Employee Field Engagement Form- MPS

• Prepared by

• Name of employee(s) engaged

• Please select level of engagement

  Permit to work

  Field conversation/engagement

  Job task observation

  Training observation

  GAPS

• Conducted on

  Date

• Shift

  Days

  Nights

• Day in rotation

  Select 1 2 3 4 5 6 7 8

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8

• Crew

  Select Crew 1 Crew 2 Crew 3 Crew 4 Straight Days Other

  • Crew 1
  • Crew 2
  • Crew 3
  • Crew 4
  • Straight Days
  • Other

• Employee department

  Select Ancillary Contractor Dewatering/Projects Maintenance Mill/Op Mine Security Site admin Tech Services

  • Ancillary
  • Contractor
  • Dewatering/Projects
  • Maintenance
  • Mill/Op
  • Mine
  • Security
  • Site admin
  • Tech Services

• Contracting group name

• Please select level of engagement

  Select Permit to work Field conversation/engagement Job task observation Training observation GAPS

  • Permit to work
  • Field conversation/engagement
  • Job task observation
  • Training observation
  • GAPS

• Permit to Work Task

  Select Working at heights Confined space Hot work Trenching Excavation Lifting Rigging

  • Working at heights
  • Confined space
  • Hot work
  • Trenching Excavation
  • Lifting Rigging

• Simple description of work being done

• Is the permit available at the work location or on iauditor

  Yes

  No

• Stop job and follow reporting structure

  Yes

  No

• Are all parts of the permit filled out correctly

  Yes

  No

• Are employees trained and competent at their assigned roles ( Authorized users, Competent persons, spotters)

  Yes

  No

• What changes or actions need to be made

• Are all hazards identified and controlled

  Yes

  No

• Please list corrective actions

• Photo of work location or task

  Media

• Task category

  Critical risk task

  High risk task

  Standard task

• Type of Observation

  Select Initial Follow Up Planned Observation Unplanned Observation

  • Initial
  • Follow Up
  • Planned Observation
  • Unplanned Observation

• Reason for Observation

  Select Critical Task New Worker Incident Follow up Good Performer Needs Coaching Other

  • Critical Task
  • New Worker
  • Incident Follow up
  • Good Performer
  • Needs Coaching
  • Other

• Task Description

• Is the worker trained for the task observed?

  Yes

  No

  N/A

• Job must be stopped until training is updated.

• Has a work place inspection been documented?

  Yes

  No

  N/A

• A document workplace exam must be conducted prior the job commencing

• Please select any improvement opportunities

  Select Training Tools Equipment Systems Other (please comment) None

  • Training
  • Tools
  • Equipment
  • Systems
  • Other (please comment)
  • None

• What training actions are required

• What tool improvements are required

• What equipment improvements are required

• What systems improvements are required

• Photos of work area

  Media

• Total Training Hours:

• Did the Trainee properly demonstrate a work place/pre-operational inspection?

  Yes

  No

• Did the Trainee properly demonstrate operation in a non-production setting?

  Yes

  No

• Did the Trainee properly demonstrate operation in a production setting?

  Yes

  No

• Has the Trainee demonstrated the ability to properly perform this job/task?

  Yes

  No

• Were there deficiencies in procedures or in performance of the task?

  Yes

  No

• What deficiencies

• Does the trainee need additional training?

  Yes

  No

• What follow up training is required

• Add photo of work area

  Media

• What were the general items discussed

  Health/Safety/Environmental

  New ideas

  Work/life concerns

  Other (please comment)

• What comments

• What new ideas

• What concerns

• Overall tone of conversation

  Positive

  Negative

  Neutral

• Any follow up needed

  Yes

  No

• Photo of work location

  Media

• Please name as many CRM's as you can

  Select Not able to name any Bulk Chemical- acid, cyanide, caustic Cable Handling- Shovel or Dewatering Fatigue Heavy equipment operation- cab to dove tail and parking areas Entanglement- Working around conveyor belts Lifting Rigging Towing- Lifting and rigging and/or Towing trailers/pipes Haul truck and small vehicle interactions-Intersections and one lane roads Working at heights- Removing components, deliveries and offloads Mid duty braking systems entering the pit Maintenance on Pressurized systems- Valves in plants Fueling equipment- fueling haul trucks at the fuel skid Ground control- Falling material from equipment working on a high wall Ground control- Equipment near a high wall Equipment fires- Hot work in a confined space Shovel swing radius- Bucket and counterweight Energy isolation- Live testing Working around underground voids Cutting tramp metal out of the crusher

  • Not able to name any
  • Bulk Chemical- acid, cyanide, caustic
  • Cable Handling- Shovel or Dewatering
  • Fatigue
  • Heavy equipment operation- cab to dove tail and parking areas
  • Entanglement- Working around conveyor belts
  • Lifting Rigging Towing- Lifting and rigging and/or Towing trailers/pipes
  • Haul truck and small vehicle interactions-Intersections and one lane roads
  • Working at heights- Removing components, deliveries and offloads
  • Mid duty braking systems entering the pit
  • Maintenance on Pressurized systems- Valves in plants
  • Fueling equipment- fueling haul trucks at the fuel skid
  • Ground control- Falling material from equipment working on a high wall
  • Ground control- Equipment near a high wall
  • Equipment fires-
  • Hot work in a confined space
  • Shovel swing radius- Bucket and counterweight
  • Energy isolation- Live testing
  • Working around underground voids
  • Cutting tramp metal out of the crusher

• What CRM's are you most exposed to

  Select Not able to name any Bulk Chemical- acid, cyanide, caustic Cable Handling- Shovel or Dewatering Fatigue Heavy equipment operation- cab to dove tail and parking areas Entanglement- Working around conveyor belts Lifting Rigging Towing- Lifting and rigging and/or Towing trailers/pipes Haul truck and small vehicle interactions-Intersections and one lane roads Working at heights- Removing components, deliveries and offloads Mid duty braking systems entering the pit Maintenance on Pressurized systems- Valves in plants Fueling equipment- fueling haul trucks at the fuel skid Ground control- Falling material from equipment working on a high wall Ground control- Equipment near a high wall Equipment fires- Hot work in a confined space Shovel swing radius- Bucket and counterweight Energy isolation- Live testing Working around underground voids Cutting tramp metal out of the crusher

  • Not able to name any
  • Bulk Chemical- acid, cyanide, caustic
  • Cable Handling- Shovel or Dewatering
  • Fatigue
  • Heavy equipment operation- cab to dove tail and parking areas
  • Entanglement- Working around conveyor belts
  • Lifting Rigging Towing- Lifting and rigging and/or Towing trailers/pipes
  • Haul truck and small vehicle interactions-Intersections and one lane roads
  • Working at heights- Removing components, deliveries and offloads
  • Mid duty braking systems entering the pit
  • Maintenance on Pressurized systems- Valves in plants
  • Fueling equipment- fueling haul trucks at the fuel skid
  • Ground control- Falling material from equipment working on a high wall
  • Ground control- Equipment near a high wall
  • Equipment fires-
  • Hot work in a confined space
  • Shovel swing radius- Bucket and counterweight
  • Energy isolation- Live testing
  • Working around underground voids
  • Cutting tramp metal out of the crusher

• How are you involved in the CRM program?

  Select Through the Bonus program I do verifications During workplace exams I work around Critical risks almost everyday I am a control owner Correcting hazards I am not involved in anyway Other (please comment)

  • Through the Bonus program
  • I do verifications
  • During workplace exams
  • I work around Critical risks almost everyday
  • I am a control owner
  • Correcting hazards
  • I am not involved in anyway
  • Other (please comment)

• How can you report a CRM hazard

  Supervisor

  Admin assistant

  Iauditor

  Paper report

  Don't know

• Is the employee able to explain how the CRM program affects the bonus program

  Yes

  No

• Add employees name so a follow up can be done

Goal

• What is the goal for today? (review with team)

Act

• What programs will be used to accomplish todays goal. (safe, efficient, production) (select all that apply)

  Select ACT card FLRA JHA Workplace exam Training/SOP's/SWP's Permits Supervisor follow up's (task obser/verifications) Other (add comment)

  • ACT card
  • FLRA
  • JHA
  • Workplace exam
  • Training/SOP's/SWP's
  • Permits
  • Supervisor follow up's (task obser/verifications)
  • Other (add comment)

• Add photo of selected programs

  Media

PLAN

• Are all tools, equipment and training correct for the job

  Yes

  No

• Stop work and get proper tools, equipment and training

• Was this plan reviewed by all affected team members

SCORE

• Overall, how well did we hit our goals today

  1

  2

  3

  4

  5

• What went well today (feed back from team)

• What can we improve on (feedback from team)

Any hazards that need to be documented

• Where there any hazards conditions found during this engagement

  Yes

  No
Hazard report

• Select Shift

  Days

  Nights

• What part of shift was the hazard found

  First third of shift

  Middle third of shift

  Last third of shift

• Is this a Critical risk report or Standard hazard report

  Critical risk report

  Standard hazard report

• Which Critical Risk would this be classified under?

