Form Title: Fire Safety Risk Assessment Template Version No.: V1.
Form Ref. No.: ADA-ADIA-OPS-ESC-FSS-FC-010 Version Date 082317
This form shall be filled up by the contractor , attached to all PTW applications and sent to firesafety@[Link] for review and approval.
Reference No.:
FIRE SAFETY RISK ASSESSMENT FORM Date of Assessment:
SECTION A – PROJECT DETAILS
Name of Project:
Company:
Permit to Work Reference #:
Fire Risk Assessment Sheet– Fire Hazards
Fire Hazards Initial Risk Residual Risk
(Looking at the potential for fire to MANAGEMENT ACTION
Evaluation Evaluation
start focusing on sources of Ignition, Identification of
Fuel & Oxygen) Measures in place to reduce the risk of
Risk of Fire Spread and Life Safety location of
occurring
(Fire Spread, Fire Protection persons at risk P S RR Measures required to maintain or reduce risk P S RL
Measures, Warnings, Evacuation
Issues)
ASESSED BY:
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Form Title: Fire Safety Risk Assessment Template Version No.: V1.0
Form Ref. No.: ADA-ADIA-OPS-ESC-FSS-FC-010 Version Date 082317
Name: Designation:
Signature: Date:
REVIEWED BY:
Name: Designation:
Signature: Date:
ACCEPTED BY : ADAC Responsible Department for these works.
Name: Designation:
Signature: Date:
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Form Title: Fire Safety Risk Assessment Template Version No.: V1.0
Form Ref. No.: ADA-ADIA-OPS-ESC-FSS-FC-010 Version Date 082317
FIRE SAFETY RISK MATRIX
Insignificant Minor Moderate Major Catastrophic
PROBABILITY SEVERITY
1 2 3 4 5
Almost Certain 5 5 10 15 20 25
Likely 4 4 8 12 16 20
Most likely 3 3 6 9 12 15
Unlikely 2 2 4 6 8 10
Remote / Rare 1 1 2 3 4 5
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