WHAT WHY PAKAT Reported by

(CODE) (CODE) Plan*Assess*Keep Looking*Agree Action*Take Note Roeland Uytdewilligen

FINDINGS Date
D 10 Air compressor making a lot of noise nearby PMT April 15th, 2013
office, hardly impossible to work (construction work
toilet area).

Follow-up required
DISCUSSION AND AGREED ACTION Action Party
Yes No

Target Date
FOLLOW-UP / REMARKS

WHAT Hazardous act / condition did you see ? WHY did the hazardous act / conditions occur?

PPE NOT AWARE

A Head protection not worn 1) Not informed
B Eye protection not worn 2) Language problem
C Face protection not worn 3) Not reading permit
D Ear protection not worn 4) Wrong interpretation of risk
E Protective clothing not worn 5) Wrong instruction
F Leg/Feet protection not worn 6) No procedure
G Hand protection not worn 7) Lack of HSE coaching / training
H PPE in bad condition 8) Behavior & Attitude (intentionally)
I Wrong PPE for the job AWARE
J Substandard PPE 9) Negligence
K PPE not worn properly 10) Working condition
L Respiratory protection not worn 11) Working layout
M Body protection not worn 12) The design of equipment / tools
TOOLS / EQUIPMENT 13) Work habits
N Wrong tool for the job 14) Lack of skill
O Tools in bad condition 15) Time pressure
P Tools not inspected 16) Not requested
Q Misuse 17) Physical limitation
R Uncertified tools 18) Not supplied / available
MATERIAL HANDLING 19) Lack of ownership
S Too heavy for manual lifting 20) Behavior & Attitude (not intentionally)
T Wrong mechanical manual lifting
U Lifting tool not inspected PERMIT / PROCEDURES
V Chemicals not properly handled MM Work without permission
W Waste not properly handled NN Wrong permit
POSITIONS OF PEOPLE OO Procedures/Standards not followed
X In danger of struck by PP Wrong instruction on permit
Y In danger of striking against QQ Permit procedures not followed
Z In danger of caught by RR Inadequate HIP
AA In danger of fall / slip / trip SS Toolbox not given
BB In danger of electrocution VEHICLE
CC In danger of burnt TT Driving recklessly
HOUSEKEEPING UU Not wearing seat belt
DD Access obstructed VV Road traffic violation – e.g. speeding, no entry, etc
EE Tools / materials disorganized XX Not inspected for compliance
FF Poor / Improper roping off YY Vehicle defects
GG Accumulation of rubbish POSITIVE CARDS
ENVIRONMENT ZZ Compliance
HH Water being polluted AAA Behavior & Attitude
II Air being polluted
JJ Too much noise
KK Soil being polluted
LL Poor illumination

N.B. If there is no unsafe act / condition during a visit, congratulate the person involved and put your remarks on the card. Revision: October 2012