Title Page
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Conducted on:
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Contractor:
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Crew Size:
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Project:
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Location
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Observer:
Safety Impact
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Safety Success or Safety Opportunity?
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Describe the Safety Success:
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Include Photos (One Required, Maximum Five Allowed):
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Describe your interaction with the crew (i.e. Safety Stand Up/Stop the Job):
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What state(s) of mind did the crew trigger on that contributed to this Safety Success?
- Rushing
- Frustration
- Fatigue
- Complacency
- Other
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Other:
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What critical error(s) did the crew avoid?
- Eyes not on Task
- Mind not on Task
- Line of Fire
- Balance/Traction/Grip
- Other
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Other:
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Describe the Safety Opportunity:
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Include Photos (One Required, Maximum Five Allowed):
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Describe your interaction with the crew (i.e. Safety Stand Up/Stop the Job):
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What state(s) of mind was the crew in that contributed to this Safety Opportunity?
- Rushing
- Frustration
- Fatigue
- Complacency
- Other
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Other:
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What critical error(s) contributed to this Safety Opportunity?
- Eyes not on Task
- Mind not on Task
- Line of Fire
- Balance/Traction/Grip
- Other
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Other:
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What corrective action was taken by the crew?
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Include Photos (One Required, Maximum Five Allowed):
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PSIF Category:
- Suspended Loads
- Arc Flash/Electrical Contact/Explosion
- Non-electrical Energy, High Heat or Toxic Chemical
- Fall From Elevation
- Confined/Enclosed Space
- Excavation
- Line of Fire
- Mobile Equipment
- N/A
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Task at Hand:
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Additional Comments:
Signatures
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Contractor Supervisor:
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Ameren Supervisor:
