Carna_Safe Act Observation

• Client / Site

• Prepared by

• Conducted on

  Date
• Location
  Address

• Document No.

• Person(s) Involved with Task

Employee

• Full Name

• Activity/task

1.0 Documentation i.e. permits, mods, etc.

• 1.1 Permit checked and signed off

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 1.2 JHA (eg signed and completed)

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 1.3 Take 5

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 1.4 Follows written take 5 and JHA

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

2.0 Standards and procedures

• 2.1 Sources of energy controlled

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 2.2 Attached lock and tag to isolation points

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

3.0 Position of people/mobile equipment

• 3.1 Avoid lines of fire (fingers, hands and body)

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 3.2 Three points of contact when climbing or descending

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 3.3 Avoid cramped or over extended posture

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

4.0 Ergonomics

• 4.1 Bends knees when lifting

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 4.2 Load close to the body

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 4.3 Strong spine when lifting

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 4.4 Turns with feet and not their back

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 4.5 Lifts with their legs

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 4.6 Mechanical aids/team lifting

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

5.0 Tools and equipment

• 5.1 Correct for task

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 5.2 Used correctly/safely

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 5.3 Seat belts

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 5.4 Pre start inspection and completed log book

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 5.5 Drives to road conditions

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 5.6 Vehicle parked correctly (reversed/chocked)

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

6.0 Housekeeping/area conditions

• 6.1 Work area tidy

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 6.2 Barricades and signs

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 6.3 Hazardous materials stored/handled/transported/used/disposed correctly

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

7.0 Personal protective equipment (PPE)

• 7.1 Head

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 7.2 Eye and face

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 7.3 Hearing

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 7.4 Respiratory

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 7.5 Hand

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 7.6 Sleeves rolled down and fastened

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 7.7 Foot

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 7.8 Fall arrest/restraint

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

• 7.9 Sun/heat protection

  Safe

  At Risk

  N/A

• What did the person say when asked why?

• Solution?

• Resolved

  Yes

  No

  N/A

Positive feedback comments

• Comments

• Supervisor Signature

  Sign

Email to site safety department.