Field Level Risk Assessment (FLRA) w/ Risk Matrix - ALPLA

• Name

• Plant

  Select BET BOW1 BOW2 COR DAY FLO HOU IOW1 IOW2 JCI LIM MCD RAE SLC SVC/TC SHE STP1 STP2 WEB

  • BET
  • BOW1
  • BOW2
  • COR
  • DAY
  • FLO
  • HOU
  • IOW1
  • IOW2
  • JCI
  • LIM
  • MCD
  • RAE
  • SLC
  • SVC/TC
  • SHE
  • STP1
  • STP2
  • WEB

• Location in facility

• Conducted on (Date and Time)

  Date

• Task Description

General Information

• Do you know where the first aid room/Kit is?

  Yes

  No

• Is hand sanitizer available?

  Yes

  No

• Do you know who is your immediate First Aid Responder?

  Yes

  No

• Do you know where to locate a Fire Extinguisher?

  Yes

  No

• Do you have a Communication Device (i.e. cell phone, radio, etc)

  Yes

  No

• Do you have a list of Emergency contacts?

  Yes

  No

• Do you have your Basic PPE Equipment?

  Yes

  No

Risk Matrix

• 

• Instructions
  -------------------------
  1. Answer "Safe", "At Risk", "N/A" for each of the hazards below
  2. If "At Risk", follow the questions to identify the likelihood of occurrence, severity and risk rating
  3. Include any notes and photos by clicking on the paperclip icon and then "Add Image"
  4. Answer the relevant control questions
  5. Complete the form by providing the relevant signatures

Social Distancing

• Social Distancing

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Close Proximity permit specific to this task received. Photograph permits.

  Yes

  No

  N/A

• Enter Description of Controls

Working at Height

• Working at Height

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Working at height permit received

  Yes

  No

  N/A

• Height safety harness worn

  Yes

  No

  N/A

• Enter description of control measures

Electricity

• Electricity

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Enter description of control measures

Compressed Air

• Compressed Air

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Enter description of control measures

Uneven/slippery Surfaces

• Uneven/slippery Surfaces

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Enter description of control measures

Vehicular movement

• Vehicular movement

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Enter description of control measures

Overhead hazards

• Overhead hazards

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Enter description of control measures

Manual handling

• Manual handling

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Enter description of control measures

Fire / Explosion

• Fire / Explosion

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Enter description of control measures

Noise

• Noise

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Rare

  Unlikely

  Likely

  Very Likely

• Severity

  Minor

  Moderate

  Significant

  Catastrophic

• Use matrix to identify risk rating and select appropriate rating below:

  

• Risk rating

  Very Low

  Low

  Moderate

  High

  Extreme

• Enter description of control measures

Recommendation

• Write recommendations here

• Work completed

  Yes

  No

  N/A

• Equipment is safe & fit to operate

  Yes

  No

  N/A

Completion

• Full Name of Inspector

• Signature of Inspector

  Sign