A. Identify Task/Job Description B.

Identify LIFEsavers Involved

1. Spreading of base course materials in coco shell
2. Concrete cutting Mobile Powered
Working at Height Electrical Work Confined Space Entry
3. Compaction of base course Equipment
PERMIT REQUIRED PERMIT REQUIRED PERMIT REQUIRED

Hot Work Hazardous Materials Lifting and Rigging Excavation and

PERMIT REQUIRED PERMIT REQUIRED PERMIT REQUIRED Trench Work
PERMIT REQUIRED
COMPI
Work Date 10/15/2021 Work Area
(Coco Shell)
Dept. /
Start Time 0800H CONNEX Lock Out Tag Out – Bulk Material Motor Vehicle – Railcar Safety
Contractor
Energy Isolation Handling and Storage Traffic Safety
Task PERMIT REQUIRED PERMIT REQUIRED
End Time 1700H G. SULADAY
Leader Other Permits may apply, like: Electrical System Change Permit, Line-Break Permit, CSD By-Pass Permit

C: Step By Step Task Breakdown And Identify Critical Task Step D. Hazard Identification E. Control Measures
Use additional sheet if this place is not enough to list all the task steps Add Worst-Case Scenario, Consequence and Error Traps to this column Refer hierarchy of control to eliminate SIFp & High Risk, with STOP Criteria

1.1 Use proper lifting techniques, do not carry more than you
1.1 Preparation & spreading of base course materials 1.1 Ergonomic hazard and Fatigue can handle, use of proper PPE like wearing of gloves, safety
googles and hard hat.
1.2 Clean work area as needed during the day. Use of Safety
1.2 Cutting of Concrete 1.2 Cuts, flying debris
Glasses.
1.3 Wear proper PPE at all times and clear the area for
1.3 Compacting of base course 1.3 Crushed by walk behind (feet)
compacting
1.4 Clean work area as needed during the day. Use of Safety
1.4 Drilling of concrete 1.4 Cuts, Flying debris
Glasses.

Worst-Case Scenario
Please mark * before the task step to indicate as “CRITICAL TASK STEP”
Possible Worst Consequence Fatality Serious Injury
 STOP CRITERIA:
STOP
 If an activity/condition may cause injury or property damage
 If the job steps or sequence are not the same as identified in the PJHA.
 If the task changes or the approved PJHA is not followed (e.g. job scope, location, work method, duration, number of people working, site conditions)
Others: _____________________________________________________________________________________________________________________________________________________________

F. Emergency Preparedness for a Worst-Case Scenario G. Sign Off by people expected to carry out the task
Yes
Emergency Rescue Team is required Role Signature over Printed Name Role Signature over Printed Name
No

Location of nearest Emergency Shower Task Leader Task Member

Location of Fire Alarm Station Task Member Task Member

Location of nearest Emergency devices

Task Member Task Member
(Fire extinguisher, spill kit, first aid kit)

Site Emergency Contact Number: Task Member Task Member

Nearest Hospital Contact Number: Task Member Task Member

H. Checking and Validation I. Sign for Approval (After Validation)

All workers/employees are qualified to perform the tasks
Role & Position Signature over Printed Name Role

3 or more LIFEsavers involved

Authorized Cargill Representative Plant Manager