Documente Academic
Documente Profesional
Documente Cultură
RISK LEVEL:
Section 1 - Work Information Section 5 - Approvals & Acceptance
Area Owner : TGPP Start Date Expiry Date
Contract Owner (Name/Dept): EV CADUNGOG PTW Validity
CMMS Work Order No./Contract No.: 51794 ( Maximum PTW Validity : 20 Days )
PTW Holder: AD GORDO JR. Date Time Name /Signature
PTW Applicant/Company: RE POVADORA / EVC PTW Issuer ER DAGLE
Work Scope: PTW Approver RP ABLEN
PTW Holder AD GORDO JR.
REPLACEMENT OF SEALPOT AND ITS TUBING PTW Applicant RE POVADORA
Section 6 - Re-Issue (NOTE: DO NOT REISSUE if there are changes
Facility/Equipment Description: in the associated clearance/s.)
Preparation of materials and tools Caught on Wound 2 1 2 Conduct housekeeping and remove any 3 1 3
protruding object that has a sharp or jagged
edges; remove jewelries (such as ring,
necklace, and the like), watch; put a yellow
caution tape and safety signage; designate a
person to oversee the barricaded area and
warn anyone to keep away from the barricade
Arrange materials according to its Caught on wound 2 1 2 Conduct housekeeping and remove any 2 1 2
type or kind protruding object that has a sharp or jagged
edges; remove jewelries (such as ring,
necklace, and the like), watch; put a yellow
caution tape and safety signage; designate a
person to oversee the barricaded area and
warn anyone to keep away from the barricade
Overexertion_Lift Back pain, 3 2 6 Lift w/ your legs, load must be closed to the 3 1 3
ing Damage to spinal body, Use trolley if available, Do not lift heavy
chord load or avoid manual handling
Hauling of materials and tools to the Overexertion_Lift Back pain, 3 2 6 Lift w/ your legs, load must be closed to the 3 1 3
area ing Damage to spinal body, Use trolley if available, Do not lift heavy
chord load or avoid manual handling
Remove old tubings Strike against Wound, pain 3 2 6 Place end cap of protruding rebars, pipes and 3 2 6
stationary objects the like; Conduct housekeeping; remove
protruding object; clear the area; check
surrounding hazards by looking above,
behind, below, & inside; put a yellow caution
tape and safety signage
2 of 8
PTW ENGR's COPY
SN:
Job Hazard Analysis & Risk Assessment Form
Section 1 - Work Information
WORK ACTIVTY DESCRIPTION JOB LOCATION
Remove old sealpot Caught in Wounds, 5 3 15 Secure hand and power tools by tying using a 4 2 8
laceration, rope/holster/case; ensure scaffolding to have
burned freom a toeboard; stay away from the line of fire;
metal chips put a yellow caution tape and safety signage;
designate a person to oversee the barricaded
area and warn anyone to keep away from the
barricade
Clear the sorroundings strike against Wounds, 4 3 12 Conduct housekeeping; remove object with 3 2 6
sharp or jagged laceration sharp or jagged edges; clear the area; check
edges surrounding hazards by looking above,
behind, below, & inside; Wear hard hat, Safety
Glass, Safety shoes, Cotton gloves or leather
gloves.
