RISK ASSESSMENT FORM / GENERAL WORK PERMIT

Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code

Preparation of Tools and

Application of proper
Equipment Such as:
positioning of body for
Installation & positioning
Manual Handling & Can cause a minor to manual handling activities.
of welding machines, Buddy 2x system/used of
Ergonomic Related serius injury to a Avoide over exertion of body S 3 2 II Con. 3 1 I
cable laying of welding mechanical techniques.
Hazard workers/ personnel movement and proper
cables & hoses and
wearing of necessary PPEs
stores tanks & pannel
Needed.
board on safe locations.

Wear appropriate hand

gloves with rubber/rubber
Cuts and Laceration
Sharp tools edges dotted to prevent hand cuts/ EL 3 2 II Con. 3 1 I
bruises
Lacerations or used leather
gloves if applicable

Proper Wearing of standard

Used of respiration if
Dust Respiratory Illness dust mask such as: KN-95/N- P 3 2 II Con. 3 1 I
needed
95

Strictly compliance at proper

wearing of skull guard with
chainstrap for head
protection on all identified low
Avulsion to medical
Low headed areas headed areas. Provide P&A 3 2 II
injury
proper illumination on site.
Provide safety signages on
all low headed areas and
familiarization of area

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 5 ) Tolerable RAC No. II ( 6 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code

Weather condition/ Heavy can cause illness on

Hauling of materials/ Divert all lifting activities on
Rain occur personnel.
Provide temporary shelter on site for minimal job task that cannot
all personnel being affected of Rain. affected by the strong winds &
Temporarily heavy rain occurs. Encourage
A 4 3 II Con 4 1 I
STOP all lifting activities while the personnel to wear proper PPEs
Lifting of materials using boom Swinging of load/ Property weather condition are not applicable for the expected weather
strong winds to proceed. conditions for wet & windy
truck damage
conditions.

Proper Barricade the affected area

and Provide spotter with equiped. Of
wistle/two way radio for proper
means of communications and Safety Provide proper trainings for
Struck by, Being hit by a sinages. drivers, operators,spotter. All
Moving Vehicle moving Vehicle, Fractured, Do not allowed other EN 5 3 III mobile vehicle must have a Con 5 1 II
LTI/ Fatality contractor/personnel to enter/ interfer warning device/back horn &
with the Barricaded affected area. revolving lights.
Only used desegnated
walkways for all workers & Being
aware of all moving Vehicle

Ensure that all lifting equipment are Personnel beng assigned on the
properly inspected and updated job task are knowlegable and
Equipment failure due to over
Can cause a minor to serius inspection tags & stickers. properly trained.
load/ Lack of inspection prior A 4 2 II Con 4 1 I
injury to a person assess the weight of load being lifted Supervision of a desegnated
to used
versus on the SWL of equipment safety officer and supervisor is a
being used. must

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 4 ) Tolerable RAC No. II ( 5 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code

failure of lifting eqipment.

Lifting of new diptube segment
using hoist
Falling of loads. Workers can cause personal injury/
being crushesd by moving
equipment. Operator
incompitence. Visual
impairment
check the swing radius of the
hoist and ensure that it is
LTI/ fatality/ property check wind speed. Do not lift load
unobstructed by any facility and A 5 3 3 CON 4 1 2
damage to equipment, when wind speed exeeds 25 knots
ensure that the hoist is
structure, person
positioned correctly.

two riggers must be assigned one

guiding at the front other at the
hoist must be third party certified
A 4 3 2 back and equipt proper means of con 4 1 1
with valid inspection certificated
communication such as two way
radio

correct capacity of lifting

accessories must be used for
lifting as per weight and shape of
load. Tag line must be used to
control the load and avoid hitting
any plant facility like pipeline,
cable trays, structure. Do not
position tha crane outriggers
near any drain line other wise
there is a chance of sinking of
these outriggers resulting crane
tipping over. barricade the
affected area, assign watchman
on all entry point to ensure no
activity under the suspension
load.

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 4 ) Tolerable RAC No. II ( 5 - 12 ) ModerateRAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000, 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code
Proper coordination with CCR & Pressence of the issuer and the
Lototo Isolation Electrical equipment Electrocution Electrical department for the proper EL 5 3 III contractor pic & safety officer on Con. 5 1 II
Equipment isolation point site is a must

Caught between, Struck Only authorize and certified Ensure that all personnel are
Rotating Parts & Moving
by/on Equipment being personnel must be performed activity trained and knowledgable about
Equipment
isolated. Fatality regarding on electrical matters LOTOTO procedures
EL 5 3 III Con. 5 1 II
Application of LOTOTO procedure Conduct try out prior to start the
and strictly checked and provide job task to ensure that the
necessary permits needed. equipment are isolated

Ensure that all personnel involved

are attach their own podlocks on the
Eliminate all kinds of jewelries
red box and double check by the
inside the plant premises
safety officers on duty prior to start
the job task.

