Sample Completed By Safety Manager

The Safety Manger’s Hazard Report Form should describe the origin of the problem such as personal factors (the human factors of physical capabilities, attitude, mental, psychomotor, psychological), or job factors (training, design of equipment, work environment, personnel, and equipment). It would also report the lack of controls: Management dysfunction (lack of supervision, planning, organizing, directing, controlling, staffing, etc.). Below is a sample completed form.

1. Hazard: Backing vehicles without ground guide.

2. Reported By: John Jones, Truck Driver

3. Date: January 15, 1988.

4. Circumstances:
a. Evidence: Individuals observed backing vehicles without using ground guides in the
garage/maintenance area.
b. Consequences: Someone could be struck by a vehicle backing up or equipment
could be damaged.

5. Supplemental Data: The individual reported seeing this every time he was in the
maintenance area, even when people were available as ground guides. It was reported
that it happens with all the vehicles. He reports that people are always walking in front
of the garage opening and equipment is always lying around .

6. Safety Manager Analysis:a. Confirmation: Interviews conducted with other drivers confirm this practice.
Maintenance personnel attribute it to a lack of available people and time constraints.
b. Risk Analysis:
(1 ) Mishap Severity (L)
(2) Mishap Probability (F)
(3) Mishap Exposure (E)
c. Immediate Causes: Substandard practices – Failure to comply with established company procedures.
d. Basic Causes:
(1) Lack of awareness of consequences for not following established policies.
(2) Lack of awareness of danger involved.
(3) Lack of training in orientation program.
e. Lack of Controls:
(1 ) Lack of supervision by Maintenance Manager.
(2) Lack of correction by other employees.
(3) Failure of management to monitor standards.

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