WESCOWEB
Hazard Observation
01 Hazard Observation V3
Name
*
Date
Site
NARM
RAWHIDE
CABALLO
Other
Site
Time
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Day of Shift
*
Day 1
Day 2
Day 3
Day 4
Day 5
Day 5+ (Overtime)
Day 5+ (Overtime)
This Was A
Near Miss
Incident
Hazard Observation
Type Of Incident
Vehicle
Personal
Site
Explosive
Other
Other
Type of Site Incident
Fire
Flood
Blizzard
Power Outage
Terrorism
Other
Other
Type of Explosive Incident
Flyrock
Misfire
Cut off
Spill
Fire
Loss
Theft
Other
Other
Type of Vehicle Incident
Backing
Pulling Forward
Turning
Other
Other
Number of People Involved
1
2
3
4
5 or More
Location
Pit
Ready Line
Haul Roads
Tower Location
Shop
Washbay
Other
Other
Tower Location
School Creek South
NARM North
East
West
Hopper Notch
Mains
Other
Other
Was Someone Injured?
Yes
No
Type of Injury
Slip, Trip, or Fall
Shocked
Struck by an Object
Caught-in/between
Cut
Back
Respiratory
Eye
Other
Other
Location of Injury
Head
Face
Eye
Neck
Shoulder
Arm
Wrist
Hand
Torso
Back
Hip
Groin
Leg
Ankle
Foot
Other
Other
Type of Treatment
None
First Aid
Medical
Other
Other
Was an Asset involved?
Yes
No
Asset Involved
Bulk Truck
Skidsteer
Pickup
Trailer
Power Washer
Forklift
Shop
Office
Tower
Drill
Other
Other
Was the Asset Damaged?
Yes
No
Was the Asset Damaged?
Yes
No
Was the Asset Damaged?
Yes
No
Area of Damage
Side
Front
Back
Door
Window
Wheel
Other
Other
Area of Damage
Window
Door
Side
Steps
Roof
Other
Other
Area of Damage
Legs
Valve
Steps
Catwalk
Life Line
Other
Other
SAFESTART States
*
Rushing
Frustration
Fatigue
Complacency
SAFESTART Critical Errors
*
Eyes not on Task
Mind not on Task
Line-of-Fire
Balance/Traction/Grip
Detailed Description
Apparent Cause(s)
*
Stuck against (running or bumping into something)
Struck by (Hit by moving object)
Fall from elevation to lower level
Fall on same level (slip and fall, trip over)
Caught in (pinch and nip points)
Caught on (Snagged, hung)
Caught between or under (crushed or amputated)
Contact with (electricity, heat, cold, radiation, chemical, noise, biological agents)
Abnormal Operation
Product contamination
Overstress, overexertion, ergonomic
Equipment failure
Environmental release
Immediate Action Taken
Suggestion
Employee’s Involved
Witnesses
Supervisor
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