Leadership HSE Observation

• Site Name

• Conducted on (Date and Time)

  Date

• Prepared by

• Location
  Address

General

• How would you rate the general 5S condition of the plant?

  Good

  Fair

  Poor

  N/A

• How would you rate the general condition of the pedestrian walkways? Are pedestrian walkways clearly identified?

  Good

  Fair

  Poor

  N/A

• How did you rate the compliance of employees and/or visitors adhering to the designated rules?

  Good

  Fair

  Poor

  N/A

• What did you see?

• How did you feel about your interaction with vehicles and fork lift trucks whilst in the manufacturing or distribution areas?

  Safe

  At Risk

  N/A

• If you felt at risk, briefly comment

Personal Protective Equipment

• Were the site PPE rules clearly defined to you before entering the workplace?

  Yes

  No

  N/A

• How would you rate employee compliance to wearing required PPE?

  Good

  Fair

  Poor

  N/A

• Note Deviation(s)

Machinery Safety

• When viewing production equipment, in general, how did you rate the condition of guarding or safety devices? Did any appear to be missing or not functional? Ask an operator if any safety devices are not functional.

  Good

  Fair

  Poor

  N/A

• Add Photograph

  Media

• Do the employees appear to be working safely in and around machinery? Observe 1 machine operation.

  Safe

  At Risk

  N/A

• Add photograph

  Media

Continuous Improvement

• Are Safety A4 Communications available in the workplace and evidence they have been communicated to employees?

  Compliant

  Non-Compliant

  N/A

• Take Photograph

  Media

• Ask any operator if they are aware of the latest A4 Safety communication. Check if the content is known.

  Fully Aware

  Some Knowledge

  Not aware

Completion

• Any other comments or questions to be raised, or feedback from the employees?

  Yes

  No

  N/A

• Provide a short description

• Full Name and Signature of the leadership team member

  Sign