Title Page
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Project Name
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Location
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Project #
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Date and Time
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Observer Name
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Observee Name
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Task Observed
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Description of Task Observed and Background Information
PERSONAL PROTECTIVE EQUIPMENT
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1. Hearing Protection (e.g., Ear Plugs)
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2. Head Protection (e.g., Hard Hat)
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3. ANSI Rated Eye Protection (e.g., Safety Glasses)
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4. Hand Protection (e.g., Kevlar Gloves)
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5. Foot Protection (e.g., Safety Shoes)
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6. Respiratory Protection
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7. Fall Protection Inspected (e.g., Harness)
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8. ANSI Rated Reflective Vest/High Visibility Clothing
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9. Other ( Specify)
BODY USE AND POSITIONING
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1. Correct Body Use and Positioning When Lifting/Pushing/Pulling
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2. Pinch Points/Moving Equipment -Hands/Body Clear
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3. Mounts/Dismounts Using 3-Points of Contact
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4. Other (Specify)
WORK ENVIRONMENT
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1. Work/Walk Surface Free of Obstructions (e.g., Tripping Hazards)
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2. Housekeeping/Storage
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3. Defined and Secured (e.g., warning devices, barricades, cones, flags)
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4. Suspended Load, Swing Radius & Lift Area is Barricaded
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5. Safety Shutdown Devices
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6. Proper Storage & Labeling /Disposal of Sample & Waste Materials
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7. Cylinders Stored Upright, Secured, & Caps in Place
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8. Manhole/vault Inspected for Hazards
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9. Other (Specify)
OPERATING PROCEDURES
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23. Job Planning (HASP reviewed, JSAs, etc.)
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24. Fire Extinguishers Accessible and Inspections Current
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25. Work Permit/Authorization to Work (Hot, Cold, LOTO, Confined Space)
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26. JSA Reviewed & Followed
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27. Hazard Assessment - Hazard Hunt
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28. Interfaces with Other Functions (awareness with other personnel on site)
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29. Operators Looking Behind Prior to Backing Up
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30. Operators Wearing Seat Belts While Operating Equipment
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31. Subsurface Structures Identified
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32. Proper Trench Protective Equipment in Place
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33. Adequate Egress Is Available for Excavation & Trench (within 25 ft. if depth is <4 ft.)
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34. All Materials Set Back at Least 2 Feet From Edge of Trench/Excavation
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35. Other (Specify)
TOOLS/EQUIPMENT
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36. Hand Tools (Proper Equipment Selection, Condition, and Use)
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37. Power Tools (Proper Equipment Selection, Condition, and Use)
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38. Equipment, Including Heavy (Proper Equipment Selection, Condition, and Use)
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39. Hoses Inspected
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40. Required Monitoring Equipment Calibrated & Used
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41. Ladders Set up Correctly & Inspected
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42. Right Tools for the Job are Available and in Good Condition - No Fixed Open Blade Knives (FOBKs)
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43. Other (Specify)
AT-RISK OBSERVATIONS/ROOT CAUSE ANALYSIS
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Personal Factor:
(1) Lack of skill or knowledge
(2) Correct way takes more time/requires more effort
(3) Shortcutting standard procedures is rewarded or appreciated
(4) In past, did not follow procedures or acceptable practices and no incident occured
Job Factor:
(5) Lack of or inadequate operational procedures or work standards
(6) Inadequate communication of expectations or work standards
(7) Inadequate tools or equipment
At-Risk Observation
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At-Risk Observation #
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Root Cause Analysis #
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Solution(s) To Prevent Potential Incident from Occuring
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Person Responsible
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Agreed Due Date
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Date Completed
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Results of Verification (were solutions done?) and Validation (were solutions effective?)
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Reviewed by PM/Supervisor (Name and Signature)
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Approved by Practice Safety Leader (Name and Signature)
SIGN OFF
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Positive Comments
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Conclusion/Why the Questionable Items Occurred?
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Feedback Session Conducted by (Name and Signature)
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Name of Observee's Supervisor (Name and Signature)
