CP - FIELD LEADERSHIP RECORD

• Date :

  Date
• Area Visited :
  Address

• Area Notified :

  Yes

  No

• Topic (LA&CCO) :

• Persons observed (optional) :

• Task / SOP/ WI Observed

• Type of FL :

  Layered Audit

  CCO

  PTO

  TTT

• Question 1 - What are the things that can kill you? Question 2 - What are the critical controls that keep you safe? Question 3 - How do you know the critical controls are working effectively?

• Team Members :

• Positive Behaviours / Conditions Observed

• At Risk Behaviours / Conditions Observed:
  CAT A -Reactions of People, CAT B - Positions of people, CAT C - PPE,
  CAT D - Tools & Equipment, CAT E - Procedures, CAT F - Work Area

• 1.

  Yes

  No

  N/A

• Category A - Reactions of people

  Select A1 Adjusting PPE A2 Rearranging job A3 Stopping job A4 Attaching to A5 Changing Lockouts A6 Not fitness for work

  • A1 Adjusting PPE
  • A2 Rearranging job
  • A3 Stopping job
  • A4 Attaching to
  • A5 Changing Lockouts
  • A6 Not fitness for work

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category B - Positions of People

  Select B1 Striking against B2 Struck by B3 Caught Between B4 Temp. Extremes B5 Inhaling B6 Absorbing B7 Swallowing B8 Posture, Lifting, Twisting B9 Over-Extension B10 Falling

  • B1 Striking against
  • B2 Struck by
  • B3 Caught Between
  • B4 Temp. Extremes
  • B5 Inhaling
  • B6 Absorbing
  • B7 Swallowing
  • B8 Posture, Lifting, Twisting
  • B9 Over-Extension
  • B10 Falling

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category C - PPE

  Select C1 Eyes & Face C2 Ears C3 Head C4 Hands & Arms C5 Feet & Legs C6 Respiratory C7 Trunk C8 Other

  • C1 Eyes & Face
  • C2 Ears
  • C3 Head
  • C4 Hands & Arms
  • C5 Feet & Legs
  • C6 Respiratory
  • C7 Trunk
  • C8 Other

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category D - Tools & Equipment

  D1 Not Right for the job

  D2 Used Incorrectly

  D3 Unsafe Condition

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• CAT E - Procedures, CAT F - Work Area

  Select E1 Procedures inadequate for the job E2 Procedure not known or understood E3 Procedure not followed F1 Poor Housekeeping F2 Inadequate Storage F3 Unclean F4 Not Barricaded

  • E1 Procedures inadequate for the job
  • E2 Procedure not known or understood
  • E3 Procedure not followed
  • F1 Poor Housekeeping
  • F2 Inadequate Storage
  • F3 Unclean
  • F4 Not Barricaded

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• 2.

  CATEGORY A

  CATEGORY B

  CATEGORY C

  CATEGORY D

  CAT E, CAT F

• Category A - Reactions of people

  Select A1 Adjusting PPE A2 Rearranging job A3 Stopping job A4 Attaching to A5 Changing Lockouts A6 Not fitness for work

  • A1 Adjusting PPE
  • A2 Rearranging job
  • A3 Stopping job
  • A4 Attaching to
  • A5 Changing Lockouts
  • A6 Not fitness for work

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category B - Positions of People

  Select B1 Striking against B2 Struck by B3 Caught Between B4 Temp. Extremes B5 Inhaling B6 Absorbing B7 Swallowing B8 Posture, Lifting, Twisting B9 Over-Extension B10 Falling

  • B1 Striking against
  • B2 Struck by
  • B3 Caught Between
  • B4 Temp. Extremes
  • B5 Inhaling
  • B6 Absorbing
  • B7 Swallowing
  • B8 Posture, Lifting, Twisting
  • B9 Over-Extension
  • B10 Falling

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category C - PPE

  Select C1 Eyes & Face C2 Ears C3 Head C4 Hands & Arms C5 Feet & Legs C6 Respiratory C7 Trunk C8 Other

