MTI Job Plan & Non Routine Task Review

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Situational Awareness - Focus on your surroundings

• Ready to perform this job safely?

  Yes

  No

  N/A

• Mind on task?

  Yes

  No

  N/A

• Is this a rush job? If so, slow down.

  Safe

  At Risk

  N/A

• Is other work being conducted nearby?

  Safe

  At Risk

  N/A

• Is your balance, traction, or grip compromised?

  Safe

  At Risk

  N/A

• Are you working in a cramped or awkward position?

  Safe

  At Risk

  N/A

• Are you working in the line of FIRE?

  Safe

  At Risk

  N/A

• Is there time to complete this job on this shift?

  Yes

  No

  N/A

• Has the job carried over from the previous shift? Has the work been coordinated with the previous shift?

  Yes

  No

  N/A

Formulate the Plan

• Is there a JSA available? If so, use it and edit as needed.

  Yes

  N/A

• Any special instructions/training required?

  Yes

  N/A

• Enter special instructions/Training required.

• What individuals or departments need to be notified?

  Yes

  N/A

• List department or individual that need to be notified.

• Any special tools or equipment needed?

  Yes

  N/A

• List special tools or equipment needed.

• Is there a need to interact with subject experts, contractors, etc.?

  Yes

  N/A

• List whom you you need to interact with.

• Any equipment drawings, operations or maintenance manuals available? If so, retrieve the manuals.

  Yes

  N/A

• Are EHS permits needed? <br><br>(Elevated Work, Confined Spaces, Electrical, Explosives, Hot Work)

  Yes

  N/A

• List permits needed.

• Are there specifications or tolerances required?

  Yes

  N/A

• List specifications and/or tolerances.

• Any testing requirements needed?

  Yes

  N/A

• List testing equipment that is required.

• Stretch if you will be lifting/bending.

  Safe

  At Risk

  N/A

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)

Assess the Risks

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

  1

  2

  3

  4

  5

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

  1

  2

  3

  4

  5

• Severity of Injury <br><br><br><br>1 - Injuries include first aid only with no lost time from work<br><br>2 - Injuries include medical treatment but no lost time from work<br><br>3 - Injuries include medical treatment and lost time from work but with a full recovery<br><br>4 - Injuries include medical treatment and lost time from work and some permanent impairment.<br><br>5 - Injuries include major permanent impairment or death<br><br><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><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).

Safety Concerns (Check all that apply)

• Mobile Equipment/Vehicle

• Toxic/Hazardous Materials

• Fumes/Mist/Dust

• Flammables

• Rotating parts (machine safeguarding)

• SDS Review

• Electrical

• Lockout/Tagout/Tryout

• Corrosives/Chemicals

• Pinch Points

• Walking/Footing/Working Surfaces

• Heat/Cold Stress

• Ergonomics

• Noise

• Excessive Force

• Potential Energy

• Elevated Work/Fall Protection

• Rigging/Hoists

• Material Handling

• Over Extension

• Homemade Tools Not Used

• PLC/Automation

• Barricades/Covers

• Ladders

• Line of Fire

Permits Required On Hand (Permits must be on hand before job is begun) (Check all that Apply)

• None

• Confined Space Entry

• Hot Work (Cutting/Welding)

• Grating Removal

• Scaffolding

• Other

• Please list other permits required

Environmental Concerns (Check all that Apply)

• None

• Atmospheric Discharges

• Liquid Discharges

• Spill Potential

• Weather Conditions

• Waste Disposal will be Required

• Recycle of materials

• Other

• Please list other requirements needed

Work Practices (Check all that apply)

• None

• Back-up Person/Watch

• Exhaust Ventilation

• Barricades

• Hoist Requires Inspection

• Spill Containment

• Posting/Warning Signs

• Other

• Please list other requirements needed

PPE Required - In addition to standard PPE of Safety Glasses, Hard Hat, and Safety Shoes (Mark yes to all that apply)

• None

• Electrical

• Arc Flash Clothing

• Chemical Resistant Suit

• Hearing Protection

• Ear Muffs

• Tyvek Suit

• PPE Inspection/Clean

• Gloves

• Goggles

• Face Shield

• Half Mask Respirator

• Dust Mask

• Powered Air Respirator

• Fall Protection/Safety Harness

• Fire Retardant Clothing

• Welding Blankets/Protective Blankets

• Other

• Please list other PPE required

List Tools Required

• Please list tools required to perform this task

List Materials Required

• Please list materials required to complete this task

Post Work Questions

• Have all lockouts been removed and test run of equipment performed?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Was housekeeping up to standard?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the work evaluated with all interacting and/or contracted parties (Experts, Contractors, Customers, ect.)?

  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 improements

• Add signature

  Sign