Attachment_4_-_Activity_Hazard_Analysis_blank_form_and_sample.pdf

EM385-1-1 (30NOV14) UFGS 103526 11/15

Activity Hazard Analysis (AHA)

Frequent Likely Occasional Seldom Unlikely

Catastrophic E E H H M

E H H M L

H M M L L

M L L L L

Signature: Step 1: Review each Hazard with identified safety

"Controls". Determine RAC (see above).

Annotate the overall highest RAC at the top of the AHA

Notes: (Field Notes, Review Comments, etc)

Controls RAC

AHA Signature Log #

Overall Risk Assessment Code (RAC) (Use highest code )

Critical

Marginal

Superintendant Signature

Project Location

Severity

Contract Number Probability

Risk Assessment Code (RAC) Matrix

Negligible

Activity/Work Task

Specific Anticipated HazardsJob Steps (Work Sequences)

L = Low Risk

RAC CHART

Probability: Likelihood the activity will cause a

Mishap (Near Miss, Incident, or Accident).

Identify as Frequent, Likely, Occasional, Seldom or Unlikely

E = Extremely High Risk

H = High Risk

M= Moderate Risk

Severity: The outcome if a mishap occurred.

Identify as Catastrophic, Critical, Marginal, or

Negligible

Step 2: Identify the RAC (probability vs. severity) as E, H, M, or L for each "Hazard" on AHA.

Subcontractor Foreman Name:

Date Prepared

SSHO Signature

QA Reviewed by (Name/Title)

QC Manager Signature

Specific Anticipated Hazards Controls RAC Job Steps (Work Sequences)

UFGS 013526 11/15 1.9 Government reserves the right to require the Contractor to revise and resubmit the AHA if it fails to effectively identify the work sequences; specific anticipated hazards, site conditions, equipment, materials, personnel and the control measures to be implemented.

UFGS 013526 1.9.1 Review the AHA list periodically (at least monthly) at supervisory safety meetings, update when procedures, scheduling or hazards change.

UFGS 013526 1.9.2 Each employee performing work...must review the AHA and sign a signature log for that AHA prior to starting work. The SSHO must maintain a signature log on site for every

AHA

Equipment to be used Training Requirements & Competent or Qualified

Personnel Name(s) Inspection Requirements