Safe Act Observation Quarry

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION 1 -TASK DETAILS

• Select date

  Date

• Department /Section

• Location

• Observer(s)

Observer

• Observer

  Sign

• Task /Activity

• Equipment

Machine/Plant

• Machine/Plant

Involved Persons

• Name

  Sign

SECTION 2- OBSERVATIONS

• SAFE PEOPLE

PERSON

• Competence - Knowledge Skill

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Following Procedure /Rule

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Operate Equipment Correctly

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Authorisation

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Fit for Duty

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• SAFE EQUIPMENT

• Equipment Fit for Purpose

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Mobile Equipment

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Lifting Equipment

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Is Test and Tag Current

  Yes

  No

  N/A

• TAGGED OUT OF SERVICE

  YES

  NO

• Person Responsible

  Sign

• Add media

  Media

• Electrical Equipment

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Is Test and Tag Current

  Yes

  No

  N/A

• Add media

  Media

• TAGGED OUT OF SERVICE

  YES

  NO

• Person Responsible

  Sign

• Machine Guarding

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Guarding in Place

  Yes

  No

  N/A

• Add media

  Media

• TAGGED OUT OF SERVICE

  YES

  NO

• Person Responsible

  Sign

• Tooling

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Access

  Select Unsafe Act Unsafe Condition Safe N/A

  • Unsafe Act
  • Unsafe Condition
  • Safe
  • N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Protecting Devices

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• PPE

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Correct PPE Worn

  YES

  NO

• Add media

  Media

• Was Task Stopped and PPE Corrected

  YES

  NO

• Responsible Person

  Sign

• SAFE CONDITIONS

• Buildings and Structures

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Areas and Roadways

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Hygiene

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Hazardous Substances

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• MSDS Available

  YES

  NO

• Was Task Stopped and MSDS Made Available

  YES

  NO

• Responsible Person

  Sign

• Ergonomics

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Lighting

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Ventilation

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Noise

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Housekeeping

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Scrap and Refuse

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Stacking and Storage

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• SAFE METHODS

• Procedure Followed/Not Followed

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Procedure Known/Not Known

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Hazard Assessment

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Work Clearance/Permits

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• SAFE ENVIRONMENT

• Dust Control

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Noise Control

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Pollution Controlled at Source

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

• Waste Management

  Unsafe Act

  Unsafe Condition

  Safe

  N/A

• Add media

  Media

• Corrective Actions

• Corrected By

  Sign

Please Provide Details of Safe and Unsafe Acts

• SAFE ACTS

• UNSAFE ACTS

SECTION 3 - ACTIONS and FOLLOW UP

Action

• Action

• Due Date

  Date

• To Be Completed by

  Sign

SECTION 6 - FEEDBACK

• Feedback ( Employees / Workgroup

SECTION 7- SIGN OFF

• Observer

  Sign

• Observer

  Sign

• Observer

  Sign

• Supervisor

  Sign

• SSE

  Sign