SOW Attachment (5) Activity Hazard Analysis Form.docx
DOCX document 34 KB Posted
- Attached to
- Building 77H Tank Farm Drainage Repairs
- Solicitation number
- N6449825Q4020
About this file
This is an Activity Hazard Analysis (AHA) form template used for construction safety planning, based on EM385-1-1 and UFGS 013526 standards. The form is designed to document work sequences, anticipated hazards, and control measures for construction activities, requiring signatures from the Site Safety and Health Officer (SSHO), QC Manager, and Prime Superintendent.
The template includes a Risk Assessment Code (RAC) matrix for evaluating hazard probability and severity, ranging from Low to Extremely High Risk. It requires contractors to detail specific job steps, hazards, and controls, as well as list equipment, training requirements, and inspection requirements. The form must be reviewed monthly, updated when procedures change, and signed by all employees before starting work. This appears to be a standard template attachment that would need to be completed by contractors as part of the Building 77H Tank Farm Drainage Repairs project at the Philadelphia Navy Yard.
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Text version
EM385-1-1 (30NOV14) UFGS 103526 11/15
Activity Hazard Analysis (AHA)
Contractor Name ( Performing the Work):
Overall Risk Assessment Code (RAC) (Use highest code )
Foreman Signature (Pe r forming the Wor k):
AHA Prepared by (Name/Title):
| Activity/Work Task: |
| Risk Assessment Code (RAC) Matrix |
AHA Signature Log #
Probability
| Contract Number: |
| Severity |
| Frequent |
| Likely |
| Occasional |
| Seldom |
| Unlikely |
| Date Prepared: |
| Catastrophic |
| E |
| E |
| H |
| H |
| M |
| Project Location: |
| Critical |
| E |
| H |
| H |
| M |
| L |
| PRIME CONTRACTOR SECTION: REV IEW ED BY: SIGNATUR E REQUIRED |
| Marginal |
| H |
| M |
| M |
| L |
| L |
| SSHO Signature: |
| Negligible |
| M |
| L |
| L |
| L |
| L |
| QC Manager Signature: |
| Step 1: Review each Hazard with identified |
"Controls". Determine RAC (see above).
Prime Superintendent Signature:
RAC CHART
| Notes: |
| 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
| Identify as Catastrophic, Critical, Marginal, or Negligible |
| H = High Risk |
Step 2: Identify the RAC (probability vs. severity) as E, H, M, or L for each "Hazard" on AHA.
Annotate the overall highest RAC at the top of the AHA
M= Moderate Risk
L = Low Risk
| Job Steps (Work Sequences) |
| Specific Anticipated Hazards |
| Controls |
| RAC |
| Job Steps (Work Sequences) |
| Specific Anticipated Hazards |
| Controls |
| RAC |
| Equipment to be used |
| Training Requirements & Competent or Qualified Personnel Name(s) |
| Inspection Requirements |
UFGS 013526 11/15 1.9 Government reserves the right to require the Contractor to revise and resubmit the AHA if it f ails to ef f ectively identif y the w ork 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 w hen procedures, scheduling or hazards change.
UFGS 013526 1.9.2 Each employee perf orming w ork...must review the AHA and sign a signature log f or that AHA prior to starting w ork. The SSHO must maintain a signature log on site f or every AHA
Standard SOW Attachment (5) Activity Hazard Analysis Form
File details come from the government source that posted it. Updated .