Ops Site Visit Observation Form

• Ops Site Observer (First & Last name):

• Site

  Select

• Basin

  Select

• Conducted on

  Date
• Location
  Address
Assest (if applicable)

Safety Observation

• Type

  Select Recognition Near Miss Stop Work (unsafe act with intervention) Stop Work (Unsafe condition with intervention) Unsafe Act Unsafe Condition

  • Recognition
  • Near Miss
  • Stop Work (unsafe act with intervention)
  • Stop Work (Unsafe condition with intervention)
  • Unsafe Act
  • Unsafe Condition

• Who are you recognizing?

  Select

• Recognition for:

• Detail the near miss and how it can be controlled

• What is the potential occurrence?

  Select Death to a worker Major equipment failure Major Release of hazardous substance. Electrical accident causing personal injury Minor injury Incident of causing damage to equipment not including injury Injury requiring medical attention Incident of injury from falling from heights Serious injury to personnel Other

  • Death to a worker
  • Major equipment failure
  • Major Release of hazardous substance.
  • Electrical accident causing personal injury
  • Minor injury
  • Incident of causing damage to equipment not including injury
  • Injury requiring medical attention
  • Incident of injury from falling from heights
  • Serious injury to personnel
  • Other

• undefined

• What was the hazard that caused the near miss?

• How was it corrected?

• undefined

• Picture?

  Media

• Expected sustainable improvement

Definitions

• Unsafe Act: Use when you have witnessed an individual behavior that could lead to an incident, this could include walking and texting, not completing JSA not wearing PPE etc. OR Use when you have witnessed an individual or group behavior that has mitigated a situation and provided and gone above and beyond the standard controls.

• Unsafe Condition: Use when you observe something in the work environment that could lead to an incident. This could include loose stair edge, housekeeping or storage issues, broken or tool issues etc. OR Use when you have witnessed a condition that is beyond the typical and has provided additional level of protection.

• Recognition: Use when you want to identify an individual or group for excellent safety performance or action in one of the identified hazard categories that are above and beyond normal duties.

Life Safety Rule

• Vehicle Safety

  Yes

  No

• Lockout/Tagout

  Yes

  No

• Electrical Safety

  Yes

  No

• Hazardous Atmospheres

  Yes

  No

• Confined Space

  Yes

  No

• Machine Guarding

  Yes

  No

• Working at Heights

  Yes

  No

• Permit to work

  Yes

  No

• Line of Fire

  Yes

  No

• Heavy Equipment Operations

  Yes

  No

Potential Hazards

• Caught in Between, under, against

  Yes

  No

• Fall from Heights

  Yes

  No

• Policy Aderence

  Yes

  No

• Struck Against

  Yes

  No

• Vehicle

  Yes

  No

• Contact with Hazardous energy

  Yes

  No

• Explosion Hazard

  Yes

  No

• Fall from Same Level

  Yes

  No

• Process or Production Upset

  Yes

  No

• Struck By

  Yes

  No

• Distraction

  Yes

  No

• Exposure to Harmful Substances (dust, chemicals, fumes, radiation, noise - any route into the body)

  Yes

  No

• Overexcretion/Ergonomic

  Yes

  No

• Simultaneous Operations

  Yes

  No

• Temperature Extremes

  Yes

  No

• Other (Safety, Health, or Environmental)

• Details of Observations

• Details of Corrective Action

Signatures

• Add Auditors

Auditor

• Name of Auditor

  Sign

• Add All Employees on Site

Employee on Site

• Name of Employee

  Sign