Safety Declaration & Action Plan

  • Safety Declaration

  • Managers' Signature

RPN

  • Likelihood of Occurence

  • Degree of Possible Harm

  • Number of People Exposed

  • Frequency of Exposure

  • Calculate RPN Number:

Tasks

  • List all regular operation tasks associated with Equipment/Area

  • Personal Protection advised for this Work?

Hazards

Hazard 1

  • Access/Egress (obstructions/congestion)

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 2

  • Slips, Trips, Falls

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 3

  • Heights (including steps, ladders, lifts, etc.)

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 4

  • Lone Work

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 5

  • Confined Spaces / Hot Work

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 6

  • Contact with Moving Equipment (entanglement, crush, etc.)

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 7

  • Hit by flying or falling objects (from cranes, ejected from machines)

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 8

  • Hit by moving objects

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 9

  • Lifting Equipment

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 10

  • Electricity (including portable appliances)

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 11

  • Flammable Materials / Hazardous Substances

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 12

  • Burns

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 13

  • Compressed Gas / Cryogenics (storage & use)

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 14

  • Pinch Points

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 15

  • Cuts

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 16

  • Noise Exposure

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 17

  • Transport (forklifts, vehicles, etc.)

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 18

  • Storage (racks, shelves, etc.)

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 19

  • Weather (hot, cold, storms, etc.)

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 20

  • Contact with a fixed/stationary object

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 21

  • Pressure Systems

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Risk Level

  • Corrective Actions & who is responsible:

  • Completion Date

Hazard 22

  • Other Hazards

  • How may harm occur?

  • Add media

  • Existing Control Measures

  • Risk Level

  • CA Required?

  • Risk Level

  • Corrective Actions & who is responsible:

  • Completion Date

Ergonomics

  • Manual Handling

  • Load Weight and lift frequency

  • Hand Distance from lower back

  • Vertical lift region

  • Trunk Twisting / Sideways bending

  • Postural Constraints

  • Grip of Load

  • Floor Surface

  • Other environmental factors

  • Load Weight & Carry Frequency

  • Trunk twisting / sideways bending

  • Postural Constraints

  • Grip of Load

  • Floor Surface

  • Other environmental factors

  • Carry Distance (carrying only)

  • Obstacles en route (carrying only)

  • CA Required?

  • Corrective Actions & who is responsible:

  • Completion Date

  • Participants to sign

  • Participants to sign

  • Participants to sign

  • Participants to sign

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