Provide proper means of

communication such as two way
radio and wistle for assign watch man

Conduct Safety briefing on all

personnel regarding on LOTOTO
procedure anad its importance.

Ensure that all personnel are properly

understand the sequence and safety
protocols regarding on working with
the equipment in the plant premises.

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 5 ) Tolerable RAC No. II ( 6 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code
Ensure that all tools and
Minor to serious injury & Application of proper positioning of equipment are inspected and
opening of manhole Manual handling EL 3 2 II Con 3 1 I
body injury body for manual handling activities update stickers by RCBMI
attached

Avoid over exertion of the body

Ergonomics related injury movement and proper wearing of S 2 2 I
necessary PPE's

Wear apropriate hand gloves with

rubber/ Rubber dotted to prevent
Sharp tools/ edges Cuts and laceration EL 2 2 I
hand cuts/ Laceration or used leather
gloves if applicable

Eliminate all fabricated tools and do

Fabricated & Defective tools
and equipment
not allow then to create another
fabricated tools exept if it is aproved
and aknowledge by the plant safety
Department & also documented. Provide sunctioning on those
Can cause a minor to Cascade awareness and safety personel that reapetedly violate on
EL 3 2 II Con 3 1 I
serious injury to a person Reminders Regarding on fabricated using fabricated tools & Defective
toos and usage of Defective tools
Equipment on site. Strictly implement
and continues monitoring of non-
usage of fabricated and defective
tools on site.

Ensure proper illumination &

Conduct housekeeping before and
Slip & trip Fractured and Sprain EL 3 2 II cable/ hyose management on site Con 3 1 I
after proir to start
are in place

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 5 ) Tolerable RAC No. II ( 6 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Pre-Heater/ Cylone 5 Revision No.
Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code

advise to used fall restarint

Working at heights
Proper Wearing of full body
system instead of fall arrest
harness with double lanyard.
system if applicable on the activity
Fractured, sprain, LTI/ Advise to used fall restarint
Fall from heights A 4 3 II being performed. Properly asses Con 4 1 2
Fatality system instead of fall arrest
the height of the flatform/scaffold
system if applicable on the
being access to compute the fall
activity being performed
distance.

Barricade the affected area with

Falling object/ parralel activity
provided of warning signs or
Safety sinages.Provide blinds the affected areas wth
Avulsion/ head injury A 4 2 2 Con 4 1 1
watchman with equip. of wistle scaffold materials/ Net
for warning device/proper means
of communications.

Provide watchman with equip. of

wistle for warning device/proper
means of communications.

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 5) Tolerable RAC No. II ( 6 - 12 ) ModerateRAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000, 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code

prepared necessarily permit needed

oxygen difficiency, toxic
working on confined space gasses, oxygen enrichment,
poor lightning
prior to entry on confined space area
collapse, dizziness, area and compete isolation of the
suffocation, LTI/Fatality, confined space to be entered. A 4 3 II con 4 1 2
slip/trip Conduct gas test on confined space
to ensure no hazardous gasses is
precent

used of GFCI on all confined spce

activity and do not allow them to
enter all the high voltage equipment
only competent person must do
on the confined space. Ensure that
electricity electric shock/ electrocution EN 5 3 3 the job task regarding on electrical con 5 1 2
the cables, extensions hoses are
matters/ activity
properly manage on site by usage of
cable post and S-hook with proper
insulation and properly.

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 4 ) Tolerable RAC No. II ( 5 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1,0 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code
Ensure that all tools and
cleaning of debris and Minor to serious injury & Application of proper positioning of equipment are inspected and
Manual handling EL 3 2 II Con 3 1 I
materials build-up body injury body for manual handling activities update stickers by RCBMI
attached

Avoid over exertion of the body

lossening of bolt Ergonomics related injury movement and proper wearing of S 2 2 I
necessary PPE's

Wear apropriate hand gloves with

removal of old dip tube holder rubber/ Rubber dotted to prevent
Sharp tools/ edges Cuts and laceration EL 2 2 I
and segment hand cuts/ Laceration or used leather
gloves if applicable

Eliminate all fabricated tools and do

Fabricated & Defective tools
and equipment
not allow then to create another
fabricated tools exept if it is aproved
and aknowledge by the plant safety
Department & also documented. Provide sunctioning on those
Can cause a minor to Cascade awareness and safety personel that reapetedly violate on
EL 3 2 II Con 3 1 I
serious injury to a person Reminders Regarding on fabricated using fabricated tools & Defective
toos and usage of Defective tools
Equipment on site. Strictly implement
and continues monitoring of non-
usage of fabricated and defective
tools on site.

