Title Page
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Prepared by
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Document No.
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Job Title/Name
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Site / Location
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Conducted on
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GPS/Map Location
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Personnel
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Photograph
Basics
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Emergency contacts and numbers
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Task (Scope)
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Do you know and understand the scope of work and how to do it safely?
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Is this a standard working procedure/activity?
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Do you know the proper and safe method to execute the job from start to finish?
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Task operating experience
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Critical steps
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Step 1
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Hazards Associated with Step 1
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Add media
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Safe Work Procedures/PPE for Step 1
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Step 2
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Hazards associated with Step 2
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Add media
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Safe Work Procedures/PPE for Step 2
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Step 3
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Hazards associated with Step 3
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Add media
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Safe Operating Procedures/PPE for Step 3
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Step 4
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Hazards associated with Step 4
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Add media
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Safe Operating Procedure/PPE for Step 4
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Step 5
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Hazards associated with Step 5
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Add media
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Safe Operating Procedures/PPE for Step 5
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What is the worst thing that could happen?
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PPE needed
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Tools required
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Additional hazard controls
Hazards/Precursors
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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
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Other hazards(s)
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Precursors (check only those 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
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Precursors
Permits/Procedures
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Work instruction (SOP)
- Required
- Received
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Safety risk assessment
- Required
- Received
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LOTO procedures
- Required
- Received
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Confined space procedures
- Required
- Received
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Confined space permit
- Required
- Received
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Electrical work permit
- Required
- Received
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Hydrostatic test permit
- Required
- Received
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Other permits/procedures
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Review/Required for "Other"
- Required
- Received
Review and Authorization
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EHS Review required for the following activities
- 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
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EHS Review required for the following activities
- 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
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Authorization
- 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?
