SAO - duplicate

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION 1 -TASK DETAILS

• Select date

  Date

• Department /Section

• Observer(s)

Observer

• Observer

  Sign

• Task /Activity

• Location

• Equipment

Machine/Plant

• Machine/Plant

Involved Persons

• Name

  Sign

SECTION 2- OBSERVATIONS

• SAFE PEOPLE

PERSON

• Competence - Knowledge Skill

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Following Procedure /Rule

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Operate Equipment Correctly

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Authorisation

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Fit for Duty

  Select Unsafe Act Unsafe Condition Safe N/A

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

• SAFE EQUIPMENT

• Equipment Fit for Purpose

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Mobile Equipment

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Lifting Equipment

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Is Test and Tag Current

  Yes

  No

  N/A

• TAGGED OUT OF SERVICE

  YES

  NO

• Person Responsible

  Sign

• Electrical Equipment

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Is Test and Tag Current

  Yes

  No

  N/A

• TAGGED OUT OF SERVICE

  YES

  NO

• Person Responsible

  Sign

• Machine Guarding

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Guarding in Place

  Yes

  No

  N/A

• TAGGED OUT OF SERVICE

  YES

  NO

• Person Responsible

  Sign

• Tooling

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Access

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Protecting Devices

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Was Task Stopped and PPE Corrected

  YES

  NO

• Responsible Person

  Sign

• PPE

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Correct PPE Worn

  YES

  NO

• Was Task Stopped and PPE Corrected

  YES

  NO

• Responsible Person

  Sign

• SAFE CONDITIONS

• Buildings and Structures

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Areas and Roadways

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Hygiene

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Hazardous Substances

  Select Unsafe Act Unsafe Condition Safe N/A

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

• MSDS Available

  YES

  NO

• Was Task Stopped and MSDS Made Available

  YES

  NO

• Responsible Person

  Sign

• Ergonomics

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Lighting

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Ventilation

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Noise

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Housekeeping

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Scrap and Refuse

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Stacking and Storage

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Colour Coding

  Select Unsafe Act Unsafe Condition Safe N/A

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

• SAFE METHODS

• Procedure Followed/Not Followed

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Procedure Known/Not Known

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Hazard Assessment

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Work Clearance/Permits

  Select Unsafe Act Unsafe Condition Safe N/A

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

• SAFE ENVIRONMENT

• Dust Control

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Noise Control

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Pollution Controlled at Source

  Select Unsafe Act Unsafe Condition Safe N/A

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

• Waste Management

  Select Unsafe Act Unsafe Condition Safe N/A

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

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 6 - SIGN OFF

• Observer

  Sign

• Observer

  Sign

• Observer

  Sign

• Supervisor

  Sign

• SSE

  Sign