C&W SERVICES - Pre Job Hazard Assessment 20151211

Pre Job Hazard Assessment

• Special Emphasis

• Name

• Add location
  Address

• Select date

  Date

• Supervisor

• Document No.

• Work Order Number & Job Description

WHAT ARE THE THREE MAIN TASKS ASSOCIATED WITH THIS JOB?

• IS A WRITTEN PROCEDURE AVAILABLE FOR THIS TASK?

  Yes

  No

  N/A

PERSONAL PROTECTIVE EQUIPMENT REQUIRED

• PPE for this task: Hardhat and safety glasses with side shields, proper gloves, hearing protection and work boots required for each worker in each job.

• PPE needed for this task: (select all that apply)

  Select Proper Hand Protection Chemical Suit, Gloves, Boots Arc Flash Protection Face Shield Monogoggles

  • Proper Hand Protection
  • Chemical Suit, Gloves, Boots
  • Arc Flash Protection
  • Face Shield
  • Monogoggles

• Respiratory Protection (select all that apply)

  Select N95 Full Face 1/2 Face

  • N95
  • Full Face
  • 1/2 Face

• Fall Protection

  Select Safety Harness Lanyard & Anchor Retractable Lifeline 5000lb Rated Anchor

  • Safety Harness
  • Lanyard & Anchor
  • Retractable Lifeline
  • 5000lb Rated Anchor

SAFE WORK PERMIT

• Select all that apply

  Select Hot Work Line Break Hazardous Chemical Flammable and Combustible Exposure Ignition Source Control Elevated Work

  • Hot Work
  • Line Break
  • Hazardous Chemical
  • Flammable and Combustible Exposure
  • Ignition Source Control
  • Elevated Work

SAFE EQUIPMENT PERMIT

• Select all that apply

  Select Critical Safety Device By-Pass Lock-Out Removal Fire System Impairment / Usage Elevated Work

  • Critical Safety Device By-Pass
  • Lock-Out Removal
  • Fire System Impairment / Usage
  • Elevated Work

STAND ALONE PERMITS/PROCEDURES

• Select all that apply

  Select Confined Space Permit Electrical Work Trenching and Excavation Crane Personnel Platform Rigging Permit (>100 lbs or 4ft High) Rail Work Procedure Material Cutting Assessment

  • Confined Space Permit
  • Electrical Work
  • Trenching and Excavation
  • Crane Personnel Platform
  • Rigging Permit (>100 lbs or 4ft High)
  • Rail Work Procedure
  • Material Cutting Assessment

OTHER SAFETY CONSIDERATIONS

• Select all that apply

  Select Fire Extinguisher Long Sleeves/Welding Jacket Fire Blanket Heat & Cold Stress Prevention Pinch Point Awareness Rubber Boots GFCI protection must be used for electrical tools, test GFCI before use. Dust Control Eye Wear (Goggles)

  • Fire Extinguisher
  • Long Sleeves/Welding Jacket
  • Fire Blanket
  • Heat & Cold Stress Prevention
  • Pinch Point Awareness
  • Rubber Boots
  • GFCI protection must be used for electrical tools, test GFCI before use.
  • Dust Control Eye Wear (Goggles)

• Other (list below)

BARRICADE CONSIDERATIONS

• Select all that apply

  Select Cones/Posts/Cables, Guardrail Danger Tape OR Caution Tape Hole Cover (marked & secured) Hard Barricade

  • Cones/Posts/Cables, Guardrail
  • Danger Tape OR Caution Tape
  • Hole Cover (marked & secured)
  • Hard Barricade

FOOD SAFETY

• Could scope of work negatively impact the Food Safety of the equipment/process?

  Yes

  No

  N/A

• If yes, how will you control/eliminate any potential impact? (Select each that apply)

  Select Possible contamination entry points protected during duration of job All tools and equipment accounted for upon completion of job utilizing procedure checklist Work area cleaned of grease and debris upon completion of job

  • Possible contamination entry points protected during duration of job
  • All tools and equipment accounted for upon completion of job utilizing procedure checklist
  • Work area cleaned of grease and debris upon completion of job

EMERGENCY ACTION PLAN

• Where is the nearest eyewash / shower station?

• Where is the nearest PEA/PEO/EAP phone?

• Plant emergency phone number:

• Where is the nearest weather shelter?

LOCK OUT / TAG OUT & ENERGY SYSTEM ISOLATION VERIFIED

• LOTO procedure obtained and utilized

• LOTO walked down with the coordinator

• Locks and tags installed

• Equipment tested to verify the effectiveness of LOTO

• Lock Box/Equip#

• Initial that all LOTO steps are completed

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WHAT are the HAZARDS; slippery cluttered floor, sharp objects, heavy objects, hazardous vapors and chemicals, working at heights. Cause what type of INJURIES?

WHAT PRECAUTIONS/PROCEDURES will be utilized (eyes in task, balance, traction, grip, mind on task/proper lifting technique, good ergonomics, communication with other workers/LOTO, permit system, written job plan, SOPS, manufacturer procedures)?

WHAT TYPE OF GLOVES ARE NEEDED FOR YOUR BEST PROTECTION?

• Select all that apply

  Select Leather Cut resistant Chemical resistant Water resistant Thermal Voltage Rated

  • Leather
  • Cut resistant
  • Chemical resistant
  • Water resistant
  • Thermal
  • Voltage Rated

• What additional PPE and TOOLS are needed to protect you from these HAZARDS? (respirator, life line, tripod, tie off point)

HEAT STRESS

• What is the heat index today?

• When was my last drink of water?

• How will I keep myself cool?

• How will I keep the work area cool?

• What is my heat stress/work-rest management plan?

STOP WORK AUTHORIZATION

• Select all that apply

  Select Scope Change EE Safety Concerns Significant Near Miss Inadequate Instruction Unplanned Hazard

  • Scope Change
  • EE Safety Concerns
  • Significant Near Miss
  • Inadequate Instruction
  • Unplanned Hazard

• *Remember routine tasks are statistically higher in injuries than non-Routine tasks.

• I/WE understand the hazards that I've listed for this job. (Please sign your name)

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• Supervisor signature and comments about the task:

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• Audited By:

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