KP HSE Intervention Program

• Conducted on

  Date

• Prepared by

• Originator

• Project

• Scope of Work

• Department

• Company

• Date

  Date

Observation Details

• Unsafe condition

  Yes

  No

  N/A

• Unsafe behaviour

  Yes

  No

  N/A

• Best practice

  Yes

  No

  N/A

• HSE suggestion

  Yes

  No

  N/A

• Issue or concern

  Yes

  No

  N/A

• Security

  Yes

  No

  N/A

• Lesson learned

  Yes

  No

  N/A

• Description of OBSERVATION

Intervention Details

• Corrective Action

  Yes

  No

  N/A

• Positive Intervention

  Yes

  No

  N/A

• Further action

  Yes

  No

  N/A

• Description of INTERVENTION

Root Cause Analysis

Personnel Factor

• Lack of skills or knowledge

  Yes

  No

  N/A

• Using the correct way takes more time and or effort

  Yes

  No

  N/A

• Not following the correct practice is positively reinforced or tolerated

  Yes

  No

  N/A

• Deviations from the correct practice have not resulted in problems in the past

  Yes

  No

  N/A

Job Factor

• Lack or inadequate procedures or standards

  Yes

  No

  N/A

• Inadequate communication of expectations, procedures or standards

  Yes

  No

  N/A

• Tools or equipment. (Availability, Design, Condition)

  Yes

  No

  N/A

External Factor

• Weather

  Yes

  No

  N/A

• Surrounding

  Yes

  No

  N/A

• Photo of Observation

  Media

• Photo of Intervention

  Media