Ensure proper illumination &

Conduct housekeeping before and
Slip & trip Fractured and Sprain EL 3 2 II cable/ hyose management on site Con 3 1 I
after proir to start
are in place

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 5 ) Tolerable RAC No. II ( 6 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code

cutting of stock up dip tube Fire, Burn, exploision

Open flame, Fluxes
holder using oxyace Property damage
fire watchers must be trained and
knowlegable on the duties and
responsibilities or a fire watch.
Proper means
of communication must be
A 4 3 II Con 4 1 I
provided. Blinds
the affected area espeacially on
those parralel job activity by the
use of fire balnkets & steel planks,
yero.

Proper wearing of eye googles & face

Spark Eye irritation/ injury P 2 2 I
shield

Proper wearing of standard dust Used of Respirators if applicable/

Toxic Gas & Fumes dust Respiratory illness P 3 2 II Con 3 1 I
mask Such as: KN-95 & N-95 needed

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 5 ) Tolerable RAC No. II ( 6 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code
Ensure that all tools and
removal of old dip tube holder Minor to serious injury & Application of proper positioning of equipment are inspected and
Manual handling EL 3 2 II Con 3 1 I
and segment body injury body for manual handling activities update stickers by RCBMI
attached

Avoid over exertion of the body

Ergonomics related injury movement and proper wearing of S 2 2 I
necessary PPE's

Wear apropriate hand gloves with

rubber/ Rubber dotted to prevent
Sharp tools/ edges Cuts and laceration EL 2 2 I
hand cuts/ Laceration or used leather
gloves if applicable

Eliminate all fabricated tools and do

Fabricated & Defective tools
and equipment
not allow then to create another
fabricated tools exept if it is aproved
and aknowledge by the plant safety
Department & also documented. Provide sunctioning on those
Can cause a minor to Cascade awareness and safety personel that reapetedly violate on
EL 3 2 II Con 3 1 I
serious injury to a person Reminders Regarding on fabricated using fabricated tools & Defective
toos and usage of Defective tools
Equipment on site. Strictly implement
and continues monitoring of non-
usage of fabricated and defective
tools on site.

Ensure proper illumination &

Conduct housekeeping before and
Slip & trip Fractured and Sprain EL 3 2 II cable/ hyose management on site Con 3 1 I
after proir to start
are in place

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 5 ) Tolerable RAC No. II ( 6 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code
Ensure that all tools and
installation of dip tube Minor to serious injury & Application of proper positioning of equipment are inspected and
Manual handling EL 3 2 II Con 3 1 I
segments body injury body for manual handling activities update stickers by RCBMI
attached

Avoid over exertion of the body

Ergonomics related injury movement and proper wearing of S 2 2 I
necessary PPE's

Wear apropriate hand gloves with

rubber/ Rubber dotted to prevent
Sharp tools/ edges Cuts and laceration EL 2 2 I
hand cuts/ Laceration or used leather
gloves if applicable

Eliminate all fabricated tools and do

Fabricated & Defective tools
and equipment
not allow then to create another
fabricated tools exept if it is aproved
and aknowledge by the plant safety
Department & also documented. Provide sunctioning on those
Can cause a minor to Cascade awareness and safety personel that reapetedly violate on
EL 3 2 II Con 3 1 I
serious injury to a person Reminders Regarding on fabricated using fabricated tools & Defective
toos and usage of Defective tools
Equipment on site. Strictly implement
and continues monitoring of non-
usage of fabricated and defective
tools on site.

