Corresponding Permit to Work No.

Risk Assessment

Risk Assessment of: Ref:

Assessor(s): Date of Assessment:

Responsible Manager: Signature Date:

Description of activity:

Description of equipment:

Overall Assessment of Risk (using ISLA LPG Risk Assessment Matrix): High Medium Low
Action needed: (inc responsible party and close out target)

Comment (if any):

Form – Risk Assessment Version 0 Page 1 of 4

Hazard Analysis Worksheet (For Assessment ref: )
Hazards & Risks Those at Risk Controls in place Risk Those Responsible Recommendations
What hazards and risks are What measures are See RAM below
Who will be affected by the Who is responsible to
associated with the task? These required to eliminate or for probable
hazards? Employees and any ensure that these
must be identified before the job is control the hazards to an consequence and
others in the area. measures are put in place?
carried out. acceptable level? likelihood

Form – Risk Assessment Version 0 Page 2 of 4

Non exhaustive list of hazard categories

1. Electricity 10. High Pressure 19. Extremes of temperature 28. Other (specify)
2. Noise 11. Explosión 20. Confined spaces
3. Lasers 12. Fire 21. Working environment
4. Radiation 13. Gas vapour release 22. Manual Handling
23. Gravity (height or above
5. Vacuum 14. Toxic chemicals
excavations)
6. Legionella 15. Flammable substances 24. Moving vehicles
7. Wiels disease 16. Hazards to eyes 25. Cleaning devices
8. Other Biological (specify) 17. Hand tools 26. Slips, Trips & Falls
9. Psychological hazards 18. Dangerous machinery 27. Environmental impact

When conducting a risk assessment:

 The assessment should be carried out in good time prior to the relevant decision being made
 When a specific assessment is needed then such an assessment, rather than a generic assessment should be made
 The risk from each activity should be considered
 A team of people or employees with practical knowledge of the process/activity being assessed should be used as appropriate
 Consultants should be used where necessary
 All the hazards associated with a particular activity should be considered
 Hazards and risk controls should be linked
 The results of the assessment should be properly used.

Form – Risk Assessment Version 0 Page 3 of 4

 Select the realistic worst case outcome
and the likelihood of it happening -
Enter an X in the box
Likelihood Categories
A Improbable OR Never Heard of in Industry.
B Possible OR Heard of in Industry.
C Has happened more than once per year in the LPG industry
D Has happened at the location or more than once per year in the Company
E Has happened more than once per year at the Location

POTENTIAL CONSEQUENCE (OUTCOME) LIKELIHOOD OF POTENTIAL

CONSEQUENCE OCCURING
Injury or Property Environmental Reputation A B C D E
Health Effect Damage Damage Damage
No Health effect No Damage No Effect No Impact
0
or injury
Slight Health Slight <$10K Slight effect Slight - Impact Low
1
effect/injury No disruption

Minor Health Minor $10K - Minor effect Minor/ Limited/

2
effect/injury $100K Local impact
Brief disruption
Major Health Local $100K- Localised effect Considerable
3 Med.
effect/injury $1M impact -
Partial shutdown
PTD or 1-3 Major $1M- Major effect Major impact High
4
Fatalities $10M
Partial
operational loss
Multiple Extensive Massive effect Massive/
5
fatalities >$10M International
Substantial/total impact -
loss
Permanent Total Disability

Form – Risk Assessment Version 0 Page 4 of 4