Type
*
Select...
Chemical Hazard
Electrical Concern
Environmental Concern
Equipment Safety
Ergonomics Concern
Fire/Smoke Hazard
Housekeeping Concern
Near Miss
Radiation Hazard
Safety Concern
Safety Suggestion
Spill/Release
Unsafe Condition
Unusual Event
Wellness Suggestion
Cannot Select
Chemical Hazard
…involves a chemical hazard posing health or physical risks
Electrical Concern
...relates to electricity, loose or exposed wiring, damaged plugs or cords, batteries, circuit breakers, or electrical equipment labeling
Environmental Concern
…poses a hazard to the environment.
Equipment Safety
…involves equipment that is unsafe or not working properly.
Ergonomics Concern
…involves worker or employee fatigue or discomfort such as caused by improper equipment/job/workstation design, setup or use
Fire/Smoke Hazard
…is a hazard that may result in smoke, sparks, or flames.
Housekeeping Concern
…relates to proper maintenance of your work area or site.
Near Miss
…is an event that could have caused a serious injury or illness, but did not in actuality. For example: Someone trips over an extension cord in a hallway but doesn't fall.
Radiation Hazard
…poses a potential hazard to personnel or the environment from exposure to or release of ionizing radiation
Safety Concern
…poses a risk to the safety of workers at your work area or site.
Safety Suggestion
...is a suggestion for Safety program improvement
Spill/Release
…poses a hazard from the unintended leak of a hazardous liquid or gas
Unsafe Condition
…is a condition that could cause an accident, I.e., an accident waiting to happen. For example, water or other material(s) on the floor that could cause a trip or fall.
Unusual Event
…is a rare event outside the norm of the routine work area or site operations.
Wellness Suggestion
A suggestion for Employee Health & Wellness Program improvement
Cannot Select
...does not match one of the above Concern types. The person responsible for follow-up will assign a valid Concern type based on other details provided by you regarding this Concern
Process Safety Incident
Dept
*
Date
*
Time
Building
Not Assigned
Shift
*
First
Second
Third
Fourth
Fifth
Day
Observer(s)
Core Activity
*
Asbestos Removal
Blending
Brazing and Welding
Cafeteria Operations
Chemical Operations
Chemical Processing
Chemical Use & Handling
Compounding
Confined Space Entry
Construction
Customer Assistance
Demolition
Equipment De-installation
Equipment Installation
Flight Operations
Housekeeping
Inspecting
Laboratory Operations
Ladder Operations
Machining
Maintenance and Repair
Manual Assembly and Disassembly
Manual Material Handling
Manufacturing Equipment Operation
Motor Vehicle Operations
Non-Specific Site Activity
Office Work
Powered Material Handling (Forktruck)
Product Testing & Quality Control Activities
Railyard Operations
Resident Assistance
Security/Emergency Response Operations
Shipping/Receiving
Surface Coating
Surface Coating Application
Surface Coating Removal
Travel
Waste Management
At risk behavior/Condition
Select...
Three point of contact
Did the observee and human assistant use the fixture handles to move a fixture greater than 40lbs?
Eyes On Path Task
Eyes On Task/Hands
Other
Pushing and Pulling
Safety Zone
Speed/Rate of Work
Three point of contact
Using Pro-Back procedures
Did the observee insure surrounding areas were free of glare from the welding arc?
Did the observee keep hand(s) out of the danger zone (pinched) during tube bending?
Did the observee use a proper eye shield?
Did the observee use the proper tools and methods to remove any fixture parts?
Did the observee use the safety hooks where applicable?
Hands/Arms
Lifting, Bending, Twisting
Overexertion - force/stress
Pushing and Pulling
Repetitive Motion
Properly Labeled
Keeps lids on containers
Only has what is needed in work area (no excess chemicals)
Spills - prompt cleanup
Stores chemicals properly
Area clear of non essential personnel
Attendant observing entrants
Completed confined space permit posted
Initial and ongoing monitoring conducted
Use of buddy system
Looking in the direction of travel
Did the observee wear hearing protection in hearing protected areas
Housekeeping
Other
Storage
Uses only approved chemicals for handwipe cleaning of aircraft engine parts.
Walking/Working Surfaces
Adequate lighting for task used
Avoids continuous or high intensity hand/arm or whole body vibration
Avoids excessive/frequent twisting
Avoids excessive/prolonged reaching
Avoids forcing equipment/part
Avoids Overexertion - pushing/pulling
Avoids prolonged bending
Avoids prolonged contact with hard edges and surfaces
Avoids prolonged kneeling on hard surfaces
Avoids prolonged periods of working overhead
Avoids using excessive force
Avoids working too far away
Awkward Body Position
Did the observee use proper lifting techniques, including using mechanical or human assistance?
Did the observee use the proper tools and methods to remove any fixture parts?
Eyes On Task/Hands
Grip/Force
Hand motion - avoids excessive gripping
Hand motion - avoids excessive pinching
Hand motion - avoids excessive pounding
Lifting, Bending, Twisting
Other
Overexertion - force/stress
Posture - hips and legs in neutral posture
Posture - neck and back in neutral posture
Posture - wrists and arms in neutral posture
Regular task rotation or changes in body position
Repetitive Motion
Takes regular breaks
Eyes on path when walking/moving
Eyes on work/task
Work not rushed
Did the observee wear safety glasses with side shields AND a face shield or goggles when needed?
Did the observee wear steel toed shoes?
Did the observee and human assistant use the fixture handles to move a fixture greater than 40lbs?
Did the observee place any loose parts, not secured down, in the parts box mounted to each fixture?
Did the observee secure all parts to the fixture prior to placing back on cart or fixture?
Did the observee use the proper tools and methods to remove any fixture parts?
Did the observee keep hand(s) out of the danger zone (pinched) during tube bending?
Did the observee place any loose parts, not secured down, in the parts box mounted to each fixture?
Inspection Checklist
Speed/Rate of Work
Three point of contact
Did the observee clear the area around the weld bench of flammable and combustible materials?
Fall protection
Fork Truck Manuvers
Horn Usage
Load Capacity
Passing
Pre-shift Inspections
Right of Way
Body parts inside cab of fork truck
Drive at safe speed
Forks not moved while vehicle is in motion
Inspection completed on forklift
Load not obstructing view - correct height
Load stable and secure
Proper signals used for forklift/other vehicle operations
Use of horn/mirrors when backing up
Wearing safety/seat belt
Ascending and Descending
Did the observee place any loose parts, not secured down, in the parts box mounted to each fixture?
Fixturing
Three point of contact
Did the observee place hand(s) in the danger zone of getting cuts from chips?
Did the observee place hand(s) in the danger zone of getting pinched in pinch point areas?
Did the observee use hand(s) as a fixture?
Did the observee use hand(s) as a tool?
Did the observee wear appropriate hand(s) PPE (e.g., gloves, gloves with long sleeves) for the task?
hands too close to moving parts
Confined Space Permits
Fall protection exposures
Hot Work Permits
Lifting Materials greater than 500 pounds
Lock Out Tag Out (LOTO) placed on equipment taken out of service for maintenance.
Assistant uses proper protection for eyes
Completed hot work permit posted
Fire x kept in area
Hot work - care taken with sparks avoid combustibles
Hot work - fire watch in place
Hot work - use of helmets or other appropriate eye/face protection
Hot work - use of shields
Use of welding gloves and other protective clothing
Aisle kept clear
Cleanup of debris
Is work area clean and orderly?
Parts/equipment not leaning
Parts/equipment stacked squarely and stable
Proper storage of equipment and tools
Replace/install barricades
Did the employee re-Job Brief after the job task changed?
Employee to Employee Job Briefing
Lighting job briefing
Pinch points job briefing
Red zone job briefing
Self Job Briefing
Supervisor to Employee Job Breifing
Suspended loads job briefings
Did the observee place any loose parts, not secured down, in the parts box mounted to each fixture?
Guards
LOTO
Other
Did the observee and human assistant use the fixture handles to move a fixture greater than 40lbs?
Correct rigging used
Daily inspection on crane completed
Inspects rigging prior to use
Load not left unattended
Maintains safe distance from load
Operate crane at safe speed
Proper signals used for crane operations
Warning verbal or other prior to load being lifted and moved
Body Part not near Pinch Point
Body Parts not in Danger Zone
Body position out of danger zone
Body position out of line of fire (spraying, striking)
Staying clear of coworkers activities and tasks
Tool in good condition
Barricades put up
Completed live electrical work permit posted
Maintains safe distance from live parts
Wears proper PPE for live electrical work
Energy isolation verified
Locks applied
People working in area notified of LOTO
Tags completed and applied
Work area cleared and checked before LOTO released
Did the observee use the safety hooks where applicable?
Improper Tool Use
Inspection Checklist
Lifting, Bending, Twisting
Part Manipulation
Using Pro-Back procedures
Adjusting height on adjustable carts
Proper lifting - assistance for heavier loads
Proper lifting - back straight
Proper lifting - load close to body
Proper lifting - load not excessive
Proper lifting - use of legs not back
Push instead of pull
Pushing/pulling - balanced body position
Pushing/Pulling - push with legs
Rack loading and unloading heavier parts on lower shelves
Rack loading and unloading not lifting excessive weight
Using carts correctly
Following proper procedures
Are body parts in a pinch point situation?
Are correct methods being used for lifting and manual exertion?
Are employees handling material over 50 lbs.?