Install the new sealpot Contact with Electric 4 3 12 Perform lockout/tagout and ensure zero 3 3 9
electricity shock/burned energy state; Do not touch any wire with bare
hands - treat any wire as live unless tested;
Verify panel meter readings; Install ground
wires; Wear adequate PPEs as identified in
the JHA (such as electrical gloves, hard hat
faceshield, arc rated gloves, safety shoes,
etc.); short circuit capacitor terminals; use
Ground Fault Circuit Interrupter; rubber mat
Install the new tubings Strike against Wound, 3 2 6 Place end cap of protruding rebars, pipes and 3 1 3
stationary objects laceration the like; Conduct housekeeping; remove
protruding object; clear the area; check
surrounding hazards by looking above,
behind, below, & inside; put a yellow caution
tape and safety signage
Housekeeping Overexertion_Lift Back pain, 3 2 6 Lift w/ your legs, load must be closed to the 3 1 3
ing Damage to spinal body, Use trolley if available, Do not lift heavy
chord load or avoid manual handling
NOTE: Refer to the Risk Matrix table for estimating the C and L (C Consequence, L Likelihood )
Section 3 - Additional Recommendations Section 4 JHA & RA development Team
PTW Applicant RE POVADORA
3 of 8
PTW ENGR's COPY
SN:
Job Hazard Analysis & Risk Assessment Form
Section 1 - Work Information
WORK ACTIVTY DESCRIPTION JOB LOCATION
4 of 8
HAZARD EVALUATION GUIDE SN:
Section 2 Tool for Identifying the Primary Sources of Potential Job Hazards Section 3 Categories for Control Measures
Hazard Analysis Consideration General Hazard Examples of Specific Hazards Pertinent to Control Measure Category Specific Control Examples
Category Category
Can worker be struck by anything? Struck by (SB) Moving objects Elimination or Substitution Use of lead free, non-toxic paint
Falling material Use a trolley instead of manual handling
Can worker strike against anything? Strike against (SA) Stationary or moving objects Engineering controls Ventilation
Protruding objects Barricades
Sharp or jagged edges Administrative controls No Smoking Policy
Can worker be caught between anything? Caught between (CB) Moving and/or stationary objects Rotating personnel
Pinch points Job frequency reduction
Can worker come into contact with any energy Contact with (CW) Electricity Safe work practice or procedure Confined Space Entry Procedure
source or hazardous material? Chemicals Lock Out/Tag Out Procedure
Extreme Heat/Cold Gas Testing Procedure
Can worker by contacted by any energy source Contacted by (CBy) Splashing chemicals Personal protective equipment Hard hats; safety shoes; safety glasses
or hazardous material? Animals and Insects Respirators
Arcing electricity Chemical Protective Clothing
Can worker be caught on anything? Caught on (CO) Moving parts Fall protection harness
Sharp or jagged edges
Protruding objects
Can worker be caught in anything? Caught in (CI) Settling material
Falling material
Moving parts
Can worker fall to same level? Fall, same level (FS) Slip/trip/fall
Poor footing
Wet surfaces
Can worker fall to level below? Fall to below (FB) Unstable footing
Unprotected platforms
Is there a possibility of overexertion? Overexertion (O)
Pulling / Pushing
Repetitive motion
Can worker be surrounded & overcome by a Engulfment (En) Cave-in
granular substance such as soil, sand, or Wall collapse
submerged in a liquid such as water or a Landslide
chemical?
Is there a possibility of exposure to hazardous Exposure (Ex) Chemical vapors; toxic gases
chemicals or temperatures or other Oxygen Deficiency
environmental conditions? Excessive noise
Radiation
Extreme weather conditions
Page 5 of 8
Is there a potential to spill, leak, or discharge Release to (RT) Ground/Water contamination
hazardous materials?
Frequency of Likelihood of
Probability
Occurrence Happening RISK MATRIX SN:
2 4 6 8 10
Rarely occurs Unlikely to
2 21% - 40% (3-5 years) occur
1 2 3 4 5
Never heard Almost no
1 1% - 20% of in the likelihod to
industry occur
Score
Medical Fatality
Treatment/ Lost Time Permanent
Physical Injuries First Aid Restricted Incident Disability (Single/
Duty Multiple)
Score 1 2 3 4 5
CONSEQUENCE
Page 6 of 8
PTW HOLDER's COPY
The requirements for the safe performance of this task/ job have been explained to us. Having clearly understood the requirements, we hereby give our
unconditional commitment to comply and adhere to them so we can do and complete the task/job in the safest and most efficient manner.
