Information
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Document No.
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Audit Title
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Location / Project Name
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Observer's Name
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Observee's Name
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Conducted on
Personal Protective Equipment
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1. Hearing Protection (e.g., ear plugs)
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2. Head Protection (e.g., hard hat)
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3. ANSI-rated Eye Protection (e.g., safety glasses)
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4. Hand Protection (e.g., Kevlar gloves)
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5. Foot Protection (e.g., safety shoes)
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6. Respiratory Protection
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7. Fall Protection Inspected (e.g., harness)
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8. ANSI-rated Reflective Vest/High-visibility Clothing
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9. Other (specify)
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Body Use and Positioning
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10. Correct Body Use and Positioning When Lifting/Pushing/Pulling
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11. Pinch Points/Moving Equipment - Hands/Body Clear
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12. Mounts/Dismounts Using Three Points of Contact
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13. Other (specify)
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Work Environment
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14. Work/Walk Surface Free of Obstructions (e.g., tripping hazards)
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15. Housekeeping/Storage
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16. Defined and Secured (e.g., warning devices, barricades, cones, flags, etc.)
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17. Suspended Load, Swing Radius, and Lift Area is Barracaded
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18. Safety Shut-down Devices
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19. Proper Storage and Labeling/Disposal of Sample and Waste Materials
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20. Cylinders Stored Upright, Secured, and Caps in Place
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21. Manhole/Vault Inspected for Hazards
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22. Other (specify)
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Operating Procedures
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23. Job Planning Discussed During Tailgate Meeting (e.g., HASP, JSAs, etc. reviewed)
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24. Fire Extinguishers Accessible and Inspections Current
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25. Work Permit/Authorization to Work (e.g., Hot, Cold, LOTO, Confined Space)
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26. JSA Reviewed and Followed
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27. Hazard Assessment Conducted - Hazard Hunt
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28. Interfaces with Other Functions (awareness with other personnel on site)
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29. Operators Looking Behind Prior to Backing Up
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30. Operators Wearing Seat Belts While Operating Equipment
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31. Subsurface Structures Identified
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32. Proper Trench Protective Equipment in Place
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33. Adequate Egress is Available for Excavation and Trench (within 25 ft. if depth is ≥4 ft.)
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34. All Materials Set Back at Least 2 Feet from Edge of Trench/Excavation
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35. Other (specify)
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Tools/Equipment
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36. Hand Tools (proper equipment selection, condition, and use)
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37. Power Tools (proper equipment selection, condition, and use)
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38. Equipment, Including Heavy (proper equipment selection, condition, and use)
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39. Hoses Inspected
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40. Required Monitoring Equipment Calibrated and Used
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41. Ladders Set Up Correctly and Inspected
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42. Right Tools for the Job are Available and in Good Condition - No Fixed Open-blade Knives (FOBKs)
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43. Other (specify)
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Quality Control
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44. Are sampling procedures/workplan/SAP/QAPP available on site?
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45. Are TRC SOPs available and being followed? (Observer should spot-check specific SOP tasks.)
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46. Are proper forms and field notes being used and collected?
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47. Is all equipment being calibrated as required?
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48. Are sample containers properly labeled and stored?
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49. Are proper QC samples (e.g., duplicate, MS, trip blanks, temperature blanks) being collected/used and being collected/used properly?
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50. Are proper decontamination procedures occuring?
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51. Is the chain-of-custody document properly filled out and provided with the samples?
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52. Other (specify)
Summary Page
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Task Observed
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Description of Task Observed and Background Information
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Positive Comments
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Conclusions / Why Questionable Items Occurred.
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Feedback Session Conducted By:
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Date / Time:
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Name of Observee's Supervisor
Questionable Observations / Root Cause Analysis
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Personal Factor: (1) Lack of skill or knowledge (2) Correct way takes more time/requires more effort (3) Shortcutting standard procedures is rewarded or appreciated (4) In past, did not follow procedures or acceptable practices and no incident occurred
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Job Factor: (5) Lack of or inadequate operational procedures or work standards (6) Inadequate communication of expectations or work standards (7) Inadequate tools or equipment
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Questionable Observation #
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Route Cause Analysis #
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Solution(s) to Prevent Potential Incident from Occuring
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Person Responsible
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Agreed Due Date
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Date Completed
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Questionable Observation #
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Route Cause Analysis #
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Solution(s) to Prevent Potential Incident from Occurring
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Person Responsible
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Agreed Due Date
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Date Completed
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Questionable Observation #
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Route Cause Analysis #
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Solution(s) to Prevent Potential Incident from Occurring
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Person Responsible
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Agreed Due Date
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Date Completed
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Questionable Observation #
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Route Cause Analysis #
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Solution(s) to Prevent Potential Incident from Occurring
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Person Responsible
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Agreed Due Date
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Date Completed
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Questionable Observation #
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Route Cause Analysis #
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Solutions(s) to Prevent Potential Incident from Occurring
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Person Responsible
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Agreed Due Date
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Date Completed
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Results of Verification (were solutions done?) and Validation (were solutions effective?)
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Reviewed by (Supervisor):
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Date:
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Approved by (Practice Safety Leader):
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Date:
