MINTEQ - NRTR

• Conducted on

  Date

• Client / Site

• Non Routine Task Review for

• Personnel working on this Job or task

• Prepared by

Management of Change

• Are you making any changes to:

  Select The Process (parameter) The Equipment The Procedure Materials Other

  • The Process (parameter)
  • The Equipment
  • The Procedure
  • Materials
  • Other

• Are you making any modifications, replacements, or additions that are not identical in configuration, fit, or function to original design or conditions?

  Yes

  No

  N/A

• If any questions above answered with “Yes”, please: STOP WORK, Contact a supervisor and reference EHS-GEN-11, to proceed with the Management of Change process.

• Does the change create safety concerns upstream of the process?

  Yes

  No

  N/A

• If any questions above answered with “Yes”, please: STOP WORK, Contact a supervisor and reference EHS-GEN-11, to proceed with the Management of Change process.

• Does the change create safety concerns downstream the process?

  Yes

  No

  N/A

• If any questions above answered with “Yes”, please: STOP WORK, Contact a supervisor and reference EHS-GEN-11, to proceed with the Management of Change process.

Situational Awareness – These situations can lead to injuries or loss. STOP WORK if these conditions arise or change and address them in the Job Plan on the next page.

• Does anyone on team need training on equipment or tools or task?

  Yes

  No

  N/A

• Will you be working/traveling through an area with mobile equipment?

  Yes

  No

  N/A

• Do you need to notify other departments of work being done?

  Yes

  No

  N/A

• Changing weather conditions?

  Yes

  No

  N/A

• Is other work being conducted Above/Below/Nearby you?

  Yes

  No

  N/A

• Will your work affect anyone/anything other than you?

  Yes

  No

  N/A

• Has job carried over from previous shift?

  Yes

  No

  N/A

• Have you checked the area for snakes, scorpions, bees, wasps, or other insects?

  Yes

  No

  N/A

Safety Concerns (Check all that apply) If you check a box below. how will you address it?

• Mobile Equipment / Vehicle / Traffic

• Toxic/Hazardous Materials / Corrosive Chemicals

• Fumes/Mist/Dust

• Flammables / Fires

• Rush Job

• Other EHS Permits Needed

• Rotating Parts (Machine / Safeguard)

• SDS Review

• Electrical (incl. overhead supply)

• Lockout / Tag out / Tryout

• Equipment drawings and/or maintenance manuals

• Balance & Traction

• Testing Requirements

• Pinch Points

• Walking / Footing Working Surface

• Heat / Cold Stress

• Confined Space

• Noise

• Ergonomics / Awkward Positions

• Line of FIRE

• Waste Disposal / Recycling of Materials

• Potential Energy

• Elevated Work/Fall Protection

• Rigging / Hoists

• Material Handling

• Excessive Force / Over-extension

• Communications with Contractors

• Environmental Spills / Discharges

• Homemade tools

• PLC/Automation

• Barricades / Covers

• Ladders

• Stretching Lifting Bending

• Not enough time to complete the job

• Other

List Tools & Materials Required

• Please list tools required to perform this task

Assess the Risks

• Frequency of Task <br> <br>1 - Issue occurs less than once per year <br>2 - Issue occurs 1-2 times per year <br>3 - Issue occurs monthly <br>4 - Issue occurs weekly <br>5 - Issue occurs daily

  1

  2

  3

  4

  5

• Likelihood of injury <br> <br>1 – Highly unlikely <br>2 – Unlikely <br>3 – Possible <br>4 – Probably <br>5 – Highly likely

  1

  2

  3

  4

  5

• Severity of Injury <br> <br>1 - Injuries include first aid only with no lost time from work <br>2 - Injuries include medical treatment but no lost time from work <br>3 - Injuries include medical treatment and lost time from work but with a full recovery <br>4 - Injuries include medical treatment and lost time from work and some permanent impairment. <br>5 - Injuries include major permanent impairment or death <br> <br>Working from Height, Confined Space, Live Electrical, and Permit Work/Licensed (Crane, Explosives, Hot work) automatically receives a 5 for severity <br> <br>

  1

  2

  3

  4

  5

• Multiply the scores above to calculate the overall score of the risk of this task. (2 x 2 x 3 = 12).

Job Plan, Enter Significant Steps to Complete the Task

• List significant step to complete task

Step

• List significant step to complete task, possible risk(s) with step and protective measure(s) to reduce risk(s)

Post Work Questions

• Has all equipment been restored to original running condition?

  Yes

  No

  N/A

• Did you notify management / departments that work has been completed?

  Yes

  No

  N/A

• Were there any Housekeeping issues?

  Yes

  No

  N/A

• Has all paperwork been completed and turned-in to required departments?

  Yes

  No

  N/A

• Did you clean-up after you completed your work?

  Yes

  No

  N/A

• Has the work been evaluated with all interacting / contracted parties (experts, contractors, customers, etc.)?

  Yes

  No

  N/A

• Have improvements been proposed during or after the task to perform same or similar tasks better and safer next time?

  Yes

  No

  N/A

• List the improvements

• Add signature

  Sign

Authorization to Proceed with MOC

• Add signature

  Sign