Information
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Date
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Prepared by:
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INITIAL PERSONNEL - Select your team members
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Initial names of Contractors (if any)
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Document #
RISK ANALYSIS & TAKE 5
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PICTURE OF SYSTEM / EQUIPMENT
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PERSONAL PROTECTIVE EQUIPMENT REQUIRED - PPE
- Arc Flash PPE
- Safety Glasses
- Steel Toe Shoes
- Hearing Protection
- Harness / Fall Protection
- Face Shield
- Particle Respirator
- Cloth Gloves
- Chemical Gloves
- Tyvek Suit
- Goggles - Chemical
- Goggles - Welding
- Heat Resistant Clothing
- Hard Hat
- Others
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LIST OF PERMITS & REQUIREMENTS
- Confined Space Permit
- Lockout / Tag Out Required
- Haz Com Review
- Hot Work Permit
- High Voltage Permit
- Other
- None or Not applicable
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OTHER PERSONAL PROTECTIVE EQUIPMENT REQUIRED (if any)
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WORK AREA PREPARATION
- Barricades / Signs Posted
- Ladders Secured
- First Aid / Emergency Contact
- Lockout Complete / Try Out Verified
- Permits Posted
- Eyewash / Shower
- Work area Defined
- Fire Extinguishers (Hot work)
- Others
THINK THROUGH THE TASK - Have a clear plan in mind
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General Scope Of work Discussed in FULL with ALL Team Members on Site. Recorded in Limble Workorder.
- Barricades / Signs Posted
- Ladders Secured
- First Aid / Emergency Contact
- Lockout Complete / Try Out Verified
- Permits Posted
- Eyewash / Shower
- Work area Defined
- Fire Extinguishers (Hot work)
- Others
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Do I understand what I am supposed to do?
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Are there standard procedures for this job?
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Do I have all of the required work permits?
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Do I have all of the required Personal Protection Equipment?
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Are my tools and equipment in good working condition?
LOOK FOR THE EXPOSURE - How and where the work is done
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JOB SPECIFICS HAZARDS (WHICH ARE IDENTIFIED AND COMMUNICATED PRIOR TO WORK BEGINNING)
- Atmosphere / Confined Space
- Contact Burns / FIRE
- Compressed Gases
- Chemical exposure / Dust
- Engulfment / Ground Control
- Electrical /Mechanical
- Fall from Heights
- Slips / Trips on same level
- Mobile equipment / Forklift usage in area
- Pinch points
- Noise
- Others
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Is there any additional hazard? (if any)
ASSES THE RISK - What could happen if things get out of control?
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GREEN (LOW) - Continue with task, watch for exposure changes
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YELLOW (MODERATE) - Continue with task; develop safe action plan
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ORANGE (HIGH) - Stop, notify Supervisor: develop safe action plan together.
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RED (CRITICAL) - Stop, notify Supervisor; complete risk assesment
TAKE PRECAUTIONS - Remove impediments to safety
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Have the hazards been removed or controlled?
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Have potential problems been discussed?
DO THE JOB SAFELY - Watch for changing conditions and exposure
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Can we perform the job safely?
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IF any other Comments or Concerns come up: WE STOP WHAT WERE DOING AND RE;Evalutate.
- Barricades / Signs Posted
- Ladders Secured
- First Aid / Emergency Contact
- Lockout Complete / Try Out Verified
- Permits Posted
- Eyewash / Shower
- Work area Defined
- Fire Extinguishers (Hot work)
- Others
Names and Signatures:
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Name of Rassaun #1
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Signature of Rassaun #1
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Name of Rassaun #2
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Signature of Rassaun #2
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SIgnature of Ted Inc #1 Dave M.
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Signature of Ted Inc #2 Denis Caron
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SIgnature of Ted Inc Zack H
HOT WORK PERMIT
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Do you require a Work Permit ?
All temporary operations involving open flames or producing heat and/or sparks require a Hot Work Permit. This includes, but is not limited to brazing, cutting, grinding, soldering, thawing, and welding.
Personel
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Name of the person doing the "Hot Work"
- Edwin Horna
- Scotty Garret
- Patrick Parker
- Clayton Parrish
- Caleb Sawyer
- Shannon Brinson
- Brandon Carter
- Dustin Lord
- Brandon Hayes
- Blake Carter
- Will Oliver
- Chip Johnson
- Glen Ziegler
- Bill Brynteson
- Slayton Kitchens
- Brad Richards
- Chad Foskey
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Additional Personnel doing Hot WORK
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Name of the "Fire Watch"
- Edwin Horna
- Scotty Garret
- Patrick Parker
- Clayton Parrish
- Caleb Sawyer
- Shannon Brinson
- Brandon Carter
- Dustin Lord
- Brandon Hayes
- Blake Carter
- Will Oliver
- Chip Johnson
- Glen Ziegler
- Bill Brynteson
- Slayton Kitchens
- Brad Richards
- Chad Foskey
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Additional Fire Watches
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Fire Watch SIGN OFF: <br>Work Area and all adjacent areas to which sparks and heat could spread must be inspected during the fire watch period. <br>Fire Watch personnel must monitor work area for at least 30 minutes following "Hot work"<br>By acknowledging this section, I understand the requirements.
START TIME
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START TIME
HOT WORK - CHECKLIST
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Sprinklers and/or fire hoses in service / operable.
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Hot work equipment in good condition (e.g power source, welding leads, torches, etc)
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Multi-purpose fire extinguisher and/or water pump can.
REQUIREMENTS WITHIN 35 FT OF WORK
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Dust, lint, debris, flammable liquids and oily deposits removed.
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Explosive hazard in area eliminated.
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Combustible floor (e.g. wood, tile, carpeting) are wet down, covered with damp sand, or fire blankets.
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Flammable and combustible material were removed where possible. Otherwise, protected with fire blankets, guards, or metal shields.
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All walls and floor openings covered.
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Walkways protected beneath hot work.
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Protect/cover or shutdown ducts and conveyors that might carry sparks to distant combustibles.
WORK ON WALLS OR CEILINGS
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Combustible moved away.
WORK IN CONFINED SPACES
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Confined space cleaned of all combustibles ( grease oil, flammable vapors)
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Containers purged of flammable liquids / vapors.
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Company confined space guidelines will be followed.
FIRE WATCH / HOT WORK AREA MONITORING
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Fire Watch will be provided during and for 30 minutes after work, including any coffee or lunch breaks.
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The Fire watch is supplied with an extinguisher, and/or water pump can. He is aware of other fire extinguishers located throughout the work area.
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ENDING TIME FOR WORK PERMIT
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Fire Alarm or extinguisher : The fire watch is trained in use of this equipment and familiar with location of sounding alarm
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The fire watch is required for opposite side of walls, above, and below floors and ceilings.
