Company: Site Incharge Signature: HSE Coordinator:

Date: Date: Date:

Activity :

Location:

RISK RATING
NO. JOB STEPS HAZARD (S) HAZARD EFFECTS TOTAL M.H.L MITIGATION R.R
Likelihood SEVERITY

FIRST TIME ON TASK DATE (VALID FOR 5 WORK DAYS) CONDITION

NO. NAME EXPERIENCE TOOLS USED
YES NO GOOD FAULTY
 HAZARD CHECKLIST
NOTE: CHECK OFF HAZARDS AND OTHER REQUIREMENTS REVIEWED AS PART OF THIS WORK PLAN
HAZARDS
Fire & Explosion Toxicity Mechanical Energy Effluents
Flammable Material H2S Kinetic Emissions
Explosive (perf. Guns.TNT etc) O2 Deficiency Equipment Dusts
Natural (e.g. forest fires) Carbon Monoxide Suspended / Potential Spills
Vapors/liquids Fumes / Vapors Trenching/Excavation Wastes
Flammable atmosphere Absorption Working at Heights Weather Conditions
Ignition Sources Chemical Slips /Trips Temperature
Welding Process People Visibility
Spark causing tools/motors Treating chemicals Physical Energy Site Conditions
Internal combustion engines Corrosives Noise/Light exposures Precipitation
Diesel Positive Air Shutoff Oxidizer/reactive Electrical Wind direction / speed
Pilot Lights Test Fluids Electromagnetic Biological
Static electricity Paints / Sealers etc. Pressurized Wildlife /animals
Identified/Controlled Asbestos Radiation (x-ray) Insects
MSDSs NORMS Bacteria/Molds/Viruses
Body fluids
RISK CONTROLS

PROCEDURES Confined Space Entry Other Overhead Power Lines

Emergency Response
Emergency Phone List
Site First Aid Plan
Alarms/Conditions
Egress/Muster
Rescue Procedures & /Equip
Plan Review & Exercise
Critical Task Procedures
Reviewed
Copy Attached
Working Alone
Company Name
Contractor
Ground Disturbance
GD Checklist Completed
Work / Rescue plan Gas Test Required Identified / Clearances
Trenching/Excavation Intermittent _______min. Hazards Related to Other Work
Work/Rescue Plan Continuous Underway __ No __Yes, Specify_____
Isolation Gas Detection Equipment Planned __No __ Yes, Specify_______
Process/Pressure Bump Tested Other___________
Bleeds & Drains Building Entry Miscellaneous
Flare System Purging/Venting/Flaring/Cleaning Lock out / Tag out
Electrical Vessels Depressuring / Venting
Cathodic protection Lines Grounding / Bonding
Mechanical Tanks/Incinerators/Flare Stacks Smoking Rules I Area
Spacing / Clearances Other Ladders / Scaffolds
Fired Equipment Hazardous Areas Fall Protection
Site Hazards Identified Buddy System
Flares/Vents/Storage Vessels Barricaded / Signed Towing Procedures
Safe Vehicle Operation Buried Facilities / Pipelines / Waste disposal
Vehicle back up beepers Conduits / Electrical Other —

TRAINING Competency for Task Fall Protection WORKPLACE

Safety Orientation
Health & Safety Rules Reviewed
Orientation
Contractor
Company Name
Mobile Equipment, Loaders,
Cranes, Forklifts. etc
Rigging and slinging High Angle Rescue Refusal of Unsafe Work
First Aid / CPR Confined Space Entry & Rescue Workplace Violence
TDG Ground Disturbance NO FEAR Workplace
WHMIS Line Locating ALL incidents reported
H2S B0P / Well Control Hazard Identification Cards
Basic Fire Training All Certifications On Site
Gas Detection Equipment Use Other

EQUIPMENT_REQUIRED Breathing Apparatus Communication Equipment Barricades

PPE Appropriate for Task SCABA (Intrinsically Safe) Miscellaneous
 Monitors (LEL. H2S, 02, CO) SABA / Air Trailer Intrinsically Safe Cords, Lights, Welding / Splash Shield
Other _______________ Respirator Flashlights, Equipment Ventilators / Air Moving Equip.
First Aid Kit / Equipment Safety / Fire Watch/Stand by Fall Protection Equipment Air Hood
Eye / Skin Wash / Shower Personnel Assigned to _______ Fall Arrest Devices Watertight Equipment
Shower Truck Ignition Equip./ Flare Gun) Harness Spill / Pollution Control Equip.
Emergency Transport Vehicle Firefly Signaling Device Equipment Spacing Tag Lines
Ambulance & EMT Fire Suppression Other Sewage Containment Equip.
Auto Resuscitator Portable Rescue Equipment Garbage/Recycle Bins
Auto Defibrillator Wheeled Ladders / Platforms / Scaffolds Supplemental Lighting
Fire Truck(s) Warning Signs Other

FOR RISK ASSESSMENTS:

1. Review generic hazards list above (memory tickler). Identify only those hazards related to the task to be completed.
2. Run each hazard identified through the risk matrix process to determine the risk level. Put a mark/write on the matrix.
3. Check off only those hazards that indicate medium to high risk (yellow to red on the matrix). There should be very few (1 to 5). Example - Confined space (2) - toxic atmosphere
and/or restricted ingress/egress. If you have more than 5, you are probably doing a site orientation, not a work permit.
4. List these hazards in Job specific terms in the Work Permit Hazard column on page 1.
5. For these identified hazards, check off all appropriate (task specific) risk control measures in the Procedures, Training and Equipment required sections of the Hazards Checklist.
6. For each hazard identified in the first column on page 1. Document specific risk controls, safety precautions, work plans (using the items checked off in the Procedures, Training,
and Equipment required columns as a reference / memory tickler) in the second column on page one.
7. Where work plans/procedures are available, you need only reference them as being reviewed. Example - Reviewed contractor “xyz’s” procedure for ‘xxxx” and assigned work
specific tasks.
8. Where work plans do not exist, then they need to be developed prior to commencing work. Document on Work Permit, or as an attachment to the permit based on complexity.