Telecom Field Leadership Safety Observation Template

• Work Site Location
  Address

• Date of Observation

  Date

• Job / Task

• Observer's Name

• Employee(s) Observed

• Primary Contact for the Job

• Clearance or HLH

  Yes

  No

  N/A

• Contract Partner Involved?

  Yes

  No

  N/A

• Prepare For The Observation By Identifying The Activities To Be Observed; and Review The Applicable Safety Rules and/or Procedures Prior To The Observation. *Utilization Of Rules And Procedures Alone Will Not Eliminate The Potential For An Error. It Is Imperative To Use Human Performance Tools During Any Work Evolution To Avoid Unplanned Events.

• SIF Precursors are detectable events, conditions or actions that are warning signs of the potential for a serious injury or fatality (SIF) if not properly mitigated. The most important thing to understand about SIF precursors is that they can be identified and mitigated before a SIF occurs.

What does leadership engagement look like? The key to a leadership engagement is the use of open-ended questions - where the answer is not just “yes” or "no”

• o Pre-job discussion - What are the key take-aways from the pre-job discussion?
  o Risk - What makes you nervous about the work today? What potential injuries are the workers exposed to? If the worst thing happens, what is in place to keep everyone safe?
  o Procedure Use and Adherence - What would be a critical step in work plan that could result in a mistake?
  o Stop Work - What would cause this work to be stopped today?
  o Unexpected Conditions - What aspect of the job you cannot perform as planned?
  o Ask about specific challenges. Showing interest and empathy creates genuine connection.
  o Ask what improvements are needed; encourage less-experienced employees to share ideas.
  o Employees should walk away from the engagement knowing they are valued, and their input will make a difference.

• Safe Work Procedure - Workers cannot express the core elements of the safe/standard workplan for their task (Weight +3)

  Safe

  Coachable Gap+3

  N/A

• Hazard Recognition - Workers do not recognize hazards or properly evaluate the severity of risks (Weight +2)

  Safe

  Coachable Gap+2

  N/A

• Departure From Routine - Unfamiliar or unseen task or job site conditions that depart from the well established routine (Weight +3)

  Safe

  Coachable Gap+3

  N/A

• Plan to Address Change - Workers do not stop and reassess conditions when work changes from what is planned (Weight +1)

  Safe

  Coachable Gap+1

  N/A

• Safety Attitudes - Workers demonstrate priority of productivity, heroic tendencies, vulnerability, fatalism, or summit fever (Weight +1)

  Safe

  Coachable Gap+1

  N/A

• Rules and Procedures - Adequate rules are communicated and documented but not followed by workers. The correct procedure is documented and communicated to workers but they are not followed. (Weight +3)

  Safe

  Coachable Gap+3

  N/A

• Familiarity with Task - Workers are not familiar with task expectations and performance standards because of lack of experience or significant procedural change. (Weight +2)

  Safe

  Coachable Gap+2

  N/A

• Risk Normalization - Lower perception of risk or higher risk tolerance resulting from repeated exposures. Tied to procedural drift. (Weight +3)

  Safe

  Coachable Gap+3

  N/A

• Productivity Pressure - Workers feel and unusual amount of pressure to work quickly and complete their task. (Weight +3)

  Safe

  Coachable Gap+3

  N/A

• Perceived Safety Culture - Lessons learned from previous projects and events are not incorporated into planning and execution. (Weight +3)

  Safe

  Coachable Gap+3

  N/A

• Stop Work Execution - Workers do not have the ability, or management does not encourage, stopping work to address hazards. (Weight +2)

  Safe

  Coachable Gap+2

  N/A

• Workers Inactive In Safety - Workers are not engaged with or diligently participating in safety activities. (Weight +2)

  Safe

  Coachable Gap+2

  N/A

• Pre-Task Plan - Workers have not completed an adequate pre-task safety plan. (Weight +3)

  Safe

  Coachable Gap+3

  N/A

Personnel

• Employee(s) qualified to perform task or being coached by a qualified person?

  Safe

  Coachable Gap

  N/A

Human Performance

• Human Performance (HU) Tools and Traps discussed - not merely stated, but discussed?

  Safe

  Coachable Gap

  N/A

Pre-Job Brief - Job Hazard Analysis (JHA)

• Emergency Action Plan (EAP)

  Safe

  Coachable Gap

  N/A

• Employee(s) demonstrate understanding of work scope and sequence?

  Safe

  Coachable Gap

  N/A

• Employee(s) demonstrate knowledge of hazards associated with the job to include critical tasks?

  Safe

  Coachable Gap

  N/A

• Employee(s) understand elimination strategy; mitigating risk; and take special precautions?

  Safe

  Coachable Gap

  N/A

• Proper energy source controls?

  Safe

  Coachable Gap

  N/A

• Hazard Model and Stuff That can Kill You (STKY) discussed?

  Safe

  Coachable Gap

  N/A

• Hazard Model discussion questions:
  o What is the stuff that can kill you on your jobsite or task?
  o What controls are in place to protect you from the Stuff That can Kill You?
  o Is that enough protection or do you need more?

  

• All employees signed on to JHA - understood and discussed?

  Safe

  Coachable Gap

  N/A

Personal Protective Equipment - PPE and Insulated Protective Equipment - IPE

• Employee(s) utilize required PPE?

  Safe

  Coachable Gap

  N/A

• PPE and IPE in good condition and within test date?

  Safe

  Coachable Gap

  N/A

Tools and Equipment

• Appropriate tools or equipment being used and in good condition?

  Safe

  Coachable Gap

  N/A

• Tools or equipment being used correctly?

  Safe

  Coachable Gap

  N/A

Work Site Safety and Safe-Work Practices

• Employee(s) utilize proper fall protection and identify and document a rescue plan?

  Safe

  Coachable Gap

  N/A

• Cover-up and/or insulated barrier(s) needed and utilized?

  Safe

  Coachable Gap

  N/A

• Confined Space Entry? AM-ST-AD-004 Employee(s) identify and document a confined space rescue plan?

  Safe

  Coachable Gap

  N/A

• Barricades/Barriers; Hi-Viz Vests; Traffic Cones; Signs; Flagmen

  Safe

  Coachable Gap

  N/A

• Written Traffic Control plan?

  Safe

  Coachable Gap

  N/A

• Employee(s) identify and mitigate / take special precautions against line of fire; pinch-points hazards?

  Safe

  Coachable Gap

  N/A

• Employee(s) follow company procedures for Excavation / Boring / Trenching? Telecom procedure IT-PR-051

  Safe

  Coachable Gap

  N/A

• Housekeeping

  Safe

  Coachable Gap

  N/A

• Hot Work Permit - welding or other such as cadwelding

  Safe

  Coachable Gap

  N/A

• Minimum Approach Distance (MAD) - discussed and understood where applicable

  Safe

  Coachable Gap

  N/A

Body Use and Positioning

• Lifting - Pulling - Pushing - Cramped - Overextended

  Safe

  Coachable Gap

  N/A

• Pinch Points

  Safe

  Coachable Gap

  N/A

• Stretching

  Safe

  Coachable Gap

  N/A

Vehicles and Equipment

• Vehicle and related equipment condition

  Safe

  Coachable Gap

  N/A

• Safe vehicle operation

  Safe

  Coachable Gap

  N/A

• Circle for Safety

  Safe

  Coachable Gap

  N/A

At-Risk behaviors observed-action taken to correct and prevent recurrence

• Cause of At-Risk Behavior

• Correctional Action Taken / Suggestion

Safe behaviors observed - positive coaching provided

• undefined

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Signature(s)

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