PMC Behavior Observation Form

• PMC Behavior Observation Form

• Cayuga SCR Project

• Conducted on

  Date

• Lead Assessor

  Sign

• Contractors

• Areas Inspected

• Personnel

1. Falls

• Housekeeping maintained to prevent slips and falls? (employees have materials stacked neatly, cords, and hoses out of the way, waste disposed properly?)

  Safe

  At Risk

  N/A

• Personal fall arrest system adequate (pre-planning, equipment inspected and in good condition, employees know and have availability of anchorage points)?

  Safe

  At Risk

  N/A

• Proper use of PFAS or equipment? (harness, lanyard, attachment points,<br>100% tie off, stored properly?)*<br>

  Safe

  At Risk

  N/A

• Employees have properly installing and using guardrails? (top rail, mid-rail, toe-board, netting if needed; no standing or sitting on rails, feet on platform at all times including aerial lift baskets)

  Safe

  At Risk

  N/A

• Are workers protected from open holes? (Includes dropping materials) employees recognize hazards and have covered holes or are using 100% fall protection?

  Safe

  At Risk

  N/A

• Are workers safe from falling off ladders? (Employees have properly set up and secured ladders. Employees climbing and descending properly?)

  Safe

  At Risk

  N/A

• Does all equipment in use have current inspection? (scaffolds, ladders,<br>mobile equipment, etc.). Did employees document inspection?<br>

  Safe

  At Risk

  N/A

• Other:

  Safe

  At Risk

  N/A

2. Struck By

• Have employees inspected vehicles/equipment to ensure safe operating condition?

  Safe

  At Risk

  N/A

• Are vehicles/equipment used properly? (Spotters, clearance, speed of motion<br>appropriate for amount of congestion?)<br>

  Safe

  At Risk

  N/A

• Are objects prevented from falling / landing on personnel? (equipment / material stored and properly secured, tools/equipment tethered, perimeter netted, areas barricaded?

  Safe

  At Risk

  N/A

• Are workers recognizing, avoiding, and preventing line-of-fire situations with regard to flying objects? (Are workers out of the line of fire? Are whip checks and air clips in place on pneumatic equipment?)

  Safe

  At Risk

  N/A

• Are employees using proper PPE used to prevent injury from flying objects? (face shields, safety glasses, sealable eyewear, hard hats)

  Safe

  At Risk

  N/A

• Other:

  Safe

  At Risk

  N/A

3. Caught Between

• Are workers practicing proper use of hand and power tools? (tools inspected, tools not modified)

  Safe

  At Risk

  N/A

• Is body positioning correct for the task, are workers out of the line-of- fire? (hands, arms, legs, etc. out of pinch points? Does clothing, hair, jewelry propose risk?

  Safe

  At Risk

  N/A

• Is proper PPE utilized? (e.g. gloves)

  Safe

  At Risk

  N/A

• Is there exposure to moving parts? (are equipment guards in place, handles<br>used on tools, clearances utilized, etc.) <br>

  Safe

  At Risk

  N/A

• Is moving / rotating equipment (e.g. cranes / JLG’s adequately barricaded)?

  Safe

  At Risk

  N/A

• Is equipment (e.g. fork trucks / JLG’s / cranes) being adequately coordinated in congested areas?

  Safe

  At Risk

  N/A

• Other:

  Safe

  At Risk

  N/A

4. Electrical

• Are workers protected from electric shock? (open, exposed, live parts)

  Safe

  At Risk

  N/A

• Clearances in place, workers signed on, workers understand boundaries?

  Safe

  At Risk

  N/A

• Employees are implementing best practices used for electrical equipment? (inspections, storage, condition, GFCI, etc.)*

  Safe

  At Risk

  N/A

• Have employees ensured that all devices/objects that need grounding are properly grounded?

  Safe

  At Risk

  N/A

• Other:

  Safe

  At Risk

  N/A

5. General

• Are workers using proper lifting techniques (bend knees, straighten back, assistance lifting for heavy objects)?

  Safe

  At Risk

  N/A

• Do employees have proper measures in place to control fire if necessary? (Fire watch, appropriate fire extinguishers & inspection, fire blankets, etc.)

  Safe

  At Risk

  N/A

• Are employees properly utilizing rigging equipment (slings, chain falls, shackles) for rigging activities?

  Safe

  At Risk

  N/A

• Are drivers and equipment operators wearing seatbelts at all times?

  Safe

  At Risk

  N/A

• Are workers wearing appropriate hearing protection for work in their area?

  Safe

  At Risk

  N/A

• Pre-planning: Are JHA and TSA’s completed. Are all permits (confined space, hot work, trench) in place for work observed?

  Safe

  At Risk

  N/A

• Are workers using safe access to work areas?

  Safe

  At Risk

  N/A

• Other:

  Safe

  At Risk

  N/A

Fall Hazard Assessment

• Can a scaffold, aerial lift, temporary platform or other means be utilized to perform work task in a safer manner?

  Safe

  At Risk

  N/A

• Is tieoff at foot level required? If so, has fall distance been minimized to less than 6ft?

  Safe

  At Risk

  N/A

• Does work require an SRL? If so, has SRL been installed overhead (less than 30 degrees from center) to prevent pendulum effect?

  Safe

  At Risk

  N/A

• Have all potential "strike points" been identified?

  Safe

  At Risk

  N/A

• Is any implement protection required?

  Safe

  At Risk

  N/A

• Does access to work area have any obstructions (handrail, piping, etc)?

  Safe

  At Risk

  N/A

• Is this work considered "leading edge" work?

  Safe

  At Risk

  N/A

• Does area below require barricading from dropped objects?

  Safe

  At Risk

  N/A

• Has incident reporting protocol been reviewed?

  Safe

  At Risk

  N/A

• Is JSA/JHA adequate?

  Safe

  At Risk

  N/A

• Select date

  Date