TRC (NPV) SAFETY OBSERVATION FORM

• Conducted on

  Date

• Prepared by

• Location
  Address

Project Information

• Location/Project Name:

• Project Number

• Observer Name:

• Observee Name:

• Task Observed

• Description of Task Observed and Background Information

• Positive Comments

• Conclusions / Why the Questionable Items Occurred?

• Feedback Session Conducted By:

• Name of Observee's Supervisor:

• Date:

  Date

• Time:

  Date

At-Risk Observations

Personal Factors

• (1) Lack of skill or knowledge

  Yes

  No

  N/A

• (2) Correct way takes more time/requires more effort

  Yes

  No

  N/A

• (3) Shortcutting standard procedures is rewarded or appreciated

  Yes

  No

  N/A

• (4) In past, did not follow procedures or acceptable practices and no incident occurred

  Yes

  No

  N/A

Job Factors

• (5) Lack of or inadequate operational procedures or work standards

  Yes

  No

  N/A

• (6) Inadequate communication of expectations or work standards

  Yes

  No

  N/A

• (7) Inadequate tools or equipment

  Yes

  No

  N/A

Root Cause Analysis

• Solution(s) To Prevent Potential Incident from Occurring

  Yes

  No

  N/A

• Person Responsible

• Agreed Due Date

  Date

• Date Completed

  Date

• Results of Verification (were solutions done?) and Validation (were solutions effective?)

  Yes

  No

  N/A

• Reviewed by (PM/Supervisor):

• Date:

  Date

• Approved by (Practice Safety Leader):

• Date:

  Date

CP015 - TRC Safety Observation Form

PERSONAL PROTECTIVE EQUIPMENT

• 1. Hearing Protection (e.g., Ear Plugs)

  Yes

  No

  N/A

• 2. Head Protection (e.g., Hard Hat)

  Yes

  No

  N/A

• 3. ANSI Rated Eye Protection (e.g., Safety Glasses)

  Yes

  No

  N/A

• 4. Hand Protection (e.g., Kevlar Gloves)

  Yes

  No

  N/A

• 5. Foot Protection (e.g., Safety Shoes)

  Yes

  No

  N/A

• 6. Respiratory Protection

  Yes

  No

  N/A

• 7. Fall Protection Inspected (e.g., Harness)

  Yes

  No

  N/A

• 8. ANSI Rated Reflective Vest/High Visibility Clothing

  Yes

  No

  N/A

• 9. Other ( Specify)

BODY USE AND POSITIONING

• 10. Correct Body Use and Positioning When Lifting/Pushing/Pulling

  Safe

  At Risk

  N/A

• 11. Pinch Points/Moving Equipment - Hands/Body Clear

  Safe

  At Risk

  N/A

• 12. Mounts/Dismounts Using 3-Points of Contact

  Safe

  At Risk

  N/A

• 13. Other (Specify)

WORK ENVIRONMENT

• 14. Work/Walk Surface Free of Obstructions (e.g., Tripping Hazards)

  Safe

  At Risk

  N/A

• 15. Housekeeping/Storage

  Safe

  At Risk

  N/A

• 16. Defined and Secured (e.g., warning devices, barricades, cones, flags)

  Safe

  At Risk

  N/A

• 17. Suspended Load, Swing Radius & Lift Area is Barricaded

  Safe

  At Risk

  N/A

• 18. Safety Shutdown Devices

  Safe

  At Risk

  N/A

• 19. Proper Storage & Labeling/Disposal of Sample & Waste Materials

  Safe

  At Risk

  N/A

• 20. Cylinders Stored Upright, Secured, & Caps in Place

  Safe

  At Risk

  N/A

• 21. Manhole/vault Inspected for Hazards

  Safe

  At Risk

  N/A

• 22. Other (Specify)

OPERATING PROCEDURES

• 23. Job Planning (HASP reviewed, JSAs, etc)

  Safe

  At Risk

  N/A

• 24. Fire Extinguishers Accessible and Inspections Current

  Safe

  At Risk

  N/A

• 25. Work Permit/Authorization to Work (Hot, Cold, LOTO, Confined Space)

  Safe

  At Risk

  N/A

• 26. JSA Reviewed & Followed

  Safe

  At Risk

  N/A

• 27. Hazard Assessment - Hazard Hunt

  Safe

  At Risk

  N/A

• 28. Interfaces with Other Functions (awareness with other personnel on site)

  Safe

  At Risk

  N/A

• 29. Operators Looking Behind Prior to Backing Up

  Safe

  At Risk

  N/A

• 30. Operators Wearing Seat Belts While Operating Equipment

  Safe

  At Risk

  N/A

• 31. Subsurface Structures Identified

  Safe

  At Risk

  N/A

• 32. Proper Trench Protective Equipment in Place

  Safe

  At Risk

  N/A

• 33. Adequate Egress Is Available for Excavation & Trench (within 25 ft. if depth is <4 ft.)

  Safe

  At Risk

  N/A

• 34. All Materials Set Back at Least 2 ft. From Edge of Trench/Excavation

  Safe

  At Risk

  N/A

• 35. Other (Specify)

TOOLS/EQUIPMENT

• 36. Hand Tools (Proper Equipment Selection, Condition, and Use)

  Safe

  At Risk

  N/A

• 37. Power Tools (Proper Equipment Selection, Condition, and Use)

  Safe

  At Risk

  N/A

• 38. Equipment, Including Heavy (Proper Equipment Selection, Condition, and Use)

  Safe

  At Risk

  N/A

• 39. Hoses Inspected

  Safe

  At Risk

  N/A

• 40. Required Monitoring Equipment Calibrated & Used

  Safe

  At Risk

  N/A

• 41. Ladders Set up Correctly & Inspected

  Safe

  At Risk

  N/A

• 42. Right Tools for the Job are Available and in Good Condition - No Fixed Open Blade Knives (FOBKs)

  Safe

  At Risk

  N/A

• 43. Other (Specify)

Totals

• Total # Safe

• Total # At-Risk