1 APPLIC 1 APPLIC
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
Pre Task Safety Meeting Conducted by (PTW Applicant) : [Name & Signature]
Section 6 - Housekeeping Section 7 - Stop Work Instructions
This is to confirm that housekeeping was done prior leaving the workplace.
The work activity shall be stopped when: (1) An alarm is sounded; or (2) An incident, accident or near
miss occurs; or (3) The Scope of Work changes; or (4) New hazards develop; or (5) The validity of the
Permit expires.
When the Emergency Alarm sounds, all work shall stop and any motorized equipment shutdown. All
personnel will exit the work area in a safe manner and report to their assigned assembly point unless
instructed otherwise.
Verified by: PTW Holder
PTW HOLDER's COPY
REPLACEMENT OF SEALPOT AND ITS TUBING Gas cylinders secured and upright?
Flammable/combustible materials removed?
Facility/Equipment Description: Materials that can not be removed is wet down
Job Location & Work Boundaries (indicate specific work site and physical Hot Work equipment in good condition?
limits; attach sketch if needed): Job site clear of trash & combustibles?
GCGI STEAM HEADER UNIT 1 Correct CB rating for hot work equipment?
Section 2 - Hot Work Particulars & Hazard Assessment Section 5 - Supplementary Attachment
Y N
Hot work involves the following activities: (check all that apply) Gas testing Record (Required where there is potential
presence of chemicals, flammable liquids and gas)
Grinding Hot Tapping Open Flame Works
Brazing Heat Treatment Other (specify)
Burning Soldering Section 6 - Approvals & Acceptance
Chipping Torch Cutting Date Time Name /Signature
Arc Welding Grift Blasting PTW Issuer ER DAGLE
Gas Welding Sand Blasting PTW Approver RP ABLEN
PTW Holder AD GORDO JR.
Hazard Assessment PTW Applicant RE POVADORA
Will the Hot Work be performed inside Classified Areas?
Will the Hot Work be performed where wall/floor openings Section 7 - Clearance Cancellation
expose combustibles in adjacent areas? Date Time Name /Signature
Will fire alarms or suppression systems be disabled during Cancelled by:
the hot work? Returned by:
State Reasons for Cancellation:
Is MSDS available? Y N
Will the work generate hazwaste? Y N
Toxic Y N
Reactive Y N Section 8 - Work Completion and Close Out
Flammable Y N Y N N/A
Corrosive Y N The fire watcher(s) stayed for 30 minutes
after hot work?
Section 3 - Safety Requirements Is the job complete?
Fire watcher(s) deployed SCBA Has the work area been restored
Fire extinguishers Evacuation & assembly point and cleaned up?
Two Way Radio Continuous forced ventilation Have all tools and equipment been removed?
Fall Protection Supplied Air Respirator Have all PTW documents been returned?
Gas badge Charge fire hose when req'd. All members of the work party are
Rescue Team required Respirator - Type accounted for?
Fire blanket/spark Ear Protection
containment Surrounding sewer/drain Clearance Closed by: Date Time Name / Signature
Work Area isolated with within 15 meters covered PTW Applicant
signs/barriers Welding goggles/gloves/apron PTW Holder
Others: PTW Issuer
PTW Approver
Section 4 - Work Area Preparation
Y N NA Section 9 - Conditions of Hot Work Clearance (HOW)
Equipment & lines depressurized? PTW Holder confirms that the PTW Applicant has complete
Equipment & lines flushed? understanding of all the conditions of this Clearance.
Equipment & lines drained/emptied? After accounting for all members of working party, the PTW
Equipment & lines water washed? Applicant shall return all PTW documents to the PTW Holder
Equipment & lines chemical washed? daily at the end of the work day or work shift, regardless of
Equipment & lines steamed out? whether the work is completed or not.
Lines/spool pieces removed HW Clearance shall be renewed daily.