  • C1 Eyes & Face
  • C2 Ears
  • C3 Head
  • C4 Hands & Arms
  • C5 Feet & Legs
  • C6 Respiratory
  • C7 Trunk
  • C8 Other

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category D - Tools & Equipment

  D1 Not Right for the job

  D2 Used Incorrectly

  D3 Unsafe Condition

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• CAT E - Procedures, CAT F - Work Area

  Select E1 Procedures inadequate for the job E2 Procedure not known or understood E3 Procedure not followed F1 Poor Housekeeping F2 Inadequate Storage F3 Unclean F4 Not Barricaded

  • E1 Procedures inadequate for the job
  • E2 Procedure not known or understood
  • E3 Procedure not followed
  • F1 Poor Housekeeping
  • F2 Inadequate Storage
  • F3 Unclean
  • F4 Not Barricaded

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• 3.

  CATEGORY A

  CATEGORY B

  CATEGORY C

  CATEGORY D

  CAT E, CAT F

• Category A - Reactions of people

  Select A1 Adjusting PPE A2 Rearranging job A3 Stopping job A4 Attaching to A5 Changing Lockouts A6 Not fitness for work

  • A1 Adjusting PPE
  • A2 Rearranging job
  • A3 Stopping job
  • A4 Attaching to
  • A5 Changing Lockouts
  • A6 Not fitness for work

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category B - Positions of People

  Select B1 Striking against B2 Struck by B3 Caught Between B4 Temp. Extremes B5 Inhaling B6 Absorbing B7 Swallowing B8 Posture, Lifting, Twisting B9 Over-Extension B10 Falling

  • B1 Striking against
  • B2 Struck by
  • B3 Caught Between
  • B4 Temp. Extremes
  • B5 Inhaling
  • B6 Absorbing
  • B7 Swallowing
  • B8 Posture, Lifting, Twisting
  • B9 Over-Extension
  • B10 Falling

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category C - PPE

  Select C1 Eyes & Face C2 Ears C3 Head C4 Hands & Arms C5 Feet & Legs C6 Respiratory C7 Trunk C8 Other

  • C1 Eyes & Face
  • C2 Ears
  • C3 Head
  • C4 Hands & Arms
  • C5 Feet & Legs
  • C6 Respiratory
  • C7 Trunk
  • C8 Other

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category D - Tools & Equipment

  D1 Not Right for the job

  D2 Used Incorrectly

  D3 Unsafe Condition

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• CAT E - Procedures, CAT F - Work Area

  Select E1 Procedures inadequate for the job E2 Procedure not known or understood E3 Procedure not followed F1 Poor Housekeeping F2 Inadequate Storage F3 Unclean F4 Not Barricaded

  • E1 Procedures inadequate for the job
  • E2 Procedure not known or understood
  • E3 Procedure not followed
  • F1 Poor Housekeeping
  • F2 Inadequate Storage
  • F3 Unclean
  • F4 Not Barricaded

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• 4.

  CATEGORY A

  CATEGORY B

  CATEGORY C

  CATEGORY D

  CAT E, CAT F

• Category A - Reactions of people

  Select A1 Adjusting PPE A2 Rearranging job A3 Stopping job A4 Attaching to A5 Changing Lockouts A6 Not fitness for work

  • A1 Adjusting PPE
  • A2 Rearranging job
  • A3 Stopping job
  • A4 Attaching to
  • A5 Changing Lockouts
  • A6 Not fitness for work

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category B - Positions of People

  Select B1 Striking against B2 Struck by B3 Caught Between B4 Temp. Extremes B5 Inhaling B6 Absorbing B7 Swallowing B8 Posture, Lifting, Twisting B9 Over-Extension B10 Falling

  • B1 Striking against
  • B2 Struck by
  • B3 Caught Between
  • B4 Temp. Extremes
  • B5 Inhaling
  • B6 Absorbing
  • B7 Swallowing
  • B8 Posture, Lifting, Twisting
  • B9 Over-Extension
  • B10 Falling