  Select Contact with electricity Entanglement Slope failure Exposure to hazardous substances Falling objects Confined space Drowning Exposure to thermal extremes Fall from heights Lifting Operations Uncontrolled release of energy Underground hazardous atmosphere Underground inrush Underground rock fall Unplanned initiation of explosives Vehicle collision or rollover Vehicle impact on person Exposure to dust and fumes

  • Contact with electricity
  • Entanglement
  • Slope failure
  • Exposure to hazardous substances
  • Falling objects
  • Confined space
  • Drowning
  • Exposure to thermal extremes
  • Fall from heights
  • Lifting Operations
  • Uncontrolled release of energy
  • Underground hazardous atmosphere
  • Underground inrush
  • Underground rock fall
  • Unplanned initiation of explosives
  • Vehicle collision or rollover
  • Vehicle impact on person
  • Exposure to dust and fumes

• Description of condition or practice

• Photo of condition

  Media

• Immediate action(s) taken

  Select Reported to supervisor/management Shut the area/task down Added controls Other (please comment)

  • Reported to supervisor/management
  • Shut the area/task down
  • Added controls
  • Other (please comment)

• Reported to who

• What controls

  Select Elimination (Complete removal of hazard to worker) Substitution (Replace a hazard with something less hazardous) Engineering (Guards, alarms, reduce exposure, modify work) Administrative (Training, policies etc.) PPE (gloves, hearing protection etc. )

  • Elimination (Complete removal of hazard to worker)
  • Substitution (Replace a hazard with something less hazardous)
  • Engineering (Guards, alarms, reduce exposure, modify work)
  • Administrative (Training, policies etc.)
  • PPE (gloves, hearing protection etc. )

• Comment required

• Hazard Classification

  Select Housekeeping Safe Access Electrical Guarding Chemical IH-OH (Noise, dust, eyewash station, PPE, etc.) Environmental Damaged tools/Equipment Slip/trip/fall hazard Flammable, Combustible, disposal/storage Accumulation of Trash or missing lid Travel ways/roadways Poor or inadequate safety behavior Poor or inadequate safety procedure Inadequate Berms/Barriers Stored energy Other (please comment)

  • Housekeeping
  • Safe Access
  • Electrical
  • Guarding
  • Chemical
  • IH-OH (Noise, dust, eyewash station, PPE, etc.)
  • Environmental
  • Damaged tools/Equipment
  • Slip/trip/fall hazard
  • Flammable, Combustible, disposal/storage
  • Accumulation of Trash or missing lid
  • Travel ways/roadways
  • Poor or inadequate safety behavior
  • Poor or inadequate safety procedure
  • Inadequate Berms/Barriers
  • Stored energy
  • Other (please comment)

• Is this hazard cyanide related

  Yes

  No

• Description of condition or practice

• Photo of condition

  Media

• Immediate action(s) taken

  Select Reported to supervisor/management Shut the area/task down Added controls Other (please comment)

  • Reported to supervisor/management
  • Shut the area/task down
  • Added controls
  • Other (please comment)

• Reported to who

• What controls

  Select Elimination (Complete removal of hazard to worker) Substitution (Replace a hazard with something less hazardous) Engineering (Guards, alarms, reduce exposure, modify work) Administrative (Training, policies etc.) PPE (gloves, hearing protection etc. )

  • Elimination (Complete removal of hazard to worker)
  • Substitution (Replace a hazard with something less hazardous)
  • Engineering (Guards, alarms, reduce exposure, modify work)
  • Administrative (Training, policies etc.)
  • PPE (gloves, hearing protection etc. )

• What controls were added

• Was work stopped to mitigate the hazard?

  Yes

  No

• Describe resolution