MDLZ - DSD GROUP - Revision #3

• Document No.

• Audit Title

• Is this a warehouse or Driver observation?

  Select Warehouse Driver

  • Warehouse
  • Driver

• Area Observed

• Branch Location

• Branch IBL Number

• Conducted on

  Date

• Prepared by

PURPOSE: To encourage leaders to perform routine safety observations of the work environment and actively engage with their employees regarding safe and/or unsafe behaviors and conditions. These engagement activities will provide coaching and listening opportunities to improve our overall safety program.

KEY OBSERVATION POINTS 1. A safety observation should take 10-15 minutes. 2. List the positive and improvement opportunities found. 3. Provide coaching and feedback on observations noted. 4. Develop corrective actions, document on action register and track through closure. 5. Retain observations for 12 months.

OBSERVATION SEVERITY RATING INFORMATION A - A condition or practice likely to immediately cause loss of life. TAKE IMMEDIATELY CORRECTIVE ACTION. B - A condition or practice likely to cause at least a Lost-Time Incident (LTI) or require Medical Treatment (MT). C - A condition or practice likely to only cause a First-Aid Case (FA) injury or recoverable damage.

1.0 HOUSEKEEPING CONDITIONS

• 1.1 Is progressive clean-up being followed to maintain the work area clean and orderly?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 1.1 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 1.2 Are walking and working surfaces free of any slip/trip/fall hazards (i.e. electrical cords, broken pallet pieces, straps, liquids, etc.)?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 1.2 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 1.3 Is the area free of leaning materials (load bars, skids, dock plates, etc.)?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 1.3 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 1.4 Any other housekeeping observations?

  Yes

  No

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 1.4 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

2.0 PERSONAL PROTECTIVE EQUIPMENT

• 2.1 Are employees wearing the appropriate personal protective equipment (i.e. safety glasses, protected toe shoes, gloves, etc.)?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 2.1 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 2.2 Any other personal protective equipment observations?

  Yes

  No

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 2.2 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

3.0 PICK LINE AREA

• 3.1 Is the employee using proper material handling techniques?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 3.1 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 3.2 Are pick pallet locations maintained at a height that can be safely accessed?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 3.2 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 3.3 Is the pick path maintained in good condition and free of trip hazards?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 3.3 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 3.4 Any other pick line area observations?

  Yes

  No

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 3.4 observations?<br>A - A condition or practice likely to immediately cause loss of life. TAKE IMMEDIATELY CORRECTIVE ACTION.<br>B - A condition or practice like to cause at least a Lost-Time Incident (LTI) or require Medical Treatment (MT).<br>C - A condition or practice likely to only cause a First-Aid Case (FA) injury or recoverable damage.

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

4.0 PALLET AND CART BUILDING

• 4.1 Is the employee using proper material handling techniques?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 4.1 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 4.2 Are flex belts appropriately positioned to carts/pallets to safely build orders?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 4.2 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 4.3 Any other pallet and cart building observations?

  Yes

  No

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 4.3 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

5. 0 STRETCHING

• 5.1 Was pre-shift stretching completed today?

  Safe

  At Risk

  N/A

• Please provide details on what you observed or discussion with employee(s).

• Select Severity Rating for 5.1 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

6.0 DRIVER WORK PRACTICES

• 6.1 Were Pre/Post Trip inspections conducted correctly and deficiencies documented in ZONAR system?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 6.1 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 6.2 Are 3 points of contact being used when entering and exiting the truck?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 6.2 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 6.3 Is the employee using proper material handling techniques (proper lifting/lowering/bending, pushing vs pulling, etc.)?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 6.3 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 6.4 Are proper driver methods being used?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 6.4 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 6.5 Was that delivery unit secured (cab locked, wheels chocked, trailer door locked when away from unit) while making deliveries?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 6.4 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 6.5 Did the employee raise and lower the trailer door in a safe manner?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 6.5 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 6.6 Did the employee use and store the portable dock plate in a safe manner?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 6.6 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 6.7 Any other Driver work practice observations?

  Yes

  No

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 6.7 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

7.0 POWERED INDUSTRIAL TRUCKS

• 7.1 Are pre-use inspections being completed?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 7.1 observations?<br>A

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 7.2 Are forklift operators wearing seatbelts? Give instant feedback (positive or negative).

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 7.2 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 7.3 Are powered industrial truck operators operating in a safe manner (i.e. safe speed, using horns at blind corners/intersections, maintaining clear view in the direction of travel, etc.)?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 7.3 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 7.4 Are powered industrial truck units parked with attachments lowered to the ground and the units shut down?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 7.4 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 7.5 Any other powered industrial truck observations?

  Yes

  No

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 7.5 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

8.0 DOCK LOADING / UNLOADING

• 8.1 Are dock doors/screens in closed position when not in use?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 8.1 observations?<br><br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 8.2 Are key control methods being used?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 8.2 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 8.3 Are jack stands used on all decoupled trailers?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 8.3 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 8.4 Are orange cones used to designate an active load / unload process?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 8.4 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 8.5 Are wheel chocks being used?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 8.5 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

• 8.6 Any other dock loading / unloading observations?

  Yes

  No

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 8.6 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

9.0 TRAINING

• 9.1 Do you feel you have received sufficient safety training for your job?

  Safe

  At Risk

  N/A

• Please provide details on what you observed (include any feedback given to the employee).

• Select Severity Rating for 9.1 observations?<br>

  A - Likely to cause loss of life. TAKE ACTION

  B - Likely to cause LTI or MT incident.

  C - Likely to cause FA injury or recoverable damage.

• Was the situation corrected on the spot?

  Yes

  No

  N/A

GENERAL QUESTIONS TO ASK WHEN ENGAGING EMPLOYEES 1. How would you evacuate and where would you go in an emergency situation. 2. Do you have any suggestions to make this branch a safer place to work? 3. What are you personally working on to improve your safety and that of your co-workers?

OBSERVATION SUMMARY - THIS SECTION MUST BE FULLY COMPLETED

• Do you feel this observation should be considered a SAFE or AT RISK observation?

  Safe

  At Risk

  N/A

• Did the observation process include employee interactions?

  Yes

  No

  N/A

• Enter number of employees that were engaged.

  Select 1 2 3 4 5 or more

  • 1
  • 2
  • 3
  • 4
  • 5 or more

• Were there any deficiencies noted?

  Yes

  No

  N/A

• Enter the number of deficiencies that were found.

  Select 1 2 3 4 5 or more

  • 1
  • 2
  • 3
  • 4
  • 5 or more

• Please provide details on what you observed (include feedback given to the employee).

• If an opportunity was observed, what will the employee be working on?

• Were there any positive findings observed?

  Yes

  No

  N/A

• Enter number of positive findings observations.

  Select 1 2 3 4 5 or more

  • 1
  • 2
  • 3
  • 4
  • 5 or more

• Please provide details on what you observed (include feedback given to the employee).

• Was an operational change made as a result of this observation?

  Yes

  No

  N/A

• Please provide details on the operational change that was made.