TVA - Safety Coaching Checklist

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• LOCATION:

• DATE & TIME OF OBSERVATION:

  Date

• TYPE OF WORK BEING OBSERVED:

• NUMBER OF PEOPLE BEING OBSERVED:

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 19 20 >20

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 19
  • 20
  • >20

• EQUIPMENT BEING WORKED ON:

• NAME OF SCV COACH:

• WAS A PRE-JOB BRIEFING CONDUCTED?

  Yes

  No

  N/A

• WAS THE 2-MINUTE RULE USED TO IDENTIFY WORK PLACE HAZARDS DURING YOUR OBSERVATION?

  Yes

  No

  N/A

• WAS "EYES ON PATH" USED DURING YOUR ONSERVATION?

  Yes

  No

  N/A

CATEGORY A (Adequacy of personal protective equipment)

• Eyes & Face

  Safe

  At Risk

  N/A

• Ears

  Safe

  At Risk

  N/A

• Head

  Safe

  At Risk

  N/A

• Hands & Arms

  Safe

  At Risk

  N/A

• Feet & Legs

  Safe

  At Risk

  N/A

• Respiratory System

  Safe

  At Risk

  N/A

• Trunck

  Safe

  At Risk

  N/A

• Arc Flash PPE

  Safe

  At Risk

  N/A

CATEGORY B (Positions of people)

• Striking Against and/or Struck By

  Safe

  At Risk

  N/A

• Being off balance

  Safe

  At Risk

  N/A

• Being caught between (pinch points)

  Safe

  At Risk

  N/A

• Falling

  Safe

  At Risk

  N/A

• Riding on Mobile Equipment

  Safe

  At Risk

  N/A

• Electrical Current contact

  Safe

  At Risk

  N/A

• Inhaling / absorbing material

  Safe

  At Risk

  N/A

• Overexertion

  Safe

  At Risk

  N/A

• Repetitive body motions

  Safe

  At Risk

  N/A

CATEGORY C (Are Reactions of people appropriate)

• Adjusting PPE

  Safe

  At Risk

  N/A

• Changing Positions

  Safe

  At Risk

  N/A

• Rearranging Job

  Safe

  At Risk

  N/A

• Stopping Job

  Safe

  At Risk

  N/A

• Attaching Grounds

  Safe

  At Risk

  N/A

• Exposure to Moving Equipment

  Safe

  At Risk

  N/A

• Changing Tools

  Safe

  At Risk

  N/A

• Hurrying

  Safe

  At Risk

  N/A

CATEGORY D (Tools & Equipment)

• Right for Job

  Safe

  At Risk

  N/A

• Used correctly

  Safe

  At Risk

  N/A

• Carried and Stored properly

  Safe

  At Risk

  N/A

• In Safe Condition

  Safe

  At Risk

  N/A

• Seat Belt In Use

  Safe

  At Risk

  N/A

• Barricades and/or Warning Lights

  Safe

  At Risk

  N/A

• Chokes / Restraints properly used

  Safe

  At Risk

  N/A

• Inspection Color Code present and correct

  Safe

  At Risk

  N/A

• Mobile Equipment Operational Requirements

  Safe

  At Risk

  N/A

CATEGORY E (Procedures)

• Is standard practice adequate for Job

  Safe

  At Risk

  N/A

• Is standard practice established

  Safe

  At Risk

  N/A

• Is standard practice being maintained

  Safe

  At Risk

  N/A

• Is Electrical Clearance proper

  Safe

  At Risk

  N/A

• Is Fire Watch adequate

  Safe

  At Risk

  N/A

• Properly briefed at Job / Shift briefing

  Safe

  At Risk

  N/A

• Are Clearance Boundaries evaluated

  Safe

  At Risk

  N/A

• Live-Dead-Live Checks utilized to verify absence of energy

  Safe

  At Risk

  N/A

CATEGORY F (Orderliness)

• Standard established (including JSA)

  Safe

  At Risk

  N/A

• Standards understood

  Safe

  At Risk

  N/A

• Passageways unobstructed

  Safe

  At Risk

  N/A

• Tools & Materials organized

  Safe

  At Risk

  N/A

• Stair platform unobstructed

  Safe

  At Risk

  N/A

• Housekeeping / Appearance adequate

  Safe

  At Risk

  N/A

• FME Standards Maintained

  Safe

  At Risk

  N/A

• Absence of any oil or slip hazard

  Safe

  At Risk

  N/A

OBSERVATIONS DISCUSSED WITH EMPLOYEES

• Category:

  Select A B C D E F None

  • A
  • B
  • C
  • D
  • E
  • F
  • None

• Observation:

• Category

  Select A B C D E F None

  • A
  • B
  • C
  • D
  • E
  • F
  • None

• Observation:

• Category

  Select A B C D E F None

  • A
  • B
  • C
  • D
  • E
  • F
  • None

• Observation:

• Category:

  Select A B C D E F None

  • A
  • B
  • C
  • D
  • E
  • F
  • None

• Observation:

EMPLOYEE FEEDBACK AND SUGGESTIONS

• Referred to Management Team:

  YES

  NO

  OTHER

• Feedback / Suggestion:

• Referred to Management Team:

  YES

  NO

  OTHER

• Feedback / Suggestion:

• Referred to Management Team:

  YES

  NO

  OTHER

• Feedback / Suggestion:

• Referred to Management Team:

  YES

  NO

  OTHER

• Feedback / Suggestion:

• ( Failure to Coach "At-Risk" behavior implies acceptance. ) . . . . . . . . . . . TVA 202018 [06-22-2010]