SPSI Safety Observation Template- Rev.1

• Site conducted

  Transmission Inspector

  Distribution Inspector

• Date

• Prepared by

• Location
  Address

• Inspector Lan ID

• Observer Lan ID

• FPI Index

• AQI ( Air Quality Index)

• Does Inspector Voluntarily want Respiratory Protection?

  Yes

  No

  N/A

• Does Inspector have required Respiratory Protection?

  Yes

  No

  N/A

• Is there a Company vehicle on site?

  Yes

  No

  N/A

• Is there a Risk of Electrical contact or Arc Flash?

  Yes

  No

  N/A

• Does the Inspector have an A- Tag Number?

  Yes

  No

  N/A

• Is there a wildlife or pet risk?

  Yes

  No

  N/A

• Does the Inspector have a complete Tailboard onsite and available?

  compliant

  non-compliant

  needs training

  n/a

• Did the inspector create a Tailboard when prompted?

  Yes

  No

  N/A

• Does the Inspector maintain an orderly worksite?

  Yes

  No

  N/A

• Does the Inspector have a Fire Extinguisher in good working condition?

  Yes

  No

  N/A

• Does the Inspector have a First aid kit?

  Yes

  No

  N/A

• Does the Inspector have an Emergency Action Plan?

  Yes

  No

  N/A

• Is the Inspector carrying all required Fire Equipment?

  Yes

  No

  N/A

• Is the Inspector communicating effectively?

  Good

  Fair

  Poor

  N/A

• Inspector has the necessary tools/ equipment onsite and is using it effectively

  Yes

  No

  N/A

• Take Photos of Jobsite:

  Media

• Jobsite Notes:

Struck By

• Is Inspector reasonably avoiding struck-by and caught between hazards?

  Safe

  At Risk

  N/A

• Inspector remains safe from passing vehicles?

  Safe

  At Risk

  N/A

• Does the Inspector have escape routes ?

  Good

  Fair

  Poor

  N/A

PPE

• Is Inspector wearing appropriate FR clothing ? (weather, high visability, FR, AR, long sleeves& long pants )

  Compliant

  Non-Compliant

  N/A

• Is Inspector wearing Head Protection pertinent to task?

  Yes

  No

  N/A

• Is Inspector wearing eye/ face protection pertinent to task?

  Yes

  No

  N/A

• Is Inspector wearing hand protection pertinent to task?

  Yes

  No

  N/A

• Is Inspector wearing respiratory pertinent to task?

  Yes

  No

  N/A

• Is Inspector wearing hearing protection pertinent to task?

  Yes

  No

  N/A

• Was new PPE issued to inspector?

  Yes

  No

  N/A

• PPE Notes:

Vehicle

• Vehicles on site are in safe condition:

  Safe

  At Risk

  N/A

• Vehicles are being operated and/or parked safely?

  Yes

  No

  N/A

• All loads within vehicle capacity?

  Yes

  No

  N/A

• Was problem resolved after counseling?

  Yes

  No

  N/A

• Are all loads properly secured and flagged?

  Yes

  No

  N/A

• Was problem resolved after counseling?

  Yes

  No

  N/A

• Is the vehicle in good Housekeeping condition?

  Good

  Fair

  Poor

  N/A

• Is there damage to the vehicle?

  Yes

  No

  N/A

• Was the damage reported?

  Yes

  No

  N/A

• Did inspector file damage report with Observer present?

  Yes

  No

  N/A

• Vehicle Photos ( Front, Rear, Drivers side, passengers side, truck bed):

  Media

• Vehicle Notes:

Environment

• Environment type:

  Remote

  Rural

  Suburban

  Urban

• Does the Inspector have ample water and shade available?

  Yes

  No

  N/A

• Is the Weather conducive and safe for planned activities?

  Yes

  No

  N/A

• Environment is safe to work:

  Safe

  At Risk

  N/A

• What is the temperature in the work environment?

• Has the inspector been counseled on Heat Illness Prevention?

  Yes

  No

  N/A

Observation notes:

• Safety Observation notes:

• I have reviewed and discussed the information contained in this observation ( Inspector Signature):

  Sign

• I have reviewed and discussed the information contained within this observation ( Observer Signature):

  Sign

• Declined to sign observation: