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Checklist: Behavior-based Safety Template

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6 minutes, 13 seconds read

BEHAVIOR-BASED SAFETY CHECKLIST TEMPLATE

 

At-Risk BARRIERs

  1. Training Issue, Unfamiliar – never trained, unqualified, too long since training, unusual task.
  2. Management Pressure / System – time constraints, hurry, priority, poor job coordination.
  3. Apathy, Insignificant – don’t care, unimportant.
  4. Facility and Equipment Condition – design, modification or deterioration contributing to at-risk condition or behavior.
  5. Disagreement on At-Risk Practices – cannot agree that an at-risk condition or behavior exists.
  6. Personal Factors or Distractions – not thinking, mind not on the task at hand, preoccupied, self imposed pressure.
  7. Accepted Culture or Peer Pressure – doing the wrong thing because our peers do, going along with the crowd, rather not “rock the boat”.
  8. Environment Related – affected by weather, insects, wildlife.

 

Critical Behavior Elements

1.0 PPE

1.1 • Eye & Face Protection – wearing proper eye and face protection for the task (glasses, face shield, goggles).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

1.2 • Hand Protection – proper gloves (high voltage gloves, rubber gloves, gallant style).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

1.3 • Body Protection – proper protective clothing (acid suit, steam suit, rubber apron) including seat belts.

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

1.4 • Foot Protection – proper foot protection (safety shoes, boots).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

1.5 • Fall Protection – properly protected from falling when working where this hazard exits (safety harness, body harness, tie-offs).

Safe | At Risk | N/A

At-Risk BARRIER

YesNoN/A

 

1.6 • Hearing Protection – wearing proper hearing protection where the hazard exists (ear plugs, ear muffs).

Safe | At Risk | N/A

At-Risk BARRIER

YesNoN/A

 

1.7 • Head Protection – hard hat worn appropriately where hazard exists.

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

2.0 BODY USE and POSITION

2.1 • Line of Fire – worker is positioning his body to avoid injury by any moving hazards (reflected arcs, escaping steam, falling objects).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

2.2 • Lifting – proper lifting techniques (using legs, back straight, weight close to body, feet flat on floor, knees bent).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

2.3 • Pinch Point – aware of and avoid pinch points (pinch points blocked, maintaining body parts out of pinch points).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

2.4 • Awkward Position – proper body mechanics (over-extended, using legs not back when pulling).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

3.0 TOOLS and EQUIPMENT

3.1 • Tool Use / Selection – using the right tool for the job and using it properly (correct style wrench, opening only one drawer at time).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

3.2 • Condition – tools, even if correct for the job, must be in good condition (electrical cords properly insulated).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

3.3 • Position Parked – vehicle is left in the position which creates the least possibility of incident (back before parking).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

3.4 • Ergonomics (Design) – system / component designed to be user friendly, with the operator(s) in mind (accessible, low strain).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

4.0 EYES ON PATH / HANDS

4.1 • Eyes On Path – watching what you’re doing and where you’re going (looking for / being aware of hazards).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

4.2 • Eyes On Hands – aware of hand placement (watching where hands are placed during work or near hazard, not being distracted).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

4.3 • Ascending / Descending – proper climbing techniques on ladders/stairs, both portable and stationary (facing ladder, not skipping rungs or steps, hold onto railing).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

4.4 • Travel Path – non-hazardous route of travel, path of least potential incident (walking / driving around spills, barricades, rough terrain).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

4.5 • Travel Speed – rate of speed to minimize potential incidents based on environment, surroundings or changing conditions.

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 

5.0 PROCESS HAZARDS

5.1 • Lockouts / Tagouts – are workers protected from potential hazards (locks / tags / grounds applied or removed, lines depressurized).

Safe | At Risk | N/A

At-Risk BARRIER

  1. None
  2. Training Issue, Unfamiliar
  3. Management Pressure / System
  4. Apathy, Insignificant
  5. Facility & Equipment Condition
  6. Disagreement on At-Risk Practices
  7. Personal Factors or Distractions
  8. Accepted Culture / Peer Pressure
  9. Environment Related

 


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