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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All moving machine parts observed (i.e. gears, sprockets, chains, drives, belts and take up pulleys, flywheels, couplings, shafts, fan blades or other moving parts) were provided with guards which met the requirements of MSHA and the Imerys S11 standards.
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All individuals observed working near moving equipment had removed or secured loose clothing or jewelry which could cause entanglement.
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Are guards maintained in good, secure condition and in place?
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Adequate safety procedures have been taken for any guard which was removed during equipment service or maintenance.
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All emergency stop devices appear to be in place and operational?
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Does the list include all machine guarding issues identified this observation?
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