objects or particles - goggles/face-shield. Heavy equipment movement in the area - operator aware of pedestrian? Around rigging operations - hand in pinch point not under equipment? Working in front of live electrical panel?

  Safe

  At Risk

  N/A

Safety procedures

• Lock-out/Tag-out, Hot Work Permit, Confined Space. Dig Permits etc

  Safe

  At Risk

  N/A

• Where any safety critical stop points followed

  Yes

  No

  N/A

• Was there any change in the plan

  Yes

  No

  N/A

• Was a JHA undertaken to manage change

  Yes

  No

  N/A

• Was the SWMS followed and used

  Yes

  No

  N/A

• Was the SWMS available and on site?

  Yes

  No

  N/A

Environmental

• Are environmental mitigation process in place?

  Safe

  At Risk

  N/A

• Are hydrocarbons being disposed of correctly?

  Safe

  At Risk

  N/A

• Is any flora or fauna at risk of damage or injury?

  Safe

  At Risk

  N/A

Sign off

• Auditor signature

  Sign

• Auditor Name

• Time and Date

  Date

• Auditee signature

  Sign

• Time and Date

  Date