Title Page
-
Job Lead/Prepared by
-
Document No.
-
Job Title/Name
-
Client / Site / Location
-
Conducted on
-
GPS/Map Location
-
Personnel
-
Photograph
Basics
-
Emergency contacts and numbers
-
PPE needed
-
Tools required
-
Additional hazard controls
-
What is the worst thing that could happen?
-
Critical steps
-
Task operating experience
Hazards
-
Job hazards (check only those that are present)
- Congested / Tight workspace
- New employees / New facility
- Work-distractions (fatigue, rushing, etc)
- Fall Hazards
- Electrical Hazards
- Adverse weather conditions
- Working at elevated heights
- Lighting inadequate
- Customer / Area Hazards
- Strain injury (material handling)
- Excessive force or lifting
- Awkward Positions
- Repetitive Motion
- Slip / Trip / Falls
- Chemical Exposure or Spill
- Thermal (hot/cold)
- Pinch / Caught-In Hazards
- Sharps / knives / cut hazards
- High Noise Environment
- Other
-
Other hazards(s)
Precursors
-
Precursors (check any that are present)
- Time Pressure
- Distractive Environment
- Procedures new/recently revised
- Personnel unfamiliar with tasks
- High workload
- First time evolution
- First working day after days off
- ½ hr. after wake-up or meal
- Vague/incorrect guidance
- Over confidence
- Imprecise communication
- Work stress
- Fatigue
- Peer pressure
- Multi-tasking
- Off-normal conditions
- Proper equipment not readily available
- Other
-
Other precursor(s)
Permits/Procedures
-
Work instruction (SOP)
- Required
- Received
-
Safety risk assessment
- Required
- Received
-
LOTO procedures
- Required
- Received
-
Customer safe work
- Required
- Received
-
Confined space procedures
- Required
- Received
-
Confined space permit
- Required
- Received
-
Electrical work permit
- Required
- Received
-
Line breaking permit
- Required
- Received
-
Hydrostatic test permit
- Required
- Received
-
Customer safe work
- Required
- Received
-
Other permits/procedures
-
Review/Required for "Other"
- Required
- Received
Review and Authorisation
-
EHS Review required for the following activies
- Electrical work
- Confined Space Entry with CSE checklist flags
- Work at Heights (except ladder work)
- Any non-routine task with an identified hazard
- Any new task with an identified hazard
-
Authorisation
- Task SOPs & SRAs reviewed with employee?
- Involved employees qualified for the job tasks?
- All identified hazards mitigated or controlled?
- Customer notified & requirements satisfied?
- All hazards & error precursors addressed?
- Immediate supervisor notified?
