Management of Change

  • Are you making any changes to:

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

  • 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?

  • 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?

  • 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?

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

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

  • Changing weather conditions?

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

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

  • Has job carried over from previous shift?

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

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

    1 - Issue occurs less than once per year
    2 - Issue occurs 1-2 times per year
    3 - Issue occurs monthly
    4 - Issue occurs weekly
    5 - Issue occurs daily

  • Likelihood of injury

    1 – Highly unlikely
    2 – Unlikely
    3 – Possible
    4 – Probably
    5 – Highly likely

  • Severity of Injury

    1 - Injuries include first aid only with no lost time from work
    2 - Injuries include medical treatment but no lost time from work
    3 - Injuries include medical treatment and lost time from work but with a full recovery
    4 - Injuries include medical treatment and lost time from work and some permanent impairment.
    5 - Injuries include major permanent impairment or death

    Working from Height, Confined Space, Live Electrical, and Permit Work/Licensed (Crane, Explosives, Hot work) automatically receives a 5 for severity

  • 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?

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

  • Were there any Housekeeping issues?

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

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

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

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

  • List the improvements

  • Add signature

Authorization to Proceed with MOC

  • Add signature

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