Ensure proper illumination &

Conduct housekeeping before and
Slip & trip Fractured and Sprain EL 3 2 II cable/ hyose management on site Con 3 1 I
after proir to start
are in place

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 5 ) Tolerable RAC No. II ( 6 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Location : Pre-Heater/ Cylone 5 Revision No.
Description of work : Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action
HOC Probabilit R A Additional control By RA
No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
Code y Code measures Whom Code
Electricity and defective
Welding works for repair power tools & cables, Electrocution/ Electric shock Ensure that all power tool and
Extensions Strictly checking of all power tools
cables/ extension being used on
and cables, extension proir to used
site are with approved and update
on site. Returened and put a tag of all EL 5 3 II Con. 5 1 II
inspection stickers by the RCBMI
defective tools subject for repair by a
plant. Only competent person
competent person/ Electricians
must do the job task.

Comsumable/ Flamable materials to

be secured/ Removed from the hot
works activity. Vallid fire Extnguisher Proper means of communacation
Property damage EL 3 2 II Con. 3 1 I
and fire watcher should be provided must be provided
and contenues monitoring of hot
works activity

Blinds the affected area especially on Fire watchers must be trained and
Welding/ Fluxes Fire, Burn those parralel job activity by the use EL 4 3 II knowlegable on the duties and Con. 4 1 I
of fire blanket & steel planks, yero responsibilities or a fire watc

Proper wearing of eye protection &

Spark Eye irritation/ injury P 2 2 I
face shield

Proper wearing of standard dust Use of Resperatory if aplicable/

Fumes & Dust Respiratory illnes P 3 2 II Con. 3 1 I
musk such as KN-95& N95 needed

Risk Assessment (R A Code) Members:

Risk = Severity rate ( 1 - 4 ) Tolerable RAC No. II ( 5 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________
 RISK ASSESSMENT FORM / GENERAL WORK PERMIT
Report No.
Pre-Heater/ Cylone 5 Revision No.
Replacement of Cylone 5 diptube and flap Date
Name of Contractor: NVH ENGINEERING AND SERVICES
With current control After additional corrective action

Application of propper HOC Probabilit R A Additional control By RA

No Sequence of job Potential hazards Consequence/s Current controls Severity Severity Probability
positioning of body for Code y Code measures Whom Code
manual handling activities.
Manual Handling & Can Cause a minor to
Buddy 2x system/ used of
House keeping Ergonomic Related serious injury to a EL 3 2 II Con. 3 1 I
mechanical techniques.
Harzard workers/personnel
Properly coordinated with
the area owner & safety
Avoid department on removal of
over Exertion of body machine guardings
movement and proper
wearing of Necessary PPEs
needed.
Proper wearing of standard
Used of respirators if
Dust Respiratory illness dust mask such as:KN95/n- EL 3 2 II Con. 3 1 I
needed
95
Strictly Compliance at proper
wearing of skull guard with
Low headed areas Avulsion chainstrap for head EL 3 2 II
protection on all identified low
headed areas.

Slip/Trip Fractured and Sprain EL 2 2 II Ensure that all cables and Con. 2 1 I
Provide proper illumination on hoses are not serve as
site. Provide safety signages stripping hazard. Eliminate
on all low headed areas and all obstruction on site and
familiarization of area proper storage of tools and
materials.

proper wearing of Hand

Grease Skin allergy/irritation gloves and appropiate and P 2 2 II
PPEs
Risk Assessment (R A Code) Members:
Risk = Severity rate ( 1 - 5 ) Tolerable RAC No. II ( 6 - 12 ) Moderate RAC No. III ( 13 - 25 ) Intolerable Fullname Signature
1
Severity Explanation 2
5 Fatality or paralysed, property damaged more than Php 10,000,000 Exposure Category - Tick one 3
4 Permanent disability (including occupational diseases), property damaged from Php 1,000,001 1 Greater than 50 persons exposed 4
3 Temporary disablement, LTA more than 3 days, property damaged from Php 100,001 - Php 1, 2 10 to 49 persons exposed 5
2 Minor injury, LTA with up to 3 lost days, property damaged from Php 5,000 - Php 100,000 3 5 to 9 persons exposed 6
1 First aid injury, non-LTA, property damage of <Php 5,000 4 Less than 5 persons exposed 7
8
Job Specific PPE Permit Required Probability Explanation Code Hierarchy of Control 9
Mandatory PPE Othe Work at Heights 5 Almost Certain EL Elimination 10
Hotworks PPE Deviation of Isolation/Deisolation 4 Very likely S Substitution
Confined Space Commissioning (using GWP) 3 Likely EN Engineering Date Date Date
Safety Harness Lifting 2 Unlikely A Administrative Name Name Name
Hand Gloves 1 Very unlikely P PPE Safety PIC/ Teammate / Contractor
SCBA Others : ________________