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category C - PPE

  Select C1 Eyes & Face C2 Ears C3 Head C4 Hands & Arms C5 Feet & Legs C6 Respiratory C7 Trunk C8 Other

  • C1 Eyes & Face
  • C2 Ears
  • C3 Head
  • C4 Hands & Arms
  • C5 Feet & Legs
  • C6 Respiratory
  • C7 Trunk
  • C8 Other

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category D - Tools & Equipment

  D1 Not Right for the job

  D2 Used Incorrectly

  D3 Unsafe Condition

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• CAT E - Procedures, CAT F - Work Area

  Select E1 Procedures inadequate for the job E2 Procedure not known or understood E3 Procedure not followed F1 Poor Housekeeping F2 Inadequate Storage F3 Unclean F4 Not Barricaded

  • E1 Procedures inadequate for the job
  • E2 Procedure not known or understood
  • E3 Procedure not followed
  • F1 Poor Housekeeping
  • F2 Inadequate Storage
  • F3 Unclean
  • F4 Not Barricaded

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• 5.

  CATEGORY A

  CATEGORY B

  CATEGORY C

  CATEGORY D

  CAT E, CAT F

• Category A - Reactions of people

  Select A1 Adjusting PPE A2 Rearranging job A3 Stopping job A4 Attaching to A5 Changing Lockouts A6 Not fitness for work

  • A1 Adjusting PPE
  • A2 Rearranging job
  • A3 Stopping job
  • A4 Attaching to
  • A5 Changing Lockouts
  • A6 Not fitness for work

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category B - Positions of People

  Select B1 Striking against B2 Struck by B3 Caught Between B4 Temp. Extremes B5 Inhaling B6 Absorbing B7 Swallowing B8 Posture, Lifting, Twisting B9 Over-Extension B10 Falling

  • B1 Striking against
  • B2 Struck by
  • B3 Caught Between
  • B4 Temp. Extremes
  • B5 Inhaling
  • B6 Absorbing
  • B7 Swallowing
  • B8 Posture, Lifting, Twisting
  • B9 Over-Extension
  • B10 Falling

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category C - PPE

  Select C1 Eyes & Face C2 Ears C3 Head C4 Hands & Arms C5 Feet & Legs C6 Respiratory C7 Trunk C8 Other

  • C1 Eyes & Face
  • C2 Ears
  • C3 Head
  • C4 Hands & Arms
  • C5 Feet & Legs
  • C6 Respiratory
  • C7 Trunk
  • C8 Other

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category D - Tools & Equipment

  D1 Not Right for the job

  D2 Used Incorrectly

  D3 Unsafe Condition

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• CAT E - Procedures, CAT F - Work Area

  Select E1 Procedures inadequate for the job E2 Procedure not known or understood E3 Procedure not followed F1 Poor Housekeeping F2 Inadequate Storage F3 Unclean F4 Not Barricaded

  • E1 Procedures inadequate for the job
  • E2 Procedure not known or understood
  • E3 Procedure not followed
  • F1 Poor Housekeeping
  • F2 Inadequate Storage
  • F3 Unclean
  • F4 Not Barricaded

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• 6.

  CATEGORY A

  CATEGORY B

  CATEGORY C

  CATEGORY D

  CAT E, CAT F

• Category A - Reactions of people

  Select A1 Adjusting PPE A2 Rearranging job A3 Stopping job A4 Attaching to A5 Changing Lockouts A6 Not fitness for work

  • A1 Adjusting PPE
  • A2 Rearranging job
  • A3 Stopping job
  • A4 Attaching to
  • A5 Changing Lockouts
  • A6 Not fitness for work

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category B - Positions of People

  Select B1 Striking against B2 Struck by B3 Caught Between B4 Temp. Extremes B5 Inhaling B6 Absorbing B7 Swallowing B8 Posture, Lifting, Twisting B9 Over-Extension B10 Falling

  • B1 Striking against
  • B2 Struck by
  • B3 Caught Between
  • B4 Temp. Extremes
  • B5 Inhaling
  • B6 Absorbing
  • B7 Swallowing
  • B8 Posture, Lifting, Twisting
  • B9 Over-Extension
  • B10 Falling

