Information
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PREPARED BY:
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Date
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MANUFACTURING LINE
- Line 1
- Line 2
- Common System
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LOCATION / AREA
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NAME OF EQUIPMENT
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JOB DESCRIPTION (DESCRIBE SPECIFIC TASK)
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NAME OF ADDITIONAL OBSERVERS
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NUMBER OF IMERYS EMPLOYEES OBSERVED
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NUMBER OF CONTRACTORS OBSERVED
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Additional comments
RISK ANALYSIS
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PICTURE OF THE SYSTEM / EQUIPMENT DURING THE INSPECTION
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Was a pre-job safety assessment properly completed for the job being observed ( Non routine job/task involving a forklift)
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Is there a completed vehicle inspection record for the mobile equipment observed? If a second individual operated the mobile equipment during the shift, was a visual inspection conducted and documented (initialed on the inspection form)?
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Are only Certified Forklift Operators using the equipment?
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All devices (i.e. brakes, horn, back-up alarm, rear blue light, seat sensing devices or seatbelt sensing devices, etc.) which may affect safe mobile equipment operation were functional and properly used?
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Seat belts were worn as required for the mobile equipment operation?
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Ensure loads do not exceed the adjusted capacity.
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All individuals observed remained clear of suspended loads.
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Are Pedestrian walkways marked where pedestrians and forklifts interact as described in the site traffic management plan to progressively separate the physical flow of pedestrians and forklifts?
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Safe operational practices were observed with loading and unloading operations (Looking back before moving, carrying load properly).
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Were there any other forklift safety issues identified during this observation?
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Provide details.
SAFETY VISIT CARD - CHECKLIST
SAFETY VISIT CARD
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CHECKLIST # 1 - MARK ALL BEHAVIOURS THAT APPLY
- Climbing or Standing on Equipment
- Climbing through Equipment (Awkward Position)
- Ascending/Descending (Stairs, Ladders, Platforms)
- Ergonomics (Position/Posture) (Pushing & Pulling)
- Eyes on Task
- Line of Fire (Being Struck By Something)
- Electrical Hazards (Following Safe Work Practices)
- Isolation (Installation of Lockout/Tagout / Try)
- Ergonomics (Lifting/Carrying)
- Line of Fire (Caught Between Something)
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CHECKLIST # 2 - MARK ALL BEHAVIOURS THAT APPLY
- Stepping Over or Under Equipment (Awkward Position)
- Climbing Over Handrails
- Isolation (Securing or Bleeding Off Stored Energy)
- Personnel Protective Equipment (All Needed for Job)
- Vehicles & Driving (Securing Parked Vehicles)
- Vehicles & Driving (Maintaining an appropriate Speed)
- Proper Chemical Handling (Labeling, Storage, Use)
- Tools/Equipment (Correct For Job & Proper Use)
- Tools/Equipment (Good Condition or Properly Stored)
- Are Hazards Controlled (Eliminated/Barricading)
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CHECKLIST # 3 - MARK ALL BEHAVIOURS THAT APPLY
- Reaching through Handrails
- Interaction with Vehicles
- Have Hazards/Risks been Communicated with Others
- Are there any Balance Traction Grip Issues
- Pre Job Safety Assessment Used
- Work at Heights (Protecting from Fall Hazards)
- Confined Spaces (Following Safe Work Practices)
- Work Environment (Hot, Cold, Wet, Etc.)
- Are Safe Work Practices being used?
HAZARDS & RISK ASSESMENT
ASSESMENT
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Select the level of risk: Low, Medium, High
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Is there a way to do the job/task "Better" and/or "Safer"?
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Feedback Given:
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Follow Up Action required ? (if any, submit action plan)
ENDING TIME
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ENDING TIME
