Safety Behavior Observation Form

Marvel 2 Project

Observer Name : Date :

Company : Location :
Observed Activity :
Observation Description:

Hazard Classification
Unsafe Condition Unsafe Action
A. Tools / Equipment M. License / Authority / Permit
B. PPE Quality N. PPE Usage
C. Physical Hazard O. Work at Dangerous Area
D. Access Way / Work Space P. Work using Dangerous Equipment
E. Sign / Warning system Q. Dangerous Driving / Operating
F. Hazardous Material R. Incorrect Using Equipment
G. Material Storage S. Improper Handling Material
H. Housekeeping T. Littering / Untidy
I. Biological U. Failure to Warn and or Signing
J. Inadequate guard / barrier V. Not Ergonomic Position
K. Fire and Explosion Hazard W. Unfit Physical Condition
L. Weather X. Not Following Procedure
Agreed Immediate Action:

Respons:

Does the work being observed need to be stopped (SWA) Yes No

Severity Potential: No Harm Low Harm Medium Harm High Harm
Further Agreed Action:

Due Date:
Further Action PIC:
 Hazard Classification Code
Unsafe Condition Unsafe Action
Tools / Equipment / Machine / Property License / Authority / Permit
A Defect, improper, type, size, capacity, function, M Un-authorize to operate, not held license, expired
color, maintenance, etc. license, without permit to work
Personal Protective Equipment Usage
Personal Protective Equipment Quality
B N Wrong type, insufficient size, not wear, wear
Scratch, leak, broken, inadequate, dirty, etc
improperly, modification, etc.

Physical Hazard Work at Dangerous Area

C Illumination, noise, radiation, temperature, O Work at tip area, stay on radius equipment, walk
ventilation, vibration, humidity, air pressure, etc. on middle road, servicing equipment in operation

Access Way / Road / Work Space

Work using Dangerous Equipment
D Bumpy, muddy, narrow, slippery, hollow, blind P
Using Defect/improper equipment
spot, sloping, erosion, abrasion, etc
Sign / Warning system
Dangerous Driving / Operating
E Label, safety sign, traffic light, indicator, signal, Q
Over speed, distracted, not wear safety belt, etc
alarm, siren, horn, etc
Incorrect Using Equipment
Hazardous Material
F R Incorrect type, size, capacity, quantity, usage,
Chemical, fluid, gas, bulk
safety device
Improper Handling Material
Material Storage
G S Improper loading, stacking, lifting, overload, over
Tidiness, weight, design, stacking, unsecure
height, without tighten, unbalance, etc.
Housekeeping / Waste Management
Littering / Untidy
H Waste, drainage, cleanliness, sanitation, T
Mixing waste, improper placing waste
contamination, etc.
Psychosocial hazard
Biological
Horseplay, not focus, not serious, playful,
I Insect, mosquitos, fungi, snake, rat, cockroach, U
disparaging, prank, emotional, intimidation,
etc.
bullying, harassment.
Inadequate guard / barrier Not Ergonomic Position
J V
Handrail, fence, cover, barricade, cone, etc. Squat down, tiptoe, stand on one leg
Unfit Physical Condition
Fire and Explosion Hazard
K W Under Influence Alcohol, Drug, Cigarrete, Vape,
Electrical, fuel, flammable material, tank, etc.
Sick, Fatigue, etc.
Not Following Procedure
Weather
L X Violation of Policy, Standard, Procedure, Work
Lightning, thunderstorm, wind, rain, wave
Instruction, JHA, PTW, Practice
Severity Potential
No Harm No Potential to causing harm / damage
Low Harm May causing a First Aid Case / Minor Damage
Medium Harm May causing multiple First Aid Case / Lost Time Injury / Medium Damage
High Harm May causing major injuri/disabling/major damage/fatality
 Safety Behavior Observation Form
Marvel 2 Project

Nama Observer : Tanggal :

Perusahaan : Lokasi :
Aktivitas :
Deskripsi Observasi:

Klasifikasi Bahaya
A. Peralatan M. Lisensi/Otoritas/Izin
B. Kualitas APD N. Penggunaan APD
C. Bahaya Fisik O. Bekerja di Area Berbahaya
D. Jalur Akses / Area Kerja P. Bekerja menggunakan Alat Berbahaya
E. Sistem Peringatan / Rambu Q. Mengemudi Tidak Aman
F. Material Berbahaya R. Tidak benar saat memakai peralatan
G. Penyimpanan Material S. Penanganan material yang tidak benar
H. Housekeeping T. Membuang Sampah Sembarangan
I. Biologi U. Tidak memberi peringatan / rambu
J. Kurangnya guard / barrier V. Posisi kerja tidak ergonomis
K. Bahaya Api dan Ledakan W. Kondisi Fisik Tidak Fit
L. Cuaca X. Tidak Mengikuti Prosedur
Tindakan Langsung yang disetujui:

Respon:

Apakah Pekerjaan yang diamati perlu dihentikan? (SWA) Yes No

Potensi Cedera: No Harm Low Harm Medium Harm High Harm
Tindakan Lebih Lanjut yang disetujui:

Due Date:
Penanggungjawab Tindakan Lebih Lanjut:
 Kode Klasifikasi Bahaya
Kondisi Tidak Aman Tindakan Tidak Aman
Peralatan Lisensi/Otoritas/Izin
A Rusak, Tidak layak, tidak sesuai (jenis, ukuran, M Tidak memiliki otoritas/lisensi, lisensi kadaluarsa,
kapasitas, fungsi, dll) bekerja tanpa izin
Penggunaan Alat Pelindung Diri
Kualitas Alat Pelindung Diri
B N Tidak menggunakan,Tidak sesuai (Jenis, ukuran,
Rusak, retak, kotor, bocor, dll
fungsi, cara penggunaan dll)
Bahaya Fisik Bekerja di Area Berbahaya
Penerangan, kebisingan, radiasi, temperature, Bekerja diujung area, berada dalam radius kerja
C O
ventilaai, getaran, kelembaban, tekanan udara, alat, berjalan ditengah jalan, perbaikan alat
dll. dalam keadaan menyala
Jalur Akses / Area Kerja
Work using Dangerous Equipment
D Bumpy, muddy, narrow, slippery, hollow, blind P
Using Defect/improper equipment
spot, sloping, erosion, abrasion, etc
Sistem Peringatan / Rambu Mengemudi Tidak Aman
E Label, rambu keselamatan, lampu lalu lintas, Q Melebihi batas kecepatan, terganggu, tidak
sinyal, alarm, sirene, klakson, dll. menggunakan safety belt, dll.
Memakai peralatan tidak sesuai
Material Berbahaya
F R Tidak sesuai jenis, ukuran, kapasitas, kuantitas,
Bahan Kimia, Fluida, Gas, dll
cara penggunaan, dll.

Penanganan Material yang tidak benar

Penyimpanan Material
Proses tidak benar (Pemuatan, penumpukan,
G Kerapian, disain, berat, penumpukan, S
pengangkatan, dll), beban berlebih, tinggi
kesesuaian, dll.
berlebih, tidak seimbang
Housekeeping / Manajemen Limbah
Membuang sampah sembarangan
H Limbah, drainase, kebersihan, sanitasi, T
Meletakkan sampah tidak pada tempatnya
kontaminasi, dll.

Bahaya Biologi Bahaya Psikososial

I Serangga, nyamuk, jamus, ular, tikus, kecoa, U Bermain-main, tidak fokus, prank, bercanda
lebah, dll berlebihan, emosional, intimidasi, bullying, dll.

Kurangnya Pelindung atau barrier Posisi tidak ergonomis

J V
Handrail, pagar, penutup, barricade, cone, dll. Jongkok, berjinjit, berdiri dengan satu kaki, dll.
Kondisi Fisik Tidak Fit
Bahaya Api dan Ledakan
K W Dalam pengaruk alkohol, obat-obatan, sakit,
Listrik, Bahan Bakar, Bahan Mudah terbakar, dll.
kelelahan, dll.
Not Following Procedure
Cuaca
L X Violation of Policy, Standard, Procedure, Work
Petir, badai, angin kencang, hujan, dll.
Instruction, JHA, PTW, Practice
Severity Potential
No Harm Tidak ada potensi menyebabkan cedera/kerusakan
Low Harm Dapat menyebabkan satu kasus cedera ringan (P3K) / Kerusakan ringan
Medium Harm Dapat menyebabkan beberapa kasus P3K / Kerusakan menengah
High Harm Dapat menyebabkan cedera parah/kecacatan/meninggal/kerusakan besar
HAZARD OBSERVATION (HAZOB) REGISTER

No Observer Name Company Date/ Month/Year Location Observed Activity

HAZARD OBSERVATION (HAZOB) REGISTER

Description
HAZARD OBSERVATION (HAZOB) REGISTER

Immediate Action
HAZARD OBSERVATION (HAZOB) REGISTER

Further Action Suggestion Responsible Due Date Action status Severity Potential Unsafe Condition Code
C. Physical Hazard
HAZARD OBSERVATION (HAZOB) REGISTER

Unsafe Action Code

P. Work using Dangerous Equipment
N. Personal Protective Equipment Usage
T. Littering / Untidy
O. Work at Dangerous Area
Severity Potential Action Status Hazard Observation Classification Code
No Harm Closed A. Tools / Equipment / Machine / Property
Low Harm Outstanding B. Personal Protective Equipment Quality
Medium Harm Overdue C. Physical Hazard
High Harm D. Access Way / Road / Work Space
E. Sign / Warning system
F. Hazardous Material
G. Material Storage
H. Housekeeping / Waste Management
I. Biological
J. Inadequate guard / barrier
K. Fire and Explosion Hazard
L. Weather
 Unsafe Action Classification Code
M. License / Authority / Permit
N. Personal Protective Equipment Usage
O. Work at Dangerous Area
P. Work using Dangerous Equipment
Q. Dangerous Driving / Operating
R. Incorrect Using Equipment
S. Improper Handling Material / Cargo
T. Littering / Untidy
U. Failure to Warn and or Signing
V. Not Ergonomic Position
W. Unfit Physical Condition
X. Not Following Procedure