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category C - PPE

  Select C1 Eyes & Face C2 Ears C3 Head C4 Hands & Arms C5 Feet & Legs C6 Respiratory C7 Trunk C8 Other

  • C1 Eyes & Face
  • C2 Ears
  • C3 Head
  • C4 Hands & Arms
  • C5 Feet & Legs
  • C6 Respiratory
  • C7 Trunk
  • C8 Other

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category D - Tools & Equipment

  D1 Not Right for the job

  D2 Used Incorrectly

  D3 Unsafe Condition

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• CAT E - Procedures, CAT F - Work Area

  Select E1 Procedures inadequate for the job E2 Procedure not known or understood E3 Procedure not followed F1 Poor Housekeeping F2 Inadequate Storage F3 Unclean F4 Not Barricaded

  • E1 Procedures inadequate for the job
  • E2 Procedure not known or understood
  • E3 Procedure not followed
  • F1 Poor Housekeeping
  • F2 Inadequate Storage
  • F3 Unclean
  • F4 Not Barricaded

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• 7.

  CATEGORY A

  CATEGORY B

  CATEGORY C

  CATEGORY D

  CAT E, CAT F

• Category A - Reactions of people

  Select A1 Adjusting PPE A2 Rearranging job A3 Stopping job A4 Attaching to A5 Changing Lockouts A6 Not fitness for work

  • A1 Adjusting PPE
  • A2 Rearranging job
  • A3 Stopping job
  • A4 Attaching to
  • A5 Changing Lockouts
  • A6 Not fitness for work

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category B - Positions of People

  Select B1 Striking against B2 Struck by B3 Caught Between B4 Temp. Extremes B5 Inhaling B6 Absorbing B7 Swallowing B8 Posture, Lifting, Twisting B9 Over-Extension B10 Falling

  • B1 Striking against
  • B2 Struck by
  • B3 Caught Between
  • B4 Temp. Extremes
  • B5 Inhaling
  • B6 Absorbing
  • B7 Swallowing
  • B8 Posture, Lifting, Twisting
  • B9 Over-Extension
  • B10 Falling

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category C - PPE

  Select C1 Eyes & Face C2 Ears C3 Head C4 Hands & Arms C5 Feet & Legs C6 Respiratory C7 Trunk C8 Other

  • C1 Eyes & Face
  • C2 Ears
  • C3 Head
  • C4 Hands & Arms
  • C5 Feet & Legs
  • C6 Respiratory
  • C7 Trunk
  • C8 Other

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• Category D - Tools & Equipment

  D1 Not Right for the job

  D2 Used Incorrectly

  D3 Unsafe Condition

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• CAT E - Procedures, CAT F - Work Area

  Select E1 Procedures inadequate for the job E2 Procedure not known or understood E3 Procedure not followed F1 Poor Housekeeping F2 Inadequate Storage F3 Unclean F4 Not Barricaded

  • E1 Procedures inadequate for the job
  • E2 Procedure not known or understood
  • E3 Procedure not followed
  • F1 Poor Housekeeping
  • F2 Inadequate Storage
  • F3 Unclean
  • F4 Not Barricaded

• Potential Consequence

  Level 5 (Multiple Fatality)

  Level 4 (Single Fatality)

  Level 3 (Serious Injury)

  Level 2 (Serious Injury)

  Level 1 (minor Injury)

• General Comments

• Task Risk Assessment completed :

  Yes

  No

• Comments :

• Action items - By Who?, By When?

• 1.

• By who?

• By when?

  Date

• 2.

• By who?

• By when?

  Date

• 3.

• By who?

• By when?

  Date

• 4.

• By who?

• By when?

  Date

• 5.

• By who?

• By when?

  Date

• 6.

• By who?

• By when?

  Date

Add Photos as required;

• Photo 1:

  Media

• Photo Details;

Team Members name and signatures :

• Team Member 1 :

  Sign

• Team Member 2 :

  Sign

• Team Member 3 :

  Sign

• Team Member 4 :

  Sign