Awkward Body Position
Did the observee use proper lifting techniques, including using mechanical or human assistance?
Did the observee wear safety glasses with side shields AND a face shield or goggles when needed?
Did the observee wear steel toed shoes?
Manual lifting
Pushing or pulling
Red zones
Suspended loads
Did the observee use a proper eye shield?
Foot
Gloved in good condition
Hands/Arms
Head
Hearing
Is the correct PPE being used?
Other
Proper gloves worn
Respirator in good condition and clean
Respiratory
Was the employee wearing gloves at the proper time?
Was the employee wearing the appropriate glove for the job?
Wearing coats, aprons, coveralls when required
Wearing face shield when required
Wearing hard hats/bump caps where required
Wearing hearing protection when required
Wearing proper eye protection
Wearing respirator when required
Wearing Safety glasses with side shields
Are 3 points of contact maintained while performing the job?
deburr
Did the observee wear hearing protection in hearing protected areas
Hot Work
Is a standard practice established for the Job or JSA?
Is blue flag derail protection in place as needed?
Is practice being maintained?
Job procedures are acceptable
Job procedures are followed
Job procedures are understood
LOTO
Other
Permits
Properly dispose of handwipe cleaning materials when not in use.
Did behaviors change due to being observed?
Right tool used for the job?
Tool used correctly?
Tools in satisfactory condition?
Checks to see if guards are in place and functional
Correct tool for task
Pre job inspection
Tool used as intended
Tools in satisfactory condition?
Tools secured properly
Did the observee keep hand(s) out of the danger zone (pinched) during tube bending?
Did the observee use the safety hooks where applicable?
Observes barricades and warnings
Stair use - use of handrail
Did the observee clear the area around the weld bench of flammable and combustible materials?
Did the observee close the curtains before welding or brazing?
Did the observee insure surrounding areas were free of glare from the welding arc?
Did the observee use a proper eye shield?
100% tie off
elevated equipment in good condition
Ladder secured
Maintains three points of contact when climbing
selection of proper equipment for working in elevated locations
Tie off to secure anchor
Wearing fall protection harness
Working below top step
Works facing forward
Drink fluids
Take breaks - seek shelter
Are fixtures properly secured in Stanley Stacker or on cart before and after use?
Was the fixture secured properly to a hoist, if used for moving the fixture?
Were the cabinets in the operation properly lagged to the floor?
Are machine guards in place and used properly, where applicable in operations?
Was the operation free from any blocked disconnects? 36 in front and on both sides, see note:
Were all electrical panels in the operation closed?
Was the operation free from any blocked disconnects? 36 in front and on both sides, see note:
Were all electrical panels in the operation closed?
Were all knock out plates not being utilized on electrical boxes in the operation capped?
If maintenance is being performed on any equipment in the operation, is it locked and tagged out?
Was the operations housekeeping tidy?
Are fixtures properly secured in Stanley Stacker or on cart before and after use?
Was the fixture secured properly to a hoist, if used for moving the fixture?
Was the operation free of any SLIP hazards?
Are the HAZCOM labels visible and in good condition?
Was the operation free of any OVERHEAD hazards?
Was the operation free of any SLIP hazards?
Was the operation free of any TRIP hazards?
Was the operations housekeeping tidy?
Were flammable chemicals stored in the flammable cabinet when not in use during that specific shift?
Does the LOTO tag have the responsible persons name on it?
Was the operation free of any OVERHEAD hazards?
Are walkways free of clutter.
Electrical panels not blocked.
Exits are not obstructed.
Are fixtures properly secured in Stanley Stacker or on cart before and after use?
Are the HAZCOM labels visible and in good condition?
Are LOTO procedures listed on each machine in the operation?
Does the LOTO tag have the responsible persons name on it?
If maintenance is being performed on any equipment in the operation, is it locked and tagged out?
Are machine guards in place and used properly, where applicable in operations?
Are fixtures properly secured in Stanley Stacker or on cart before and after use?
Does the LOTO tag have the responsible persons name on it?
Was the operation free of any SLIP hazards?
Was the fixture secured properly to a hoist, if used for moving the fixture?
Were all knock out plates not being utilized on electrical boxes in the operation capped?
If maintenance is being performed on any equipment in the operation, is it locked and tagged out?
Is the material on shelves stored safely and not exceeding the shelf load capacity?
Is the weight of the material clearly identified?
Was the operation free from any blocked disconnects? 36 in front and on both sides, see note:
Were flammable chemicals stored in the flammable cabinet when not in use during that specific shift?
Were the cabinets in the operation properly lagged to the floor?
Were there visible weight limit labels on the shelving where parts/supplies are stored?
Is the certification for the tool being maintained?
Immediate/Direct Cause
Description
*
Recommendations for Follow-up
Contact Information
Equipment
Manage
Multiple CC