Management Safety Observation Report (MSOR)

• Client / Site

• Conducted on

  Date

• Prepared by

Conditions

• Visibility of EHS:<br>Signs, posters, safety calendar, site orientation

  Not Acceptable

  Improve

  Good

• Emergency Plan: Evacuation routes and rally points posted, medical available, fire protection, alarms<br>

  Not Acceptable

  Improve

  Good

• Housekeeping: Clean, orderly, materials properly stored, trash properly disposed<br>

  Not Acceptable

  Improve

  Good

• Excavations: Properly shored/ sloped, safe access, protected from traffic, spoils piles<br>

  Not Acceptable

  Improve

  Good

• Scaffolds, Stairs, Ladders: Safe access, working safely, inspected, proper use, secured

  Not Acceptable

  Improve

  Good

• Chemicals and Environment: Chemicals stored properly, labeled, no visible spills, spill containment in place

  Not Acceptable

  Improve

  Good

• Lifting, Rigging Practices: Slings/chains no damage, use of certified lifting devices, tag lines, crane inspections

  Not Acceptable

  Improve

  Good

• Safe Walkways and Access: Clear designated walkways, tripping hazards, cables run safely

  Not Acceptable

  Improve

  Good

Behaviors

• Safe Equipment and Tool Use: Right for the job, inspected, used correctly

  Not Acceptable

  Improve

  Good

• Personal Protective Equipment: Proper use, worn correctly, required for the hazard

  Not Acceptable

  Improve

  Good

• Permit to Work Use: LOTO, electrical energized work, welding permits used and followed

  Not Acceptable

  Improve

  Good

• Exposure to Falls: Unsafe position, exposure to a fall, safe use aerial/scissor lifts

  Not Acceptable

  Improve

  Good

• Contacting Electrical Current: Electrical safe work practices, use of PPE (Arc Flash)

  Not Acceptable

  Improve

  Good

• Awkward Positions: Improper lifting, work positioning, reaching working over head

  Not Acceptable

  Improve

  Good

• Caught in or between Objects: Working in confined spaces, excavations, engulfment

  Not Acceptable

  Improve

  Good

• Striking Against or being Stuck By: Crane swing, mobile equipment, lifting materials

  Not Acceptable

  Improve

  Good

Other: Provide any additional comments or details not mentioned in the Conditions/Behaviors Sections

• Does the Job Safety Analysis (JSA) list all the steps of the Job?

  Yes

  No

  N/A

• Are all of the hazards of job listed on the Job Safety Analysis (JSA)?

  Yes

  No

  N/A

• Was the Job Safety Analysis (JSA) reviewed prior to the start of work?

  Yes

  No

  N/A

• Did all of the workers sign off on the Job Safety Analysis (JSA)?

  Yes

  No

  N/A

• Other comments related to work

QUESTIONS TO ASK OBSERVED WORKERS (INSERT COMMENTS)

• Company:

• Worker(s) interviewed:

• If you had to make a guess, where would the next accident occur on this site and why?

• What reasonable changes would you like to recommend making this site safer?

• Can you tell me about the last incident or injury which occurred on site?

• What Safety Rule(s) are not consistently being followed on site? Why?

• Do you have any safety concerns about the work you are performing?

• Comments:

Signature of person performing MSOR

• Signature

  Sign