Behavior Based Safety Observation Form — Pipe Pros, LLC

Behavior Based Safety Observation Form

This form is to be used to document any and all incidents, near misses, and/or observations (positive and negative) that occurs while on duty or in the field for TRK Enterprises Inc. dba Pipe Pros.

Region*
Select your location
Personal Information
Name (Employee filling out form.)*
First Last
Date*
MM slash DD slash YYYY
TRK/Pipe Pros Employee(s) Involved*
Supervisor*
Customer*
Rig*
Event Information
Date of event
MM slash DD slash YYYY
Time event occurred

: Hours

Minutes

AM/PM
Where did the event occur?*
- Location
- Road
- Shop
What was the type of event?*
- First Aid Only
- Medical Treatment
- Motor Vehicle Accident
- Near Miss
- Equipment Damage
- Environmental Impact
- General Observation
- Potential Hazard
- Positive Observation
What was the nature or potential nature of the event?*
- Cut/Abrasion
- Bruise/Contusion
- Sprain
- Heat Exhaustion
- Hypothermia/Frost Bite
- Smashed/Crushed
- Burn
- Irritation
- Hazardous Material Release
- Foreign Body
- Insect Sting
- Muscle Strain
- Motor Vehicle Damage
- Equipment Damage
- Concussion
- Positive Recognition
- Multiple Potential
- Impact to Profitability
- N/A
What was the location of the injury/potential injury/damage?*
- Head
- Neck
- Back
- Arm
- Hand
- Leg
- Ankle
- Foot
- Fingers
- Toes
- Shoulder
- Knee
- Motor Vehicle Damage
- Equipment Damage
- Eye
- Enviornmental Damage
- High Multiple Potential
- Impact to Reputation
What was the cause of the event?*
- Caught In/Under
- Illness
- Fall
- Chemical Exposure
- Improper Movement
- Spill
- Slip/Trip
- Struck By/Against
- Equipment Damage
- Motor Vehicle Accident
- Line of Fire
- Missing Equipment
- Weather Exposure
- Caught/Snagged On
- Body Position
- Not Following Policy
- N/A
Who caused the event? (Please mark all that apply.)*
- TRK/Pipe Pros Employee
- TRK/Pipe Pros SSE
- 3rd Party
- 3rd Party SSE
- Faulty/Defective Equipment
- 3rd Party Faulty/Defective Equipment
- Environmental
What type of work was being performed at the time?*
- Rigging Up Equipment
- Rigging Down Equipment
- Tallying Pipe
- Driving to/from Location
- Driving on Location
- Pulling Thread Protectors
- Rolling Pipe
- Cleaning Casing
- Unloading Casing
- Moving Casing on Location
- Stabbing Pipe
- Tailing in Casing at the V-Door
- Pulling/Setting Slips
- Running Tongs
- Filling String
- Climbing Stairs to the Rig
- Getting into/out of Truck
- Loading Equipment
- Walking
- Latching Elevators
- Using Cap Buster
- Blowing Out Casing
- Drifting
- Pulling Tongs onto Casing
- Unloading Equipment
- Throwing Backups
What was the initial root cause of the event? (Please mark all that apply.)*
- Rushing
- Distraction
- Complacency
- Weather
- Training
- Improper Use/Lack of PPE
- Stop Work Authority Initiated
- Proper Use of PPE
- Good Catch (Example: caught missing keepers)
- Fatigue
- Frustration
- Improper Tool
ACCIDENT ANALYSIS (Describe in detail where applicable)
Please give a detailed description of the event.*
Please give a brief description of the corrective measures that were taken.*
Email
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