Tier: Doc Type:
Element or Subelement: BH HSE
Doc Number: BH-HSE-201 (EN)
Rev: 1.5
Effective Date: 25 Apr 2023
Safe to Perform – Risk and Impact
Complete on site before starting work.
Note: Complete the checklist below and initial each category in the box provided (Draw a line through any content that does not
apply.) Customize the information as needed in the Risk Assessment and Lockout Tagout sections on Pages 2 and 3. After all
applicable information has been provided, crew members shall provide their names and initial. The Job Lead shall then sign off.
When completed, this form is a record of the risk and shall be maintained at the site for seven years, according to the
Baker Hughes Records Retention Schedule (IT-GLB-En-100594).
Name of person completing form: Title:
Job Description / Task being Performed
1. Scope of Work: Initials 5. Line of Fire: Initials
Confirm Scope of Work with customer/crew. If there are Confirm a safe distance for personnel’s work or staging
deviations, Stop Work and perform Change Management. area from vehicle travel path.
2. Operational Procedures and Risk Confirm vehicles parking brakes are set and wheels are
Assessments: Initials chocked.
Confirm operational procedures match the scope of work. Confirm site’s Restricted Access Zones and No Entry
For task without procedures, record job steps in section 11. Zones.
Confirm team understands procedure requirements. Confirm objects with roll or fall potential are secured before
Confirm risk assessments match the service provided and handling.
controls in place (use bottom of page for additional hazard Confirm personnel working at height (above 1 meter) have
identification and controls) tools secured against drops, either by tethering or other
positive-locking means, and Personal Fall Arrest Systems.
Confirm the sites procedure on Energy Isolation (LOTO) For energized electrical work, confirm that all hazards are
and Baker Hughes employee’s role. Use Page 3 for listing controlled. This may be documented in a separate PTW.
isolation points and actions to confirm zero energy. For tasks involving pressurized equipment – such as
Confirm if equipment and tooling rig up / make-up activities function testing and leak testing – confirm all hazards are
post additional hazards such as trips, drops, spills, controlled. This may be documented in a separate PTW.
exposure, projectile, or pushing and pulling. Confirm that work areas with springs or cables under
Confirm compliance with the site’s process for work tension or trapped pressure hazards are clear of personnel.
activities that require a Permit to Work (PTW). Confirm the lift plan for critical lifts and travel path.
Confirm lifting and rigging equipment requirements are met,
3. Communication: Initials
including the lifting points.
Confirm with customer planned Simultaneous Operations
6. Personnel Safety: Initials
Identify points of contact for the location
Confirm Baker Hughes personnel are following the fatigue
Confirm briefing of the location’s Emergency Response management guidelines. If personnel show signs of fatigue,
Plan Stop Work and notify Supervisor.
Confirm site’s Hazardous (Classified) Locations Confirm Baker Hughes personnel are following the extreme
Ensure that any Short Service Employees understand their temperature guidelines. If personnel show signs of heat
scope of work and remain within their competencies. stress or hypothermia, Stop Work and notify Supervisor.
Confirm environmental conditions, such as weather or
4. Loss of Primary Containment or Initials
lightening, do not present a hazard during the job.
Loss of Mechanical Integrity:
Before starting work, the job lead shall identify and
Confirm required physical or equipment barriers are in
document uncontrolled hazards and their recommended
place, including mechanical, such as pressure-control
controls on Page 2 (back) of this form.
equipment, and non-mechanical, such as sealants, set-
cement, and hydraulic pressure. 7. Hand Safety: Initials
Confirm alarms or safeguards are in place and settings are Confirm that “Hands-Free” tooling is available and
compliant to the approved job plan. personnel involved know when and how to use them.
Confirm controls are in place to remove or reduce hand use
(e.g., securement, mechanical devices, etc.)
If hand use is needed, confirm that pinch points are
identified, and proper hand placement has been discussed.
8. Additional Assurance
Other: Other:
Other: Other:
Copyright 2022, 2023 Baker Hughes Company. All rights Baker
reserved.Hughes Confidential Page 1
Tier: Doc Type:
Element or Subelement: BH HSE
Doc Number: BH-HSE-201 (EN)
Rev: 1.5
Effective Date: 25 Apr 2023
Other: Other:
9. Additional Comments
10. Job Lead Sign-off
I confirm that controls are in place, the findings of this form has been communicated to all relevant personnel, and all Baker Hughes personnel
understand the hazard controls and ready to Start Work.
Job Lead (Print and Sign)
11. Names and Initials of All Crew Members Present
Completion of Work
Initials Date
Confirm if equipment and tooling rig-down or break-down activities pose additional hazards such as trapped pressure,
trips, drops, spills, exposure, projectile, pushing or pulling.
Confirm 1) equipment or tools are secured for transportation, and 2) required transportation documents are completed.
Confirm 1) work are left in clean condition, 2) waste is properly Job Lead (Print and Sign)
managed, and 3) removal of hazard control measures added during
work activity.
Risk Assessments
Assigned Persons
Sequence of Job Steps Hazards: Controls:
Name Complete
Copyright 2022, 2023 Baker Hughes Company. All rights Baker
reserved.Hughes Confidential Page 2
Tier: Doc Type:
Element or Subelement: BH HSE
Doc Number: BH-HSE-201 (EN)
Rev: 1.5
Effective Date: 25 Apr 2023
Copyright 2022, 2023 Baker Hughes Company. All rights Baker
reserved.Hughes Confidential Page 3
BH-HSE-201 (EN) Rev: 1.5
Safe to Perform – Risk and Impact Effective Date: 25 Apr 2023
Risk Assessments (continued)
Assigned Persons
Sequence of Job Steps Hazards: Controls:
Name Complete
LOTO Procedure
Magnitude Actions to De- Energy Isolation Actions to Verify
Energy Type Source
(psi, Voltage) energize Device Zero Energy
Revision History
Rev. RDR Amendment Detail Reviewer Approver Effective
Date
Added to confirm with crew (“customer/crew”) in Section 1.
Added instruction to use Section 11 to record tasks that do not have a
procedure in place.
1.5 1110 Added in Section 3, “Communication,” to ensure that any Short Service Therron Shaw Bridget Todd 25 Apr 2023
Employees understand their scope of work and remain within their
competencies.in guidance.
Added Section 7, “Hand Safety”
Three Previous Revisions
Added Job description section
1.4 999 Therron Shaw Bridget Todd 8 Jul 2022
added Risk Assessment Rows (now continued to Page 3)
1.3 998 Added extreme temperature check box in Section 6, personnel safety. Therron Shaw Bridget Todd 25 May 2022
Copyright 2022, 2023 Baker Hughes Company. All rights reserved.
Baker Hughes Confidential Page 4
