Safety Form C-12
Activity Hazard Analysis
Project Name:
EDGED-DSM
Project Number:
164941
Project Location:
Ankeny IA
Company:
NORTHWEST
Activity Hazard Analysis No. 007
Total of 3 Pages
Overall Risk Assessment Code (mitigated RAC) - Use Highest Code
M
Risk Assessment Code (RAC) Matrix
Date Prepared:7.1.25
Job Description
Forklift – Load and unload materials, inspections
Superintendent:
(Name):
Kirk Kenner
(Signature)
Foreman:
(Name):
Safety
Representative:
Hazard Probability
Hazard Severity
Frequent
Likely
Occasional
Seldom
Unlikely
Catastrophic
E
E
H
H
M
(Signature)
Critical
E
H
H
M
L
(Name):
Eric Bryant
(Signature)
Marginal
H
M
M
L
L
(Name)
(Title)
Negligible
M
L
L
L
L
Notes: (Field, Review, comments, etc.):
1.
2.
3.
4.
Page 1
Forklift 12k / 8k (512-56 model JCB)
Unload steel trucks
Unload material
10,000 weight max for lifts
Job Steps (Work Sequences)
General site conditions
Setup barricades
Inspection of forklift
Pre walk site
Noise / Elevated Noise Levels
Competent Person
Risk Review Steps
RAC Chart
E- Extreme
Step 1: Review each Hazard” with identified safety “Controls” and determine RAC (See above)
“Probability” is the likelihood to cause an incident, near miss, or accident and identified as: Frequent, Likely,
H –High Risk
Occasional, Seldom or Unlikely.
“Severity” is the outcome/degree if an incident, near miss, or accident did occur and identified as:
M- Moderate Risk
Catastrophic, Critical, Marginal, or Negligible
Step 2: Identify the RAC (Probability/Severity) as E, H, M, or L for each “Hazard” on AHA. Annotate the overall L-Low Risk
highest RAC at the top right of the AHA.
Specific Anticipated Hazards
Controls
RAC
L
Slippery Conditions, Hoses, other equipment Eliminate the hazards, inspect the area, PPE driven, Hard
unused rigging, trenches, other crafts,
hat safety glasses, steel or composite boots, barricades,
signage, hearing protection.
Strains and Pulled Muscle / Lifting Items /
Carrying Items
Stretch and flex, mechanical help, assisted help, don’t lift
anything over 50lbs.
Struck by / caught between and pinch
points/ Lifting in General (manual and
Spotters, identify the caught between points,
mechanical)
Use spotters, , three-way communication, eliminate other
Moving/Operating equipment and traffic /
workers and equipment in the area for the specific task.
Congested work areas /
Inspect all rigging and take out of service and replace, use
Mechanical Lifting / Faulty Rigging
forklift for mechanical lifting up to 10,000. (safety factor)
Foot Traffic
All tasks driven ppe will be used for each task accordingly
Loud Noise / Hearing Damage
Competent person /supervision cannot operate equipment
and must be onsite while work is being performed.
Uneven surfaces
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Safety Form C-12
Activity Hazard Analysis
Poor Access on and off trailers.
Unload equipment and material
Unload pull shores
Pallets
Poor Access on and off trailers.
Shifted Loads / Collapse
Ladders / access on trailers
Awkward body positioning
Heat / Cold Stress Dehydration / Sun Burn
Fall from Heights
Sharp Objects
Hand Tools
Hoisting
Rigging plan / inspection on rigging
Weight load to be lifted (how Much)
Improper lifting technique
Damage or frayed rigging
Understand and confirm load weight may damage
equipment or persons
Equipment to be Used
Forklift 12K
Forklift 8K
Rigging / shackles
NOTE:
Practice good body mechanics and ergonomics.
Repetitive motion, and strains and sprains are the result of
adverse work positions. Do not over-reach your workbuild proper access to reach your work face. Poor body
position can also result if you are on the back side of
someone else’s work, including an employee you are
working with pushing on an object, such as a wrench
torquing bolts and the wrench slips, and you are in the line
of fire when the tool comes towards you. Stay out of the
line of fire of any object that had potential energy to travel
towards yourself.
Safe access on and off trailers shall be provided such as a
frame ladder of sufficient height secured to the trailer or
trailer ladders secured to the trailer rail. and set on a level
surface when using. Never stand on the top of the ladder.
Use three points of contact. Clean boots prior to climbing
ladders.
Always maintain 3 points of contact when mounting or
exiting any piece of equipment.
Use proper ladders inspected and secured by rope or
manufactured design / use spotter if needed.
Secure loads from collapse, use dunnage
Drink plenty of fluids self-determine rest times and breaks
Use cool packs, drinks with minimum sugars
Use cut-level sleeves and gloves
Use proper hand tools manufactured no homemade
Use proper ergonomics
Proper rigging practices will be utilized.
Weight of loads to be hoisted/moved by crane, forklifts or
any other equipment must be verified prior to lifting
All material load weights must be known and verified prior
to proceeding with any lift.
Training Requirements / Competent or Qualified Personnel Name(s)
Operator Certs
Operator cert
Rigging certs
Inspection Requirements
Daily
Daily
As need / required see C-20
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M
M
Safety Form C-12
Activity Hazard Analysis
Activity Hazard Analysis shall be completed for all scopes of work activity and revised as necessary.
ACTIVITY HAZARD ANALYSIS: #
AHA Discussed with the project personnel on:
Print: _____________________________
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AHA Review Conducted By:
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Print Name:_________________________________
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