Elevated Work Hazard Assessment and Risk Mitigation Plan

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					                                  Life-Critical Guard (LCG) Fall Protection Plan
                                                                  Job Task
  Describe the task:




                                                                    Access
  How will workers access the work area? (Check all that apply):
    Stairs        Ladder     Scaffolding         Aerial lift      Rig basket            Other _______________________________
                                                             Potential fall hazards
  Is there a potential for personnel to fall 6 feet or greater to a lower level? (Check all that apply):
    Work from ladders                      Work from aerial lift devices or rig basket        Work from unprotected sides or edges
    Holes in work surface                  Erecting/dismantling scaffold                      Work within 6’ of excavations or open pits
    Work from piperacks/cable trays        Any work over dangerous equipment                  Work from a steep sloped roof (> 4 in 12 pitch)
    Removal of permanent handrails         Work on low sloped roof < 15’ of edge              Work from transportation equipment
    Removal of grating                     Ladder use within 6 ft of a 6 ft or more fall      Work from flat roof < 6’ of edge
                                           Other: _____________________________               Potential falls through a work surface
                                                        Fall Prevention / Protection
  How will workers and others be protected from the fall hazard? (Check all that apply):
     Covers for holes      Personal fall restraint system                Positioning device system                      Safety net system
     Stair rail system     Personal fall arrest system                   Personal fall arrest system for climbing       Designated Area
     Guardrail system      Approved anchorage points available           Aerial lift device                             Other: _______________
                                                           Falling Objects Control
  How will workers and others be protected from falling objects? (Check all that apply):
     Toeboards/Toeplates        Guardrails                          Barricades                                     Catch platform
     Screens                    Keep objects from edge              Debris net or screen                           Other ________________
                                                         Work Surface Evaluation
  Is there a potential for personnel to fall 6 feet or more through a work surface?
    Structure capable of supporting weight of people and materials          SME Approval needed         SME Approval _________________



IF THE SCOPE OF WORK INCLUDES ANY OF THE TASKS LISTED BELOW, PLEASE IDENTIFY THE TASK AND ATTACH A
                        PREVENTION/ PROTECTION PLAN TO THIS HAZARD ASSESSMENT.

                                                   CRITICAL ELEVATED WORK
    Critical Scaffold     Work that creates a life-critical Non-routine use Crane-suspended                Elevated work that is not
  erection/ dismantling   fall hazard or Working inside a    of aerial lift  work platforms                protected by installed fall
                                 Life Critical Guard           devices                                     prevention/protection system
   Cantilevered Scaffold    Removing grating                 Use < once /   Rig basket                       Piperacks
   Suspended Platforms      Removing permanently             month                                           Cable trays
   Scaffold Tents            install fall prevention /                                                       Incomplete permanent
   Balconies                 protection                                                                       platform
   Tying scaffolding into   Creating an opening through
   existing support          which a person may fall
   (>1 ft gap)              Working inside a Life
   Scaffold Bridges          Critical Guard within 6’ of a
   longer than 25 ft.        fall hazard




                                                 DOW RESTRICTED - For internal use only
                               Life-Critical Guard (LCG) Fall Protection Plan
                                                             Location
Describe Location of Life Critical Guard:




                                Work that creates a life-critical fall hazard or Working inside a LCG
 Removing grating or manhole covers
 Removing permanently install fall prevention / protection
 Creating an opening through which a person may fall
 Working inside a Life Critical Guard within 6’ of a fall hazard
 Personnel will maintain 100% tie off for the duration of the job while working at elevated places

                                                  Designated Anchorage Points
List anchorage points:

Will there be unobstructed free space available in the event of a fall-based on the total free fall distance?


Life Critical Guards are not designed to be anchorage points
                                                      Barricade or Guard Type
 Continuous attendant from all sides during work (only for limited duration)   Temporary constructed barrier of approved materials
                                                  Documentation and Identification
 Safe Work Permit Obtained                LCG Tags Placed or Removed on all sides           LCG added or removed on Facility List



 Planned by:                           Date: ____________       Approved by:                             Date: __________
           (Person Planning the Elevated Work)                                  (Facility/Workgroup Leadership or Designee)


Critical Elevated Work
We / I have reviewed and understood the above plan

User signature(s)                                 Date            User signature(s)                        Date




                                             DOW RESTRICTED - For internal use only
               Life-Critical Guard (LCG) Fall Protection Plan
                          Modification Review (use only in case of change)
Describe what was changed:



      Hazard Identification and Assessment Screens Reviewed?
      Please describe the changes:




      Fall Prevention / Protection Selection Considerations Reviewed?
      Please describe the changes:




      Fall Prevention / Protection Options Reviewed?
      Please describe the changes:




    Falling Objects Control reviewed?
    Please describe the changes:




Performed by:                                                                  Date:
(Person Planning the Elevated Work)

Approved by: ________________________________________                   Date: _____________________
(Facility/Workgroup Leadership)

We / I have reviewed and understood the changes described above

User signature(s)                     Date               User signature(s)                    Date




                                DOW RESTRICTED - For internal use only